Hamilton Respiratory and Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, review of facility-initiated discharge notices, review of the discharge appeal hearing decision, staff interview, guardian interview and Hospital Social Worker (HSW) interview, the facility failed to ensure a resident was readmitted to the facility upon discharge from the hospital. This affected one resident (#8601) of three residents reviewed for discharge. The facility census was 61. Findings include: Review of Resident #8601's medical record revealed an admission date of 09/15/15. Diagnoses included Huntington's disease, Alzheimer's disease with early onset, severe protein-calorie malnutrition and repeated falls. Further review revealed Resident #8601 was transferred to the hospital and discharged on 08/28/24. Review of physician orders from orders from 08/01/24 to 09/19/24 revealed no discharge order for Resident #8601. Further review revealed a physician order, dated 08/28/24, to send Resident #8601 to the Emergency Department (ED) for further psychological evaluation,…

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 notify the physician as ordered. This affected one (#28) resident of three reviewed for change in condition. The facility census was 73. Findings include: Medical record review for Resident #28 revealed an admission date of 10/29/23. Diagnoses included Alzheimer's disease, dementia with anxiety, chronic obstructive pulmonary disease, severe protein calorie malnutrition, heart failure, and depression. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] for Resident #28 revealed the resident was assessed with an intact cognition. Resident #28 required supervision for bed mobility, transfers, toileting and eating. Resident #28 weight was documented as 186 pounds. Review of the plan of care for Resident #28 dated 11/03/23 revealed the resident was at risk for malnutrition and dehydration related to chronic disease, advanced age, and potential for weight and intake decline related to disease progression.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to follow physicians orders for obtaining weights. This affected one (#28) resident of three reviewed for weight monitoring. The facility census was 73. Findings include: Medical record review for Resident #28 revealed an admission date of 10/29/23. Diagnoses included Alzheimer's disease, dementia with anxiety, chronic obstructive pulmonary disease, severe protein calorie malnutrition, heart failure, and depression. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] for Resident #28 revealed the resident was assessed with an intact cognition. Resident #28 required supervision for bed mobility, transfers, toileting and eating. Resident #28 weight was documented as 186 pounds. Review of the plan of care for Resident #28 dated 11/03/23 revealed the resident was at risk for malnutrition and dehydration related to chronic disease, advanced age, and potential for weight and intake decline related to disease progression.…

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 and resident interview and policy review, the facility failed to ensure substitutions were available for each resident who would like a different choice of foods during meal service. This had the potential to affect all residents who receive meals from the kitchen. The facility census was 70. Findings include: Interview on 05/07/23 at 2:44 P.M., Resident #02 said they were not provided menus or substitutions for the meals served. Interview on 05/08/23 at 9:02 A.M., Resident #10 said they were not provided menus or substitutions for the meals served. Interview on 05/09/23 at 8:01 A.M., Resident #20 said they were not provided menus or substitutions for the meals served. Interview on 05/10/23 at 9:50 A.M., Resident #28 said they were not provided menus or substitutions for the meals served. Interview on 05/08/23 at 1:39 P.M., and on 05/09/23 at 11:02 A.M., with dietary staff #39 and #67 stated the menus were not offered to residents and substitutions were not offered unless brought up by the residents' and the substitutions were not always available due to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff and resident interview and policy review the facility failed to ensure residents had access to menus and substitutions were available. This affected eight residents (#02, #10, #20, #28, 26, #36, #59 and #69) out of eight residents reviewed for menus and substitutions. The facility also failed to ensure double portions were served for one resident (#59) of one resident reviewed for double portions for meals. The facility census was 70. 1. Medical record review for Resident #26 revealed an admission date of 05/14/14. Medical diagnoses included traumatic brain dysfunction, peripheral vascular disease, renal insufficiency, and dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was cognitively intact. He was independent for bed mobility, transfers, toilet use and eating. Interview and observation with Resident #26 on 05/07/23 at 3:39 P.M. revealed he didn't receive a menu and wasn't able to get a substitution if he didn't like…

