Parkview Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, resident interview, staff interview, and policy review, the facility failed to ensure colostomy drainage bag changes were completed per physician orders. This affected one (#2) of two residents reviewed for ostomy care. The facility identified two residents with colostomies. The facility census was 36.Findings include: Review of the medical record for Resident #2 revealed an admission date of 09/19/25. Diagnoses included surgical aftercare, colostomy status, pulmonary embolism, and malignant neoplasm of the colon. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the physician orders dated 09/19/25 revealed an order to change ostomy bag every three days and as needed. Review of the treatment administration record from 09/19/25 through 10/08/25 revealed no documentation Resident #2's colostomy bag changes had been completed per physician orders. Interview on 10/08/25 8:17 A.M., Resident #2 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 review of the medical record, review of available facility medications, staff interview, and policy review, the facility failed to ensure a resident was free from a significant medication error. This affected one (#2) of three residents reviewed for medications. The facility census was 36. Findings include: Review of the medical record for Resident #2 revealed an admission date of 09/19/25. Diagnoses included surgical aftercare, colostomy status, pulmonary embolism, and malignant neoplasm of the colon. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the hospital discharge physician orders revealed the resident had orders for apixaban five milligrams (mg) twice daily by mouth, dronabinol 2.5 mg capsule twice daily for 30 days, folic acid one mg daily in morning by mouth, and oxycodone five mg every eight hours as needed for pain for up to 15 doses. Review of the physician orders dated 09/19/25 revealed orders for apixaban five…

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 a the facility water management plan, staff interview, review of the Centers for Disease Control and Prevention (CDC) website, and policy review, the facility failed to implement a complete water management program to prevent the growth of Legionella bacteria and failed to wear gloves during administration of an injected medication. This had the potential to affect all 34 residents residing in the facility. The census was 34. Findings include: 1. Review of the facility the facility's water management plan lacked any information about how the facility would intervene when control measures were not met and possible contamination with Legionella bacteria was suspected or address ongoing monitoring of the plan's effectiveness. Interview with the Administrator on 03/13/25 at 10:07 A.M. verified the facility's water management plan did not address how the facility would intervene if control measures were not met, what interventions the facility would implement if contamination of Legionella bacteria was suspected, or how the facility would monitor the plan's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interview, review of activities calendars, and policy review, the facility failed to provide activities of resident preference on evenings and weekends to support the physical, mental, and psychosocial well-being of the resident. This affected one (#18) of one residents reviewed for activities. The facility census was 34. Findings include: Review of Resident #18's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included nontraumatic subdural hemorrhage, anxiety disorder, and alcohol abuse. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact and was independent with mobility and activities of daily living (ADLs). Interview with Resident #18 on 03/10/25 at 9:33 A.M. revealed the facility did not provide activities in the evening hours and lacked a variety of different activities that suited Resident #18's interest. Resident #18 also stated on weekends…

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 maintain medical equipment and supplies in a sanitary manner. This affected all 34 residents residing in the facility. Findings include: On 10/29/24 at 7:50 A.M. observation with Maintenance Director #1 during tour of the facility medical supply rooms located in the facility basement discovered the following: 1. Small medical storage room identified an open box containing 16 indwelling urinary catheter insertion trays soiled with a brown substance. Posted on the exterior of the catheter tray noted the instruction, Warning Avoid storage in direct sunlight/florescent lighting and keep area cool, dry, and well ventilated. Contents STERILE in unopened, undamaged package. 2. Small medical storage room noted a closed case of tracheostomy care kits containing 20 kits. The box was discovered with a yellow brown substance and moisture stain penetrating the box. 3. Located inside the large medical storage room noted heavy amount of debris on the floor including individual packages of incontinence briefs, open SARS-CoV-2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and staff interview the facility failed to ensure resident heating and air conditioning equipment was operational inside resident rooms. This affected one (Resident #2) of four residents reviewed for environmental heating, ventilation and cooling in the facility. The total facility was census of 34. Findings include: Resident #2 admitted to the facility on [DATE] with the diagnoses including Alzheimer's disease, multiple sclerosis, dementia, mood disturbance, anxiety disorder, and hypertension. According to the minimum data set assessment dated [DATE] Resident #2 was assessed with intact cognition, required supervision and touch assistance with activities of daily living and utilized a wheelchair for mobility. Review of facility census information Resident #2 was moved to the current room on 09/03/24. According to physician orders on 10/21/24 Resident #2 was placed into SARS-CoV-2 (COVID-19) COVID isolation. Observation on 10/29/24 at 11:40 A.M. located Resident #2 inside a single occupancy…

