Taylor Springs Health Campus

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure one resident's (#29) antihypertensive medication (medication used to lower the blood pressure) per the physician ordered parameters. This affected one resident (#29) of five residents reviewed for unnecessary medications. The facility census was 44. Findings Include: Review of the medical record for Resident #29 revealed an initial admission date of 03/22/22 with the diagnoses including but not limited to dysphagia, aphasia, dysarthria, atrial septal defect, asthma, atrial fibrillation, hypertensive urgency, hypertensive heart disease with heart failure, obesity, heart failure and hyperlipidemia. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the monthly physician orders for April 2025 identified an order dated 12/26/23 Metoprolol 25 milligrams (mg) by mouth twice daily with the special instructions to hold if systolic blood pressure (SBP) was less than…

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, interviews, and facility policy review, the facility failed to ensure one resident (#29) received emergent and/or routine dental care. This affected one resident (#29) of two residents reviewed for dental services. The facility census was 44. Findings Include: Review of the medical record for Resident #29 revealed an initial admission date of 03/22/22 with the diagnoses including but not limited to dysphagia, aphasia, dysarthria, atrial septal defect, asthma, atrial fibrillation, hypertensive urgency, hypertensive heart disease with heart failure, obesity, heart failure and hyperlipidemia. Review of the plan of care dated 03/23/22 revealed the resident had potential for oral/dental health problems related to two broken teeth and resident reports difficulty chewing. Interventions included administer medications as ordered, monitor/document for side effects and effectiveness, coordinate arrangements for dental care, transportation as needed/as ordered, diet as ordered,…

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, infection control log review, policy review and interview, the facility failed to administer antibiotics as ordered. This affected one resident (#27) of five residents sampled for unnecessary medications. The census was 44. Findings include: Medical record review revealed Resident #27 was admitted on [DATE] with diagnoses including anxiety disorder, depression, psychotic disorder with delusions, contractures and cerebellar stroke. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #27 was cognitively intact for daily-decision making. Review of the Nurse Practitioner Progress Note Details dated 03/04/25 revealed Resident #27 was seen for evaluation of some right lower extremity (RLE) edema and mild pain. The assessment and plan revealed very mild cellulitis of the right lower extremity but the resident was insistent on the fact that his RLE was more painful and swollen, as well as, some mild erythema. Will start Resident #27 on a short…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure a resident who was dependent on staff for eating received timely meal assistance. This affected one resident (#44) of 10 residents who required assistance at meals. The facility census was 48. Findings include: Review of the medical record for Resident #44 revealed an admission date of 09/23/24 with diagnoses including dementia, osteoporosis, contracture of left hand, and muscle weakness. Review of Resident #44's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had severely impaired cognition. She was dependent on staff for eating Review of Resident #44's diet order dated 12/18/24 revealed an order for a puree diet. Review of Resident #44's profile care guide last updated 01/31/25 revealed she required physical assistance with eating. Observation on 02/26/25 at 8:01 A.M. revealed Resident #44 sitting in the dining room with a plate in front of her, she was not eating. At that time, only one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, facility self-reported incident (SRI) review, and facility policy review the facility failed to timely report an allegation of abuse by Resident #3 to the executive director and state agency in a timely manner. This affected one resident (#3) of three residents reviewed for abuse. The facility census was 45. Findings include: Review of the medical record for the Resident #3 revealed an admission date of 04/26/24 with diagnoses including gastro-esophageal reflux disease, hypertension, osteoporosis, and diverticulosis of intestine. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the Resident #3 had a severe cognitive impairment. Review of the progress note dated 06/08/24 at 3:06 A.M. revealed Resident #3 called the police and reported that a man had come into her hotel room and had his way with her. The police verified that the complaint was unsubstantiated; therefore, they left. The resident was confused and called people to pick her up…

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 closed record review, staff interview, and emergency room discharge instructions, the facility failed to provide care for a broken left wrist for one (Resident #10) of three residents reviewed for accidents. The facility census was 45. Findings include: Review of the closed medical record for Resident #10, revealed an admission date of 02/16/24 and a discharge date of 3/11/24. Diagnoses included displaced bicondylar fracture of right tibia, subsequent encounter for closed fracture with routine healing, age related osteoporosis without current pathological fracture, and unspecified dementia, unspecified severity, with other behavioral disturbances. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 5 out of 15 which revealed severe cognitive impairment. Resident #10 was assessed to require substantial/maximal assistance with toilet hygiene, shower/bathe, lying to sitting on the side of the bed, toilet transfer and chair/bed…

