Windsor Lane Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview, observation, review of the medical record, and review of the facility policy, the facility failed to ensure residents wore smoking aprons as ordered by the physician. This affected one (#5) of two residents reviewed for smoking. The facility census was 61. Findings include: Review of the medical record for Resident #5 revealed an admission date of 12/10/22 with a diagnosis of chronic respiratory failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had intact cognition. Review of a current physician order for 07/2024 revealed Resident #5 was required to wear a smoking apron while smoking, initiated on 03/23/23. Review of the most recent Smoking Assessment completed on 01/11/24 revealed Resident #5 no longer smoked. The assessment did not clarify whether Resident #5 could smoke independently. Review of a nursing progress note dated 05/01/24 revealed Resident #5 was reminded to wear a smoking apron when out smoking, Resident #5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff and resident interview, the facility failed to ensure residents received high protein nutritional supplementation per dietary's recommendations. This affected one (#16) of three residents reviewed for nutrition. The facility census was 61. Findings include: Review of the medical record for Resident #16 revealed an admission date of 08/03/19 with diagnoses of type II diabetes mellitus, morbid obesity, and irritable bowel syndrome. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had intact cognition. Review of the current and discontinued orders dated 07/01/24 through 07/24/24 revealed no current or discontinued order for a high-protein nutrition supplement. Review of a nursing progress note dated 07/12/24 revealed Resident #16 received new orders to start a 1,200 kilocalorie (kcal) partial liquid diet. Review of a dietary progress note written by Dietary Manager (DM) #237, dated 07/15/24, revealed DM #237 clarified 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 record review, staff interview, and review of the facility policy, the facility failed to ensure the resident's nutritional and hydration needs were assessed and monitored after beginning on dialysis and collaborated with the hemodialysis center. This affected one (#10) of three residents reviewed for nutrition. The facility census was 61. Findings include: Review of the medical record for Resident #10 revealed an admission date of 11/08/17 with a diagnosis of kidney failure (05/27/24). Review of the Brief Interview for Mental Status (BIMS) dated 05/31/24 revealed Resident #10 had moderately impaired cognition. Review of a nutrition progress note dated 05/23/24 revealed Resident #10 was hospitalized to establish dialysis. Review of a nutrition progress note dated 05/29/24 revealed Resident #10 was readmitted to the facility. RD #290 recommended a no concentrated sweets (NCS), no added salt diet (NAS) and thickened liquids to continue. RD #290 did not indicate in his note whether Resident #10 should continue to receive double protein portions. No additional assessment 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 resident interview, record review and staff interview, the facility failed to timely provide a cancer medication to a resident who had a history of cancer. This affected one (#58) of six residents reviewed for medications. The facility census was 61. Findings include: Review of the medical record for Resident #58 revealed a readmission date of 07/11/24 with diagnoses of type II diabetes mellitus and obesity. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 had intact cognition. Review of the hospital paperwork dated 07/07/24, provided to the facility during Resident #58's referral for readmission, revealed Resident #58 had a past medical history of prostate cancer. Review of the fax transmission form dated 07/12/24 revealed a nurse identified as N. Nurse documented Resident #58 had a cancer medication at bedside and requested an order for the medication from the physician. Further review revealed the facility's Nurse Practitioner addressed the request 10 days later 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, resident and staff interview, and policy review, the facility failed to timely arrange dental services for a resident. This affected one (#56) of three residents reviewed for dental services. The facility census was 61. Findings include Review of the medical record revealed Resident #56 had an admission date of 04/15/24. Diagnoses included morbid obesity with alveolar hypoventilation, atrial fibrillation, and chronic respiratory failure with hypoxia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had intact cognition. Review of the care plan initiated 04/27/23 revealed Resident #56 had dental problems related to poor oral hygiene. Interventions included to coordinate arrangements for dental care, transportation as needed/as ordered and provide mouth care as per the activities of daily living personal hygiene. Review of a dental note dated 06/28/24 revealed the resident needed extraction of two teeth and would need an oral…