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 the physical environment was maintained free of damage or hazardous conditions. This affected one (Resident #1) of four residents rooms observed for environmental conditions in the facility. The total facility census was 34. Findings include: On 10/29/24 at 9:13 A.M. observation discovered Resident #1 in bed with the bed located next to an exterior window. The window fixture was equipped with a single pane glass storm window containing two windows. One window pane was broken with three fractures in the glass extending across the entire pane. No additional windows were installed in the fixture to prevent exterior air movement from entering the room. Further tour of the room noted three electrical receptacles with electronic devices plugged to the outlets. The outlets were discovered to be extremely loose in the electrical junction boxes. One of the three outlets were discovered to be dislodged with approximately a one foot diameter section of drywall broken way from the wall. On 10/30/24 at 2:25 P.M. observation…

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 of review of quarterly Quality Assessment and Assurance (QAA) meeting sign in sheets, interview, and policy review, the facility failed to ensure quarterly QAA meetings were completed as required. This had the potential to affect all residents. The facility census was 28. Findings include Review of the quarterly QAA meeting sign in sheets revealed the facility had no documentation a quarterly QAA meeting was held with all the required members for the second and third quarter of 2023. Interview on 05/08/24 at 1:10 P.M., the Director of Nursing (DON) verified there were no sign in sheets for the quarterly meetings for the second quarter and third quarter of 2023. The DON revealed a former administrator was in charge of the sign in sheets. Review of the policy, Quality Assurance and Performance Improvement (QAPI), dated 2024, revealed the QAA committee would meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program. This was an incidental finding found over the course of the complaint investigation.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, review of nurse practitioner progress notes and physician progress notes, interview, and policy review, the facility failed to ensure the physician and nurse practitioner were alternating resident visits. This affected five (#17, #19, #03, #02, #11) of six residents reviewed for physician visits. The facility census was 28. Findings include 1. Review of the medical records revealed Resident #17 had an admission date of 10/27/21. Diagnoses included dementia, diabetes mellitus type two, epilepsy, hypertension, depressive disorder, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the Nurse Practitioner (NP) progress notes revealed the NP had visits with the resident on 02/21/23, 03/09/23, 04/11/23, 05/02/23, 05/04/23, 06/01/23, 07/07/23, 08/10/23, 08/24/23, 09/07/23, 10/12/23, 11/16/23, 12/07/23, 01/04/23, 03/14/23, 04/04/24, and 05/01/24. The NP electronically signed each progress note.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of Self-Reported Incidents (SRIs), review of the medical record, interview, and policy review, the facility failed to report allegations of sexual abuse. This affected three (Residents #21, #02, #03) of four residents reviewed for abuse. The facility census was 28. Findings include: 1. Review of the medical record for Resident #21 revealed an admission date of 02/06/24. Diagnoses included malignant neoplasm of left breast, secondary malignant neoplasm of brain, secondary neoplasm of right lung, chronic obstructive pulmonary disease, bipolar disorder, anxiety disorder, and type two diabetes mellitus. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was not ambulating. Review of the plan of care initiated 04/04/24 for Resident #21 revealed the resident had a behavior problem fidgeting with medical equipment and sexually inappropriate comments related to cognitive decline and confusion. Interventions included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, observation, interview, and policy review, the facility failed to ensure nutritional supplements were provided per physician orders. This affected two (#25, #19) of three residents reviewed for nutrition. The facility census was 28. Findings include 1. Review of the medical record for Resident #25 revealed an admission date of 08/18/22. Diagnoses included bipolar disorder, dementia, diabetes mellitus type two, protein calorie malnutrition, chronic kidney disease, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment, required set up assistance for meals, and had significant weight loss of five percent in one month or ten percent in six months. Review of the physician orders for Resident #25 revealed orders dated 08/23/22 for a regular diet, with regular texture and thin liquids. On 01/16/24, the resident was ordered a house shake twice daily related to protein-calorie malnutrition. 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 review of the medical record, staff interview, and review of facility policies, the facility failed to ensure a physician was notified when the facility was unable to administer a resident's enteral nutrition as ordered. This affected one (#38) of two residents reviewed for tube feeding. The facility census was 28. Findings include: Review of the medical record revealed Resident #38 had an admission date of 02/12/24 and a discharge date of 02/20/24. Diagnoses included end stage renal disease, liver disease, autoimmune hepatitis, depression, generalized anxiety disorder, dysphagia, gastrostomy status, and liver transplant status. Review of the Minimum Data Set (MDS) five-day assessment dated [DATE] revealed Resident #38 had intact cognition. The resident required set-up assistance for meals and had a feeding tube. Review of hospital discharge orders dated 02/12/24 revealed Resident #38 had orders for Jevity 1.5 (nutritional formula) at 20 milliliters (ml) per hour by percutaneous endoscopic gastrostomy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, staff interview, and policy review, the facility failed to ensure a resident received enteral feedings per physician orders. This affected one (#38) of two residents reviewed for tube feedings. The facility census was 28. Findings include Review of the medical record revealed Resident #38 had an admission date of 02/12/24 and a discharge date of 02/20/24. Diagnoses included end stage renal disease, liver disease, autoimmune hepatitis, depression, generalized anxiety disorder, dysphagia, gastrostomy status, and liver transplant status. Review of the Minimum Data Set (MDS) five-day assessment dated [DATE] revealed Resident #38 had intact cognition. The resident required set-up assistance for meals and had a feeding tube. Review of hospital discharge orders dated 02/12/24 revealed Resident #38 had orders for Jevity 1.5 (nutritional formula) at 20 milliliters (ml) per hour by percutaneous endoscopic gastrostomy (PEG) tube. Review of a physician order dated 02/12/24 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 review of the medical record, review of Self-Reported Incidents (SRI), agency staff interview, staff interview, and policy review, the facility failed to ensure a resident's narcotic medication was not misappropriated. This affected one (#25) of one resident reviewed for misappropriation. The facility census is 28. Findings include: Review of the medical record revealed Resident #25 was initially admitted on [DATE]. Diagnoses included chronic combined systolic (congestive) heart failure, unspecified cirrhosis of liver, type two diabetes mellitus without complications, type two diabetes mellitus with diabetic neuropathy, epilepsy, essential (primary) hypertension, chronic obstructive pulmonary disease with exacerbation, depression, bipolar disorder, and chronic pain syndrome. Review of the Minimum Data Set (MDS) assessment, dated 01/19/24, revealed the resident was cognitively intact and received antianxiety, antidepressant, and opioid medications. Review of physician orders, dated 07/26/23, revealed…