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 closed medical record review and staff interviews, the facility failed to administer medication as ordered by the physician for one ( Resident #10) out of three residents reviewed for medication. The facility census was 45. Findings include: Review of the medical record for Resident #10, revealed an admission date of 02/16/24 and a discharge date of 3/11/24. Diagnoses included displaced bicondylar fracture of right tibia, subsequent encounter for closed fracture with routine healing, age related osteoporosis without current pathological fracture, and unspecified dementia, unspecified severity, with other behavioral disturbances. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 5 out of 15 which revealed severe cognitive impairment. Resident #10 was assessed to require substantial/maximal assistance with toilet hygiene, shower/bathe, lying to sitting on the side of the bed, toilet transfer and chair/bed to chair transfer…

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 closed medical record review and interviews, the facility failed to maintain an accurate medical record for a controlled drug for one ( Resident #10) out of three residents reviewed for medication. The facility census was 45. Findings include: Review of the closed medical record for Resident #10, revealed an admission date of 02/16/24 and a discharge date of 3/11/24. Diagnoses included displaced bicondylar fracture of right tibia, subsequent encounter for closed fracture with routine healing, age related osteoporosis without current pathological fracture, and unspecified dementia, unspecified severity, with other behavioral disturbances. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 5 out of 15 which revealed severe cognitive impairment. The resident was assessed to require substantial/maximal assistance with toilet hygiene, shower/bathe, lying to sitting on the side of the bed, toilet transfer and chair/bed to chair…

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 call lights response reports, review of concern logs, interviews, and observation the facility failed to ensure sufficient staffing to provide care and services to residents. This affected three residents (#11, #20, and #52) of four residents interviewed with the potential to affect all 50 residents. Finding included: Observation on 02/26/24 at 8:00 A.M. during the initial tour revealed there were several resident call lights activated on the 100 and 300 halls. Four nurses were observed administering medication and there were four State Tested Nurse Aides providing care. 1. Review of Resident #11's call light response report dated 02/26/24 revealed on 02/26/24 at 4:30 A.M. the call light went off for 22 minutes and two seconds and at 7:01 A.M. it went off 33 minutes and 28 seconds. Interview on 02/26/24 at 8:15 A.M. and 11:10 A.M., with Resident #11 revealed she was just admitted on Thursday, but the call light response time was not always prompt. The resident reported she had to wait half an hour to 45 minutes for someone to answer her call light. Once she waited…

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 shower schedule, review of shower sheets, review of concern log, review of resident council minutes, interviews, and policy review the facility failed to ensure dependent residents received showers per preference. This affected two residents (#20, #52) of three reviewed for showers. Findings included: 1. Closed record review revealed Resident #52 was admitted to the facility on [DATE] and discharged back to the Assisting Living on 02/23/24 per the wife's request. The resident's diagnoses included dementia, need for assistance with personal care, difficulty walking, muscle weakness encephalitis, and other abnormalities of gait and mobility. Review of Resident #52's activity of daily living (ADL) plan of care dated 02/14/24 revealed the resident requires staff assistance to complete self-care and mobility functional tasks completely and safely. Offer nail care and facial shaving on shower days and as needed or requested. Notify nursing of refusals. Review of Resident #52's…

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

Based on observations, staff interviews, and facility policy review the facility failed to properly store and date opened food items and failed to have dietary staff secure loose hair in a hair restraint during food preparation. This had the potential to affect all 50 residents in the facility. The facility census was 50. Findings include: During the initial tour of the kitchen on 04/03/23 from 8:20 A.M. to 9:15 A.M. the following was observed in Freezer #1: - A bag of frozen plant based meatballs was placed inside an opened cardboard box. The plant based meatballs was exposed to the air. The meatballs were not dated. This was confirmed with Dietary Supervisor (DS) #167 at 8:35 A.M. - A bag of frozen plant based patties was placed inside an opened cardboard box. The plant based patties were exposed to the air. The patties were not dated. This was confirmed with DS #167 at 8:35 A.M. - A bag of frozen hamburger patties was placed inside an opened cardboard box. The hamburger patties were exposed to the air. The patties were not dated. This was confirmed with DS #167 at 8:35 A.M. - A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interview, medical record review, and facility policy review, the facility failed to provide adequate accommodations for a resident to elevate his legs when he was out of bed as ordered. This affected one resident (#42) of two reviewed for environment. The facility census was 50. Findings include: Review of the medical record for Resident #42 revealed an admission date on 03/03/23. Medical diagnoses included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disorder (COPD), hypertensive chronic kidney disease Stage 3, lymphedema, morbid obesity, and Type II Diabetes Mellitus. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #42 had mildly impaired cognition and scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #42 required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). Review of the physician orders dated March 2023…