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 facility policy, observation, record review, and staff interview, the facility failed to ensure residents received diets as ordered and failed to provide diets as recommended by the registered dietitian. This affected three (#10, #17, and #26) of six residents reviewed for food. The facility census was 61. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 11/08/17 with a diagnosis of kidney failure. Review of the Brief Interview for Mental Status (BIMS) dated 05/31/24 revealed Resident #10 had moderately impaired cognition. Review of a physician order dated 05/30/24 revealed Resident #10 received a no-added salt, no concentrated sweets diet with double protein, regular texture food with nectar thickened liquids. Observations in the kitchen on 07/23/24 beginning at 11:53 A.M. revealed [NAME] #227 plating meals. [NAME] #227 plated one scoop of spaghetti for residents who received standard portions. [NAME] #227 proceeded to plate Resident #10's…

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

Based on observation, resident and staff interviews, and record review, the facility failed to ensure residents received thickened fluids as physician ordered. This affected one (#10) of six residents reviewed for food. The facility census was 61. Findings include: Review of the medical record for Resident #10 revealed an admission date of 11/08/17 with a diagnosis of kidney failure. Review of the Brief Interview for Mental Status (BIMS) dated 05/31/24 revealed Resident #10 had moderately impaired cognition. Review of a physician order dated 05/30/24 revealed Resident #10 received a no-added salt, no concentrated sweets diet with double protein, regular texture foods and nectar thickened liquids. Observation on 07/23/24 at 8:39 A.M. revealed Resident #10 eating breakfast in his room. Resident #10 had a carton of milk with his breakfast. The milk appeared to be unthickened. Additionally, a pitcher of water was on Resident #10's tray table and the water appeared unthickened. Resident #10 provided a tray card from his garbage can dated 07/20/24 for a breakfast meal. Review of the tray…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation, medical record review, contingency medication box medication list review, staff interview, and review of a facility policy, the facility failed to ensure newly admitted residents had medications pulled from the contingency medication supply and administered the night of admission as ordered. This affected two (#11 and #67) of three residents reviewed for medications. The facility census was 63. Findings include: 1. Review of Resident #11's medical record revealed admission to the facility on [DATE] with medical diagnoses including morbid obesity, kidney failure, anxiety, and congestive heart failure (CHF). Review of Resident #11's hospital discharge medications list prior to admission included the muscle relaxant cyclobenzaprine five (5) milligrams and the pain medication Neurontin 600 mg were ordered for bedtime. Review of Resident #11's progress notes revealed the resident arrived to the facility on [DATE] at 6:45 P.M. Review of Resident #11's February 2024 medication administration record…

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 the facility policy, the facility failed to notify the physician of a significant weight change for Resident #34. This affected one (Resident #34) of three residents reviewed for notification of change. The facility census was 67. Findings include: Review of Resident #34's medical record revealed an admission date of 07/12/23. The resident was discharged from the facility on 08/22/23. Diagnoses included Alzheimer's disease, hypertension, and chronic kidney disease stage four. Review of the admission Minimum Data Set (MDS) assessment, dated 07/24/23, revealed Resident #34 was cognitively impaired. Review of Resident #34's physician orders, revealed an order for weekly weights, one time per day every four weeks on Wednesday. Review of Resident #34's plan of care dated 07/26/23, revealed the resident had altered cardiovascular status related to arrhythmia, mitral insufficiency, mitral prolapse, aortic valve stenosis, and hypertension, with a goal to remain free from signs/symptoms of complications. 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.