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

Based on observation, staff interview, and policy review, the facility failed to store, prepare, distribute, and serve foods in accordance with professional standards for food service safety. This had the ability to affect all 30 residents who received food from the kitchen. The facility census was 30. Findings included: Observation of the kitchen on 12/15/23 at 11:11 A.M. revealed Kitchen Aide #510 was observed preparing meal trays for the resident room service. Kitchen Aide #510 was observed to not be wearing a hairnet. Interview with [NAME] #500 on 12/15/23 at 11:13 A.M. verified Kitchen Aide #510 failed to wear the proper attire to prevent possible hair contamination in the food. Review of the facility policy titled Staff Attire revised on 09/2017 revealed all staff members will have their hair off the shoulders, confined in a hair net or cap and facial hair properly restrained.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interviews, the facility failed to provide timely dental services for a resident. This affected one (Resident #12) of three residents reviewed for dental services. The facility census was 33. Findings include: Review of Resident #12's medical record revealed Resident #12 was initially admitted to the facility on [DATE]. Diagnoses included schizophrenia, anxiety, major depressive disorder, heartburn, restlessness and agitation, other psychoactive substance abuse, and homelessness. Review of the significant change Minimum Data Set (MDS) assessment, dated 08/22/23, revealed Resident #12 was cognitively impaired with moderately severe depression. There were no behaviors or rejection of care. Resident #12 required supervision for a majority of the activities of daily living. Review of Resident #12's physician orders for October 2023 revealed an order dated 08/17/23 for dental as needed. Review of the nursing progress notes dated 08/19/23, revealed Resident #12…

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 interviews, and review of policy, the facility failed to ensure a safe, comfortable, homelike environment by not ensuring the floors were maintained; showers were free from disrepair and discolored grout. This affected all 31 residents in the facility. The facility census was 31. Findings include: Interview and observations on 10/03/23 beginning at 9:50 A.M., with Maintenance Director #500 revealed the flooring in the facility was planks of flooring approximately three feet long fitting together throughout the common areas. Continued observation revealed the planks in high-traveled common areas, except the dining room, were taped with duct tape and black tape, curved, buckling, warped, and poorly fitted. In some areas the planks were raised along the long edge as if they were put in too tight and were squeezed together and raised off the subfloor, and in other places gaps were noted between the short ends. Maintenance Director #500 confirmed all observations of poorly fitting and taped together flooring in the high-traveled areas, except the dining room.…

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 medical records contained accurate and identifiable entries by specified nursing staff. This affected four (#23, #6, #10 and #5) of four medical records reviewed for accuracy and had the potential to affect all 27 residents residing in the facility. The facility census was 27. Findings include: 1. Review of Resident #23's medical record revealed an admission date of 08/25/22, with the diagnoses including: major depression, dementia with behavioral and psychotic disturbance, delusional disorder, anxiety disorder, benign prostatic hyperplasia with lower urinary tract symptoms, urinary tract infection, urinary retention, supra pubic urinary catheter, coronary artery disease, hypertension, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #23 was assessed with severe cognitive impairment, dependent on staff for the completion of activities of daily…

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

Based on observation, staff interview and policy review, the facility failed to ensure multiple use medication vials were stored and maintained to promote effectiveness. This affected one (#9) resident receiving insulin and a undetermined number of residents regarding tuberculosis testing in a facility census of 27. Findings include: 1. Observation on 10/18/22 at 7:42 A.M., of the Front medication cart with Licensed Practical Nurse (LPN) #206 discovered an open multiple use vial of Lantus insulin. The vial was opened and did not contain a date opened. Interview with LPN #206, at the time of the observation, confirmed all multiple use medication vials are to be marked with an open date when first opened. Review of the policy tiled Insulin Administration Procedure, revised September 2014, instructs staff to check an expiration date, if drawing from a opened multi-dose vial. If opening a new vial, record expiration date and time on the vial. 2. Observation on 10/18/22 at 7:45 A.M., with LPN #206, of the facility medication storage room discovered two multiple use vials of tuberculin…