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, medical record review, review of an invoice and policy review, the facility failed to ensure residents were treated with dignity and respect. This affected two residents (#05 and #59) of 24 residents sampled for dignified care. The facility census was 70. Findings Include: 1. Review of the medical record for the Resident #05 revealed an admission date of 08/22/22. Diagnoses included acute osteomyelitis. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #05 had intact cognition, had no behaviors, did not reject care, and did not wander. Resident #05 required supervision assistance for activities of daily living (ADL) care. Review of an invoice dated 05/03/23 revealed [NAME] Plumbing and Sewer provided plumbing services to the facility for concerns with water pressure. During an interview on 05/07/23 at 10:54 A.M., Resident #05 stated last week, unsure of exact date, a plumber walked into her room without her permission to look at something…

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 and resident interview, observation, and record review, the facility failed to ensure resident rooms were equipped to maintain complete privacy. This affected one resident (#05) of 24 residents screened for privacy. The facility census was 70. Findings include: Review of the medical record for the Resident #05 revealed an admission date of 08/22/22. Diagnoses included acute osteomyelitis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #05 had intact cognition, had no behaviors, did not reject care, and did not wander. Resident #05 required supervision assistance for activities of daily living. During an interview on 05/07/2023 at 10:57 A.M. Resident #05 stated her room di not allow her to maintain privacy because her privacy curtain was broken and did not provide privacy all the way around her living area. During an observation and interview on 05/10/2023 at 9:42 A.M. Housekeeper #85 verified the privacy curtain in Resident #05's room was missing a panel and could…

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 and resident interview, observation, review of the activity calender, and policy review, the facility failed to ensure activities of resident interests were provided on the weekends. This affected two residents (#26 and #36) of four residents reviewed for activities. The census was 70. Findings included: 1. Medical record review for Resident #26 revealed an admission date of 05/14/14. Diagnoses included traumatic brain dysfunction, peripheral vascular disease, renal insufficiency, and dementia. Review of the activity evaluation dated 01/04/23 for Resident #26 revealed it was very important to keep up with the news, go outside for fresh air, and have books and magazines. The assessment documented it was somewhat important to listen to music, to do his favorite activities, and do activities with groups of people. Review of the activity progress notes from 02/08/23 to 05/07/23 revealed there wasn't any refusals for activities. Review of activity documentation from 04/08/23 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and resident and staff interview, the facility failed to ensure residents received timely medical treatment. This affected one resident (#15) of two residents reviewed for bowel and bladder. The facility census was 70. Findings included: Medical record review for Resident #15 revealed an admission date of 06/14/22. Diagnoses included coronary artery disease, heart failure, hypertension, diabetes and renal insufficiency. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #15 was cognitively intact. She was independent for bed mobility, transfers, eating and toilet use. She was always continent of bowel and bladder. Review of the physician orders dated 02/13//23 revealed to give Imodium two milligram (mg) one tablet every six hours as needed for diarrhea. Review of the Medication Administration Record (MAR) for Imodium, revealed from 05/01/23 through 05/08/23 the resident had not been given Imodium for diarrhea. Interview with Resident #15 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to ensure residents had clean pressure ulcer reducing devices to promote healing and prevent infection. This affected one resident (#03) of four residents reviewed for pressure ulcers. The facility census was 70. Findings included: Medical record review for Resident #03 revealed an admission date of 03/13/12. Diagnoses included non-traumatic brain dysfunction, dementia, neurogenic bladder, and obstructive uropathy. Review of the care plan dated 02/09/23 for Resident #03 revealed to float heels off the bed as tolerated. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #03 had moderately impaired cognition, the resident required extensive assistance for bed mobility, total dependence for bed transfers, eating and toilet use. Observation during a dressing change to the right heel of Resident #03 on 05/08/23 at 1:13 P.M. revealed his heel boots were interchangeable with the right and left foot. When 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, and policy review, the facility failed to ensure resident oxygen tubing and nebulizers were labeled and changed timely. This affected one resident (#13) of two residents sampled for respiratory care. The facility census was 70. Findings include: Review of the medical record for the Resident #13 revealed an admission date of 05/24/22. Diagnoses included chronic diastolic heart failure, emphysema, and chronic obstructive pulmonary disease (COPD). Review of the care plan dated 06/07/2022 revealed Resident #13 had a potential for difficulty breathing and risk for respiratory complications related to diagnoses of Emphysema/COPD. Interventions included observe/report symptoms of difficulty breathing or respiratory infection and administer medications/treatments as ordered. Review of the medical record revealed Resident #13 had physician orders for Ipatropium-albuterol 0.5-2.5 mg solution (3 mg/ml) one vial inhaled orally every four hours, oxygen continuous at three liters per minute per nasal cannula to maintain…