Based on medical record review and staff interview, the facility failed to follow physician orders to obtain weekly weights for Resident #34. This affected one (Resident #34) of three residents reviewed for weights. The facility census was 67. Findings include: Review of Resident #34's medical record revealed an admission date of 07/12/23. The resident was discharged from the facility on 08/22/23. Diagnoses included Alzheimer's disease, dementia, anemia, hypertension, and chronic kidney disease stage four. Review of the admission Minimum Data Set (MDS) assessment, dated 07/24/23, revealed Resident #34 was cognitively impaired and required extensive assistance of one staff for toileting and personal hygiene. Review of Resident #34's physician orders,dated 07/12/23, revealed an order for weekly weights, one time per day every four weeks on Wednesday. Review of Resident #34's plan of care dated 07/26/23, revealed the resident had altered cardiovascular status related to arrhythmia, mitral insufficiency, mitral prolapse, aortic valve stenosis, and hypertension, with a goal to remain…

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 facility's policy, observation and resident and staff interview, the facility failed to maintain a sanitary and homelike environment. This affected three resident rooms and six residents (#2, #9, #38, #46, #51, and #56) who resided in the those rooms. The facility census was 60. Findings include: Observation on 11/21/21 between 9:00 A.M. and 11:00 A.M. revealed three resident rooms had sticky fly traps suspended from the ceiling with dead flies noted on each trap. The sticky fly trap in Resident #2 and #38's room was located on the wall above the television on bed #1's side of the room and contained 10 dead flies. The sticky fly trap in Resident #46 and #51's room was located on the ceiling directly over Resident #51's bed and contained in excess of 50 dead flies. The sticky fly trap in Resident #9 and #56's room was located on the ceiling attached to a hook on the privacy curtain track between Resident #9 and #56's beds and contained approximately 30 dead flies. No active fly activity was observed during these observations. Observation on 11/22/21 between 8:00…

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 interview, staff interview, review of self-reported incidents (SRIs), review of a facility employee handbook, and review of a Centers for Medicare and Medicaid (CMS) memorandum, the facility failed to reasonable allow residents to have visitors of their choosing. This affected one (#4) of one resident reviewed for visitation. The facility census was 60. Findings include: Review of Resident #4's medical record revealed an admission date of 06/09/21. Diagnoses included hypertensive heart disease, morbid obesity, muscle weakness, and localized edema. Review of the most recently completed Minimum Data Set (MDS) assessment, dated 08/26/21, revealed Resident #4 had intact cognition. Interview on 11/21/21 at 11:59 A.M. with Resident #4 stated a former dietary staff member (Dietary Aide (DA) #877) recently quit working in the facility and wanted to come visit him, but the Administrator told her she was not allowed to enter the facility for visits. A telephone interview was conducted on 11/22/21 at 10:12 A.M. with Human Resources Manager (HRM) #725 who verified DA #877 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 observation, medical record review, staff interview, resident interview, review of a facility policy, and review of the Centers for Disease Control and Prevention (CDC) COVID-19 guidance, the facility failed to ensure a Resident (#57) was not involuntary secluded to their room unnecessarily. Resident #57 was the only resident in the facility identified as being on COVID-19 quarantine. The facility census was 60. Findings include: Review of Resident #57's medical record revealed an original admission date of 06/11/19 and a most recent readmission date of 11/19/21. Diagnoses included acute and chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, morbid severe obesity, and unspecified immunodeficiency. Review of the Minimum Data Set (MDS) assessment, dated 10/25/21, revealed Resident #57 had intact cognition. Review of a document titled, COVID-19 Vaccine Registration Form, revealed Resident #57 received her first dose of the COVID-19 vaccine on 06/17/21 and her second dose…

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, medical record review, and review of a facility policy, the facility failed to evaluate the need for use of a restraint and routinely re-evaluate for continued use of a restraint. This affected one (Resident #26) of one resident reviewed for restraint use. The facility identified one resident with a physical restraint. The facility census was 60. Findings include: Review of the medical record for Resident #26 revealed the resident was admitted on [DATE]. Diagnoses included dementia with behavioral disturbance, schizoaffective disorder, psychotic disorder with hallucinations, Alzheimer's disease, and abnormal posture. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/10/21, revealed Resident #26 was severely cognitively impaired. Resident #26 utilized a chair that prevented her from rising and a bed alarm. Review of the plan of care, initiated 06/29/20, revealed Resident #26 used a geri walker related to a history of falling, dementia, and inability to keep…