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 policy, the facility failed to distribute meals to residents in a safe and sanitary manner. This affected 15 (#4, #5, #9, #10, #11, #13, #14, #16, #19, #20, #22, #24, #25, #26, and #78) of 15 residents who received meal trays in their rooms. The facility census was 27. Findings include: Observations beginning on 10/17/22 at 11:44 A.M., revealed tray carts containing food trays for the lunch meal were not enclosed and contained saucers with frosted chocolate cake on them. The chocolate cake was not covered and was open-to-air. Meal trays containing uncovered chocolate cake were delivered to the rooms of Resident #4, #5, #9, #10, #11, #13, #14, #16, #19, #20, #22, #24, #25, #26, and #78. Interview with State Tested Nurse Aide (STNA) #204, at the time of observation, verified the chocolate cake was uncovered and open-to-air as it was transported throughout the facility. Interview on 10/18/22 at 11:40 A.M., with Dietary Manager #300 revealed food items contained on tray carts were required to be covered and verified the chocolate cake…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the facility's documents, the facility failed to allow residents to smoke. This affected one (#4) of three residents reviewed for smoking. The facility census was 27. Findings include: Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, depression, and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/28/22, revealed Resident #4 was cognitively intact and was independent for the activities of daily living. Review of the smoking assessment dated [DATE] revealed Resident #4 required supervision for smoking. Review of the nursing progress notes dated 09/26/22 at 1:12 P.M. revealed Resident #4 was a supervised smoker and lit up a cigarette and began to smoke stating she hated the rules about smoking. Resident #4 was reminded of the smoking contract she signed and continued to smoke her cigarette. Resident #4 was suspended from smoking…

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 resident and staff interview, the facility failed to ensure nail care and bathing was provided timely to a resident who required assistance from staff with activities of daily living. This affected one (Resident #11) of 16 residents observed for activities of daily living. The facility identified 19 residents who required assistance from staff with bathing and 20 residents who required assistance from staff with dressing. The facility census was 27. Findings include: Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, chronic obstructive pulmonary disease, psoriasis, polyneuropathy, candidiasis of skin and nail, peripheral vascular disease, and abnormal posture. Review of the Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #11 had moderately impaired cognition. Resident #11 was dependent on staff for physical assistance of one person for the completion 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, medical record review, review of the facility's skin assessment policy, and resident and staff interview, the facility failed to ensure a resident's skin was monitored routinely and the resident's skin impairments were reported to the nurse and physician timely. This affected one (Resident #11) of one residents reviewed for non-pressure related skin issues. The facility identified one resident with a rash related skin issue. The facility census was 27. Findings include: Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, chronic obstructive pulmonary disease, psoriasis, polyneuropathy, candidiasis of skin and nail, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #11 had moderately impaired cognition. Resident #11 was dependent on staff for physical assistance of one person for the completion of activities of daily living (ADL) including…

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's policy, the facility failed to ensure treatments were completed per physician order. This affected one (#5) of one resident reviewed for pressure ulcers. The facility identified three current residents with pressure ulcers residing in the facility. The facility census was 27. Findings Include: Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizophrenia, bipolar disorder, anxiety, depression, psychotic disorder, hallucinations, irritability and anger, muscle weakness, pressure ulcer of left heel, pressure-induced deep tissue damage of right and left heels, non-pressure chronic ulcer of lower left and right legs, edema, chronic pain, and type II diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/05/22, revealed Resident #5 was cognitively intact and was independent for activities of daily living. Resident #5 had two…

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 resident and staff interview, the facility failed to ensure residents who required supervision were monitored during smoking. This affected one (Resident #10) of seven residents identified by the facility who required supervision while smoking. The facility census was 27. Findings include: Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, glaucoma, anxiety disorder, dry eye syndrome, cataract let eye, psychosis, major depression, dementia, suicidal ideations, and pigmentary retinal dystrophy. Review of the Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #10 was cognitively intact, had severely impaired vision, depressed mood, dependent on staff for the provision of hygiene and dressing, independent with bed mobility, and propels self in wheelchair. Review of the nursing plan of care, last revised on 08/03/22, revealed Resident #10 was a smoker and required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, staff interviews, and review of the facility's policy, the facility failed to ensure Resident #23 received appropriate treatment regarding the maintenance of a suprapubic indwelling urinary catheter and failed to ensure Resident #78 was provided with specific interventions to maintain urinary and bowel continence. This affected two of two residents (#23 and #78) reviewed for catheter care and incontinence care. The facility identified two residents with an indwelling or external catheter. The facility identified two residents on a urinary toileting program and three residents on bowel toileting program. The facility census was 27. Findings include: 1. Review of Resident #23's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included major depression, dementia with behavioral and psychotic disturbance, delusional disorder, anxiety disorder, benign prostatic hyperplasia with lower urinary tract symptoms, urinary tract infection,…