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, observation, record review, and policy review, the facility failed to ensure residents with a dialysis access site were monitored. This affected two residents (#23 and #66) of two residents reviewed for dialysis care. The facility census was 70. Findings include: 1. Review of the medical record for the Resident #23 revealed an admission date of 04/02/22. Diagnoses included type II diabetes, hypertensive heart disease, and stage V chronic kidney disease. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact, had no behaviors, did not reject care, and did not wander. Review of the care plan dated 04/03/22 revealed Resident #23 was at risk for complications related to dialysis and end stage renal disease. Interventions included upon return from the dialysis center observe the resident's access site, obtain vital signs, and document findings in the medical record. Report abnormal findings to the physician. 2. Review of the medical…

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, interview, record review, and policy review, the facility failed to ensure medications were administered to residents as ordered. This affected two residents (#35 and #42) of four residents sampled for medication administration. The facility census was 70. Findings include: 1. Review of the medical record for Resident #35 revealed an admission date of 05/27/22. Diagnoses included dementia, schizoaffective disorder bipolar type, and Parkinson's disease. Review of the physician orders revealed Resident #35 for routine medications scheduled for administration at 8:00 A.M. included Ativan (antianxiety medication) 0.5 milligrams (mg) by mouth twice daily, benztropine (anticholinergic medication) one mg by mouth twice daily, divalproex (anticonvulsant medication) sodium 500 mg delayed release by mouth twice daily, haloperidol (antipsychotic medication) five mg by mouth once daily, and hydroxyzine (antihistamine) 50 mg by mouth twice daily. 2. Review of the medical record for Resident #42 revealed an admission date of 09/01/22. Diagnoses included dementia and type II…

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, interview, record review, and policy review, the facility failed to ensure medications were stored properly. This affected two residents (#35 and #42) of four residents sampled for medication administration. The facility census was 70. Findings include: 1. Review of the medical record for Resident #35 revealed an admission date of 05/27/22. Diagnoses included dementia, schizoaffective disorder bipolar type, and Parkinson's disease. Review of the physician orders revealed Resident #35 for routine medications scheduled for administration at 8:00 A.M. included Ativan (antianxiety medication) 0.5 milligrams (mg) by mouth twice daily, benztropine (anticholinergic medication) one mg by mouth twice daily, divalproex (anticonvulsant medication) sodium 500 mg delayed release by mouth twice daily, haloperidol (antipsychotic medication) five mg by mouth once daily, and hydroxyzine (antihistamine) 50 mg by mouth twice daily. 2. Review of the medical record for Resident #42 revealed an admission date of 09/01/22. Diagnoses included dementia and type II diabetes. Review 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.