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 develop a comprehensive care to include the use of a restraint. This affected one (Resident #26) of 21 residents reviewed for care plans. The facility census was 60. Findings include: Review of the medical record revealed Resident #26 was admitted on [DATE] with diagnoses including dementia with behavioral disturbance, schizoaffective disorder, psychotic disorder with hallucinations, Alzheimer's disease, and abnormal posture. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/10/21, revealed Resident #26 was severely cognitively impaired. Resident #26 utilized a chair that prevented her from rising and a bed alarm. Review of the plan of care, initiated 06/29/20, revealed Resident #26 used a geri walker related to a history of falling, dementia, and inability to keep her head upright when walking. The plan of care was silent for any care planned interventions utilizing the use of a 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 observation, staff interview, and medical record review, the facility failed to ensure Resident #43's environment was free from accident hazards. This affected one (Resident #43) of four residents reviewed for accident hazards. The facility census was 60. Findings include: Review of the medical record for Resident #43 revealed an admission date of 01/08/21. Diagnoses included schizophrenia, bipolar disorder, generalized anxiety disorder, agoraphobia with panic disorder, hemiplegia and hemiparesis following cerebral infarction (stroke), and voice and resonance disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/08/21, revealed Resident #43 had a moderate degree of cognitive impairment. The assessment indicated Resident #43 felt depressed seven to 11 days during the review period but did not have thoughts he would be better off dead. Review of the care plan for Resident #43 revealed it identified the presence of behavioral symptoms that may be harmful to himself, 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 monitor and timely follow up on a resident's significant weight loss. This affected one (Resident #26) of four residents reviewed for nutrition. The facility identified four residents with unplanned significant weight gain or loss. The facility census was 60. Findings include: Review of the medical record for Resident #26 revealed the resident was admitted to the facility on [DATE]. Diagnoses including dementia with behavioral disturbance, schizoaffective disorder, psychotic disorder with hallucinations, Alzheimer's disease, and abnormal posture. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/10/21, revealed Resident #26 was severely cognitively impaired. Review of the plan of care, initiated 07/12/18, revealed Resident #26 had a nutritional problem related to dementia, dysphasia, and not wanting to eat. Interventions included to monitor weights. Review of the Mini Nutritional…

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 the facility's policy, the facility failed to ensure pharmacy recommendations were followed up with by the physician in a timely manner. This affected one (Resident #32) of five residents reviewed for unnecessary medications. The facility census was 60. Findings include: Review of Resident #32's medical record revealed an admission date of 05/07/21. Diagnoses included Alzheimer's disease, dementia, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 09/14/21, revealed Resident #32 was severely cognitively impaired. Resident #32 displayed no behaviors during the review period. Review of Resident #32's physician orders revealed an order with a start date of 05/13/21 and a discontinuation date of 09/14/21 for Lorazepam Tablet 0.5 milligrams (mg) to be given .25 mg as needed for anxiety behaviors twice daily. The as needed (PRN) exceeded the 14 day limit for a PRN anti-anxiety medication. Review of Resident #32's pharmacy reviews revealed on 06/14/21 a pharmacy review was completed and the pharmacist…

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 the facility's policy, the facility failed to ensure resident's as needed (PRN) antianxiety medications were limited to 14 days or had a rationale for extension. This affected one (Resident #32) of five residents reviewed for unnecessary medications. The facility census was 60. Findings include: Review of Resident #32's medical record revealed an admission date of 05/07/21. Diagnoses included anxiety disorder. Review of Resident #32's Minimum Data Set (MDS) assessment, dated 09/14/21, revealed Resident #32 was severely cognitively impaired. Review of Resident #32's physician orders revealed an order with a start date of 05/13/21 and a discontinuation date of 09/14/21 for Lorazepam Tablet 0.5 milligrams (mg) to be given .025 mg as needed for anxiety behaviors twice daily. The as needed (PRN) exceeded the 14 day limit for a PRN anti-anxiety medication. Review of Resident #32's Medication Administration Record (MAR) for May 2021 through November 2021 revealed Resident #32 had her PRN Lorazepam available for 124 days. 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.