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 reviews, staff interview, and policy review, the facility failed to ensure pharmaceutical recommendations were reviewed by the physician. This affected three (#5, #6, and #10) of five residents reviewed for unnecessary medications. The facility census was 27. Findings include: 1. Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizophrenia, bipolar disorder, anxiety, depression, psychotic disorder, hallucinations, irritability and anger, muscle weakness, pressure ulcer of left heel, pressure-induced deep tissue damage of right and left heels, non-pressure chronic ulcer of lower left and right legs, edema, chronic pain, and type II diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/05/22, revealed Resident #5 was cognitively intact and was independent for activities of daily living. Review of Resident #5's prescribed medications list for May 2022 through October 2022 identified a 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 medical record review, family and staff interview, and review of policy, the facility failed to ensure resident food preferences were identified and subsequently honored. This affected one (#22) of two residents reviewed for food preferences. The facility census was 27. Findings include: Review of Resident #22's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses including dementia, bipolar disorder, type II diabetes mellitus, vitamin D deficiency, and anemia. Review of Resident #22's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was identified as having severe cognitive impairment and was independent for bed mobility and eating. Review of Resident #22's electronic and paper medical records revealed no information pertaining to Resident #22's dietary preferences. Interview on 10/17/22 at 10:25 A.M., with Resident #22's family member stated Resident #22 had not been eating much because she did not like to eat American food.…

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

Based on observation, review of a manufacture's instructions, review of the infection control surveillance log, staff interview and policy review, the facility failed to ensure glucometers were properly sanitized/disinfect prior to use on resident's. This had the potential to affect five residents (#1, #5, #8, #9, #25) who had orders for blood sugar monitoring on the C and D halls. Additionally, the facility failed to establish and implement an infection control program to ensure ongoing surveillance of infections to to prevent the spread of infections and ensure appropriate treatment of infections. This had the potential to affect all 29 residents. The facility census was 29. Findings include: 1. Observation on 11/12/19 at 4:28 P.M. Registered Nurse (RN) #305 obtained a glucometer and supplies from a medication cart and proceeded to Resident #25's room. RN #305 pricked the resident's index finger with a lancet device, expelled a drop of the resident's blood, and used the glucometer to obtain the drop of blood to obtain a blood sugar reading. RN #305 then returned to the medication…