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 facility policy review, the facility failed to provide a written notice of transfer to a resident upon being transferred to the hospital. This affected one (#44) of one resident reviewed for hospitalization. The facility census was 50. Findings Include: Review of the closed medical record for former Resident #44 revealed an admission date on [DATE]. The resident expired on [DATE]. Medical diagnoses included unspecified dementia, congestive heart failure (CHF), pleural effusion, morbid obesity, schizophrenia, depression, muscle weakness, dysphagia, and encephalopathy (a brain disease). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #44's cognition was not assessed. However, per staff assessment, Resident #44 had moderately impaired cognition. Resident #44 required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). Review of the progress notes revealed on [DATE] at 10:17 A.M.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to provide a written bed hold notice to a resident upon being transferred to the hospital. This affected one (#44) of one resident reviewed for hospitalization. The facility census was 50. Findings Include: Review of the closed medical record for former Resident #44 revealed an admission date on [DATE]. The resident expired on [DATE]. Medical diagnoses included unspecified dementia, congestive heart failure (CHF), pleural effusion, morbid obesity, schizophrenia, depression, muscle weakness, dysphagia, and encephalopathy (a brain disease). Review of Resident #44's payer source revealed the resident had Medicaid. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #44's cognition was not assessed. However, per staff assessment, Resident #44 had moderately impaired cognition. Resident #44 required extensive assistance from one to two staff to complete Activities of Daily Living…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, document review, and policy review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) for Resident #1 when she had a new diagnosis of schizophrenia and Resident #8 when they did not have a correct mental health diagnosis. This affected two residents (#1 and #8) of two residents reviewed for PASARR. The facility census was 50. Findings include: 1. Record review of Resident #1 revealed an admission date of 01/28/22 with pertinent diagnoses of: schizoaffective disorder depressive type 9/27/22, chronic obstructive pulmonary disease, asthma, hypertensive heart disease with heart failure, heart failure, obsessive-compulsive disorder, unspecified dementia, generalized anxiety disorder, hypertension, other sleep disorders, and functional urinary incontinence. Review of the 03/02/23 quarterly Minimum Data Set (MDS) assessment revealed Resident #1 was cognitively intact and required physical help in bathing, supervision for personal hygiene…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, document review, and policy review the facility failed to notify the state mental health authority for Resident #1 when she had a new diagnosis of schizophrenia and Resident #8 when had a new mental health diagnoses of vascular dementia, major depressive disorder, and psychotic disorder with delusions. This affected two residents (#1 and #8) of two residents reviewed for mental health screening. The facility census was 50. Findings include: 1. Record review of Resident #1 revealed an admission date of 01/28/22 with pertinent diagnosis of: schizoaffective disorder depressive type 9/27/22, chronic obstructive pulmonary disease, asthma, hypertensive heart disease with heart failure, heart failure, obsessive-compulsive disorder, unspecified dementia, generalized anxiety disorder, hypertension, other sleep disorders, and functional urinary incontinence. Review of the 03/02/23 quarterly Minimum Data Set (MDS) assessment revealed Resident #1 was cognitively intact and required physical help in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person centered dental care plan. This affected one resident (#6) of two residents reviewed for dental care. The facility census was 50. Findings include: Resident observation on 04/03/23 at 10:45 A.M. revealed Resident #6 had natural teeth with several broken or missing, teeth were discolored. Gums were moist and pink in color with no bleeding observed. Tongue was pink in color. No food particles were observed. Record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, vascular dementia, weakness and depression disorder. The resident had a diet order for regular textured foods with special instructions for mechanical soft foods on request by resident. Record review revealed Resident #6's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 indicated oral pain and difficulty with chewing. The MDS revealed Resident #6 had obvious or…