Based on observation, staff interview, and medical record review, the facility failed to provide beverage consistencies in accordance with physician orders and the care plan. This affected one (Resident #43) of seven residents reviewed for hydration and/or nutrition. The facility census was 60. Findings include: Review of the medical record for Resident #43 revealed an admission date of 01/08/21. Diagnoses included hemiplegia and hemiparesis following cerebral infarction (stroke), Type II diabetes mellitus, and dysphagia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/08/21, revealed Resident #43 had a moderate degree of cognitive impairment. The assessment indicated Resident #43 required extensive assistance by one staff person for eating, and experienced coughing or choking during meals. Review of the physician orders for Resident #43 revealed an order, dated 08/24/21, for nectar-thick liquids. Review of the care plan for Resident #43 revealed it identified a swallowing problem due to dysphagia, with a goal to have reduced aspiration. The plan included an…

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 policy review, the facility failed to properly store boxes of food and failed to ensure food safety by properly storing food scoops. This had the potential to affect 72 residents identified by the facility as receiving meals from the kitchen. Findings include: Observation on 05/19/19 at 8:40 A.M. revealed food scoops were left inside four cereal bins on a rolling cart. The handle of the food scoop was in contact with the cereal in each of the four cereal containers. Interview on 05/19/19 at 8:40 A.M. with [NAME] #92 revealed the scoops were just left in the cereal containers during breakfast. Observation on 05/19/19 at 8:41 A.M. revealed a plastic cup scoop was inside a barrel of thickener in the dry good storage room. Interview on 05/19/19 at 8:41 A.M. with the Dietary Manager (DM) #90 verified there was a cup scoop inside the barrel of thickener. Observation on 05/19/19 at 8:36 A.M. revealed a box of milk was left on the floor in the outdoor walk-in cooler. Interview on 05/19/19 at 8:36 A.M. with Dietary Manager (DM) #90 verified the box…

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, review of a menu preference sheets, staff and resident interview, and policy review, the facility failed to ensure residents were provided a choice in menu selection. This affected 26 residents (#7, #10, #11, #13, #15, #17, #19, #21, #23, #24, #27, #30, #32, #35, #38, #39, #40, #41, #47, #50, #55, #58, #60, #63, #66, and #67) who were not provided a choice in menu selection on 05/10/19. The facility census was 72. Findings include: Review of the medical record revealed Resident #38 had an admission date of 11/22/17. Diagnoses included chronic respiratory failure, chronic kidney disease, chronic obstructive pulmonary disease, lymphedema, depressive disorder, diabetes mellitus type two, hypertension, persistent mood disorder, anxiety disorder, and morbid obesity. Review of the Minimum Data Set (MDS) annual assessment, dated 04/13/19, revealed Resident #38 had intact cognition. The resident required setup help and supervision for eating meals. Review of a nurse's progress note dated 05/10/19 at 11:35 P.M. revealed Resident #38 was upset with supper 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, resident and staff interview, medical record review and review of facility policy, the facility failed to ensure residents who had skin protectant geriatric sleeves were treated in a dignified manner. This affected two (#57 and #59) of five reviewed for dignity. The facility identified 69 residents who received preventative skin care. In addition, the facility failed to allow a resident to finish a meal when a staff member removed a food tray from a resident room before the resident was finished eating. This affected one (#50) of 14 residents observed eating breakfast in their room on the South Hall. The census was 72. Findings include: 1. Review of Resident #57's medical record for Resident #57 revealed an admission date of 05/10/18. Diagnoses included spinal stenosis, insomnia, anxiety disorder, dementia, atrial fibrillation, hypomagnesaemia, pain, aortic insufficiency, hypothyroidism, hyperlipidemia, heart failure, and heart disease. Review of the Minimum Data Set (MDS) assessment, dated 03/08/19, revealed Resident #57 was severely cognitively impaired.…