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 the infection control surveillance log, staff interview and policy review the facility failed to implement an antibiotic stewardship program to prevent the spread and ensure appropriate treatment of infections. This had the potential to affect all 29 residents. The facility census was 29. Findings include: Review of the infection control surveillance log at the time of the annual survey revealed documentation from January 2019 to November 2019 which lacked supporting information for appropriate antibiotic stewardship. The infection control surveillance log provided no evidence the facility had monitored the tracking and trending of infectious facility diseases. The infection control surveillance log did not contain any documentation of infectious organisms that would have been identified in the laboratory culture and sensitivity testing. The infection control surveillance log provided no documentation of the dates of onset of infections, and no monitoring of weather or not the antibiotic was started or completed. The infection control surveillance log provided no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the facility activities calendars and staff and resident interview, the facility failed to provide scheduled group activities for the residents. This affected one (#16) out of two residents reviewed for activities and had the potential to affect 14 additional residents (#12, #127, #8, #17, #130, #2, #3, #4, #1, #25, #15, #14, #13, #9) identified by the facility who typically attended group activities. The facility census was 29. Findings include: Medical record review revealed Resident #16 admitted to the facility on [DATE]. Diagnoses included legal blindness, diabetes and heart failure. Review of Resident #16's most recent plan of care revealed the resident was depended on staff for activities due to his blindness, anxiety and depression. Interventions included to provide one to one activities and to invite the resident to scheduled activities. Interview on 11/12/19 at 9:43 A.M., Resident #16 stated he did not feel the facility provided enough group activities 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 a record review and family and staff interviews, the facility failed to provide resident's responsible party statements of residents trust accounts. This affected one (#8) of 18 residents reviewed during the initial pool process of the annual survey. The facility census was 29. Findings include: Medical record review revealed Resident #8 admitted to the facility on [DATE]. Review of the resident's most recent Minimum Data Sets assessment, dated 09/19/19, revealed the resident's cognition was severely impaired. Review of Resident #8's trust fund quarterly statements revealed a signature by Resident #8 verifying receipt. No other signature was observed. Phone interview on 11/12/19 at 11:19 A.M., with Resident #8's Power of Attorney (POA), revealed he was the responsible for the resident's medical and financial needs. The POA confirmed the resident had a resident trust account the facility managed but stated he did not know how much was in the account. The POA revealed he did not receive statements for 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 a resident was free from unnecessary medication when staff failed to monitor a resident's blood pressure and/or pulse rate prior to administering medications with physician ordered parameters. This affected one (#2) of five residents reviewed for unnecessary medications during the annual survey. The facility census was 29. Findings include: Medical record review revealed Resident #2 admitted to the facility on [DATE]. Diagnoses included chronic atrial fibrillation, hypertension and heart failure. Review of Resident #2's physician orders revealed the resident was ordered Coreg (mediation to treat high blood pressure and heart failure) 12.5 milligrams (mg) twice a day. Further review of the order revealed staff were supposed to hold the medication for a systolic blood pressure less than 110 millimeters of mercury (mm Hg) and/or a heart rate less than 50 beats per minute (bmp). Review of the resident's 10/2019 and…

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

Based on medical record review, staff interview and policy review, the facility failed to ensure laboratory testing was completed per physician orders. This affected one (#24) of five residents reviewed for unnecessary medications during the annual survey. The facility census was 29. Findings include Review of the medical record for Resident #24 revealed an admission date of 10/13/19. Diagnoses included atrial fibrillation, heart failure, hypertension and a history of a pulmonary embolism and deep vein thrombosis. Review of a physician order dated 10/13/19 revealed Resident #24 was ordered Coumadin (anticoagulant (blood thinning medication) to treat and/or prevent blood clots and pulmonary embolisms) nine milligrams (mg) daily. Further review of the order revealed Resident #24 was ordered laboratory testing to monitor prothrombin time (PT) (a test used to help detect and diagnose a bleeding disorder or excessive clotting disorder) and the international normalized ratio (INR) (a value calculated from a PT result and is used to monitor how well blood-thinning medication is working 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 medical record review, review of the influenza (flu) shot log, staff interview and policy review, the facility failed to administer the appropriate influenza vaccination to Resident #122 and flailed to offer the appropriate pneumococcal vaccinations to Resident #8. This affected two (#8 and #122) of five residents reviewed for immunizations. The facility census was 29. Findings include: 1. Record review revealed the Resident #8 was admitted on [DATE] with diagnosis of chronic obstructive pulmonary disease, type two diabetes mellitus and muscle weakness. Review of the Resident #8's immunization record revealed the influenza vaccination was administered on 10/23/19 and documented on a two-sided informed consent for influenza and pneumococcal vaccinations. Further review of the Resident #8's immunization record revealed no documentation the pneumococcal vaccination was offered to the Resident #8 since September of 2018. Interview on 11/14/19 at 9:09 A.M. with the Director of Nursing (DON) revealed 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.