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 facility policy review, the facility failed to appropriately assess and monitor pressures ulcers. This affected one resident (#152) of four residents reviewed for pressure ulcers. The census was 50. Findings Include: Record review revealed Resident #152 was admitted to the facility on [DATE]. Her diagnoses were encounter for surgical aftercare following surgery of the skin and subcutaneous tissue, fibromyalgia, cervical disc degeneration, rheumatoid arthritis, urinary tract infection, morbid obesity, lymphedema, pressure ulcer of sacral region, depression, anxiety disorder, type II diabetes, hypothyroidism, overactive bladder, hyperlipidemia, bacteremia, rectal abscess, age related physical debility, weakness, and sepsis. Review of her Minimum Data Set (MDS) assessment, dated 02/16/23, revealed she was cognitively intact. Review of Resident #152's pressure ulcer skin logs and assessments, dated 02/16/23 and 02/17/23, revealed she had three pressure ulcers…

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 resident and staff interview, observation, and record review the facility failed to store drugs in locked compartments when staff left an inhaler and nasal spray in a resident's room. This affected one resident (#1) of five residents reviewed for medications. The facility census was 50. Findings Include: Record review of Resident #1 revealed an admission date of 01/28/22 with pertinent diagnoses of: schizoaffective disorder depressive type 9/27/22, chronic obstructive pulmonary disease, asthma, hypertensive heart disease with heart failure, heart failure, obsessive-compulsive disorder, unspecified dementia, generalized anxiety disorder, hypertension, other sleep disorders, and functional urinary incontinence. Review of the 03/02/23 quarterly Minimum Data Set (MDS) assessment revealed Resident #1 was cognitively intact and required physical help in bathing, supervision for personal hygiene and was independent in all other activities of daily living. The resident used a walker to aid in mobility and was frequently incontinent of bowel and bladder. Observation of Resident #1'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 observation, interview, policy review, and record review the facility failed to provide emergency dental care. This affected one resident (#6) of two residents reviewed for dental services. The facility census was 50. Findings include: Resident interview on 04/03/23 at 10:39 A.M. revealed Resident #6 complained of oral discomfort when chewing meat. Resident #6 stated he had requested to see a dentist several times to staff. Resident observation on 04/03/23 at 10:45 A.M. revealed Resident #6 had natural teeth with several broken or missing, teeth were discolored. Gums were moist and pink in color with no bleeding observed. Tongue was pink in color. No food particles were observed. Resident observation on 04/05/23 at 8:35 A.M. revealed resident requested to see a dentist to Registered Nurse (RN) #195 because of oral discomfort. Record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, vascular dementia, weakness and depression disorder. The resident…

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

Based on medical record review, staff interview, review of the hospice binder, and review of the hospice contract, the facility failed to ensure continuity of care for a resident receiving hospice services when hospice progress notes were not readily available to facility staff caring for a resident. This affected one resident (#35) of one resident reviewed for hospice services. The facility census was 50. Findings Include: Review of the medical record for Resident #35 revealed an admission date on 02/01/22. Medical diagnoses included encephalopathy (a brain disease), unspecified dementia, unspecified psychosis, developmental disorder of scholastic skills, and other forms of scute ischemic heart disease. Review of the physician orders dated March 2023 revealed Resident #35 had the following order dated 02/11/23: admitted under hospice services related to other symptoms and signs involving cognitive functions following cerebral infarction. Review of the significant change Minimum Data Set (MDS) 3.0 assessment revealed Resident #35's cognition was not assessed. However, pre staff…

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 facility policy review, the facility failed to adequately follow antibiotic stewardship procedures prior to the ordering and administering of antibiotics. This affected one resident (#33) of two residents reviewed for antibiotic use. The census was 50. Findings Include: Record review revealed Resident #33 was admitted to the facility on [DATE]. Her diagnoses were encephalopathy, sepsis, enterocolitis due to CDiff, acute respiratory failure, shock, pneumonia, dementia, acute posthemorrhagic anemia, hyperlipidemia, hyperosmolality and hypernatremia, acute kidney failure, major depressive disorder, insomnia, melena, hematemesis, hypertension, altered mental status, and elevated white blood cell count. Review of Minimum Data Set (MDS) assessment, dated 02/12/23, revealed she had a significant cognitive impairment. Review of Resident #33's progress note, dated 03/30/23, revealed Resident #33's family member was at the facility and requested a urinalysis to be…

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.