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 an admission packet, the facility failed to issue a notice of the facility's bed hold policy upon transfer to the hospital for one (#10) of one residents reviewed for hospitalization. The facility identified 21 residents identified by the facility who were transferred to the facility in the last 90 days. The census was 72. Findings include: Review of Resident #10's medical record revealed an admission date of 01/14/19. Diagnoses included urinary tract infection, extended spectrum beta lactamase (EBSL) resistance, difficulty walking, major depression, diabetes mellitus type II, and morbid severe obesity. Review of discharge return anticipated Minimum Date Set (MDS) assessments completed on 03/01/19 and 05/14/19 revealed Resident #10 had unplanned discharges to an acute hospital. A quarterly MDS assessment was completed on 04/19/19 and revealed Resident #10 was cognitively intact. Review of a nursing progress note and resident transfer form dated 03/01/19 revealed Resident #10 was transferred to the hospital due to an…

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 review of the facility policy, the facility failed to ensure smoking care plan supports were in place for cognitively impaired residents who smoked. This affected one (#269) of two residents reviewed for smoking. The facility identified seven residents who smoked. The facility census was 72. Finding include: Review of Resident #269 medical record revealed an admission date 05/01/19. Diagnoses included symbolic dysfunctions, atrial fibrillation, osteoarthritis, schizophrenia, heart disease, type II diabetes, hypertension, dementia, atrial flutter, heart failure, and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 05/08/19, revealed Resident #269 was severely cognitively impaired. Review of Resident #269's care plan, revised 05/14/19, revealed the care plan was silent to supports and interventions for smoking. Review of Resident #269's Smoking assessment dated [DATE] revealed Resident #269 smoked. The assessment indicated…

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, medical record review, and review of facility policies, the facility failed to position a resident in a manner to allow reasonable access to food items during a meal. This affected one (#50) of 14 residents observed eating breakfast in their room on the South Hall. The census was 72. Findings include: Review of Resident #50's medical record revealed an admission date of 08/24/09. Diagnoses included retention of urine, cerebral infarction, cellulitis, hemiplegia, Alzheimer's disease, major depression, and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 03/27/19, revealed Resident #50 was cognitively intact, required extensive one person physical assistance for eating, and extensive two person plus assistance of staff for bed mobility. Review of an activities of daily living (ADL) care plan revealed Resident #50 needed staff assistance with ADLs related to weakness, impaired mobility, and obesity. The care plan included interventions for Resident #50 to participate in care to the greatest extent possible then staff 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.

Based on observation, medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to follow their smoking policy to keep smoking materials secured for two (#62 and #13) of three residents reviewed for smoking. The facility census was 72. Findings include: 1. Review of Resident #62's medical record revealed an admission date of 11/08/17. Diagnoses included altered mental status, dysphagia, malignant neoplasm of lung, ataxia, protein calorie malnutrition, nicotine dependence, dementia, hypotension, and alcohol abuse. Review of the Minimum Data Set (MDS) assessment, dated 02/19/19, revealed Resident #62 was cognitive intact. Review of Resident #62's care plan revised 05/20/19 revealed supports and interventions for potential for ineffective breathing patterns related to smoking, activities. Observation on 05/20/19 at 9:10 A.M. found Resident #62 was in the smoking area and had a pack of Kool brand cigarettes and a lighter in the front pocket of his shirt. Resident #62 was observed lighting his own cigarette and placing 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, medical record review, review of a nurse aide communication book, and review of facility policies, the facility failed to ensure residents who were incontinent of bowel and urine were provided timely incontinence care for one (#270) of one resident reviewed for bladder and bowel incontinence. The facility identified 53 residents who were assessed as incontinent of bowel and bladder. Additionally, the facility failed to ensure an anchoring device was in place to attempt to secure the tubing of an indwelling urinary catheter for one (#6) of one resident reviewed for urinary catheters. The facility had seven residents with indwelling urinary catheters. The census was 72. Findings include: 1. Review of Resident #270's medical record revealed an original admission date of 06/21/18, and a re-admission date of 05/10/19. Diagnoses included sepsis with unspecified organism, anxiety, morbid severe obesity, major depression, cellulitis of the left lower limb, and congestive heart failure. Review of an annual Minimum Data Set (MDS) assessment,…

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.