Based on observation, staff interview, review of manufacturer's instructions and review of facility policy, the facility failed to properly store resident medications and discard expired medications. This had the potential to affect all 24 of the resident residing on the 100 Hall with the exception of Resident #26 whom the facility identified as having a contraindication to receiving a tuberculin testing solution injection, eleven facility identified residents residing on the 100 hall with orders for Melatonin, (Residents #21, #26, #31, #49, #53, #57, #62, #72, #173, #174, #175), seven facility-identified residents residing on the 100 hall who are diabetic (Residents #6, #11, #37, #52, #53, #72, #173), and two facility-identified residents residing on the 100 hall with orders for Phenergan (Residents #52, #175). The census was 75. Findings include: Observation of 100 Hall medication cart on 11/25/19 at 1:29 P.M. with Registered Nurse (RN) #24 revealed the cart contained a house stock bottle of Melatonin with a manufacturer's expiration date of 10/2019. Observation of the 100 Hall…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure that resident's advanced directives specifically regarding the residents elected code status was consistent and matched in the medical record. This affected three (#5, #7, #66) of 18 residents sampled. The census was 75. Findings include: 1. Review of record revealed Resident #5 was admitted on [DATE] with a diagnosis of Alzheimer's disease. Review of physician orders for November 2019 Resident #5 revealed resident had chosen full code as her code status. Review of [NAME] for Resident #5 revealed it was blank in the section for resident code status. 2. Review of record revealed Resident #7 was admitted [DATE] with diagnoses which included low back pain and other chronic pain. Review of physician orders for November 2019 Resident #7 revealed resident had a current do not resuscitate (DNR) order in place. Review of [NAME] for Resident #7 revealed resident was noted to be full code status. 3. Review of record for Resident #66 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to notify the attending physician of elevated resident blood sugars. This affected one (#27) of six residents reviewed for medications. The census was 75. Findings include: Review of record for Resident #27 revealed as admission date of 05/01/17 with a diagnosis of diabetes. Review of Minimum Data Set (MDS) dated [DATE] for Resident #27 revealed resident had mild cognitive impairment and required supervision with activities of daily living. Review of November 2019 physician orders for Resident #27 revealed an order for insulin be administered per a sliding scale and that if blood sugar was above 450 to administer 12 units of insulin and then to recheck the blood sugar in one hour and notify the physician. Review of the Medication Administration Record (MAR) for November 2019 for Resident #27 revealed the resident's blood sugar (BS) was over 450 on the following dates/times: 11/01/19 at 3:30 P.M.- BS was 492, 11/11/19 at 630 A.M.-BS was 552,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff and resident interview, and review of facility policy, the facility failed to provide a comfortable and homelike dining experience for residents residing on the female secured unit. This affected two (#58 and #71) of five residents observed for dining on the unit. The census was 75. Findings include: Review of record for Resident #58 revealed resident was admitted on [DATE] with a diagnosis of dementia without behavioral disturbance. Review of Minimum Data Set (MDS) for Resident #58 dated 10/03/19 revealed resident was cognitively impaired and required supervision with eating. Review of record for Resident #71 revealed resident was admitted on [DATE] with a diagnosis of unspecified dementia without behavioral disturbance. Review of MDS for Resident #71 dated 11/07/19 revealed resident was cognitively impaired and required limited assistance of one staff with eating. Review of care plans for Resident #58 and Resident #71 revealed neither resident was care planned…

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 facility self-reported incidents (SRI's), resident and staff interview, and review of facility policy, the facility failed to report an allegation of possible resident to resident physical abuse to the state agency. This affected one (#5) of three residents reviewed for abuse concerns. The census was 75. Findings include: Review of record revealed Resident #5 was admitted on [DATE] with a diagnosis of Alzheimer's disease. Review of Minimum Data Set (MDS) dated [DATE] for Resident #5 revealed resident was cognitively intact and required limited assistance with activities of daily living. Review of record for Resident #73 revealed resident had a diagnosis of dementia with behavioral disturbance and was discharged from the facility on 10/08/19. Review of nurse progress note dated 10/02/19 for Resident #73 revealed the resident swatted Resident #5 on her bottom and that Resident #5 was very upset and stated the other resident's action had startled her. Review of nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interview and review of the Resident Assessment Instrument (RAI) manual, the facility failed to accurately assess resident dental status. This affected one (#66) of three residents reviewed for dental concerns. The census was 75. Findings include: Review of record for Resident #66 revealed an admission date of 04/11/14 with a diagnosis of schizophrenia. Review of the quarterly Minimum Data Set (MDS) for Resident #66 dated 10/01/19 revealed the resident was cognitively intact and required extensive assistance with activities of daily living. Review of the comprehensive MDS for Resident #66 dated 10/30/19 section V, care area assessment worksheet for dental care revealed the resident had no natural teeth and was at risk for chewing issues and mouth pain related to denture use, that resident needs assistance with denture care, and that a care plan would be developed to avoid complications and minimize risks related to denture use. Review of care plan for Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and resident and staff interview, the facility failed to update resident care plans regarding dental status. This affected one (#66) of three residents reviewed for dental concerns. The census was 75. Findings include: Review of record for Resident #66 revealed an admission date of 04/11/14 with a diagnosis of schizophrenia. Review of the quarterly Minimum Data Set (MDS) for Resident #66 dated 10/01/19 revealed the resident was cognitively intact and required extensive assistance with activities of daily living. Review of the comprehensive MDS for Resident #66 dated 10/30/19 section V, care area assessment worksheet for dental care revealed the resident had no natural teeth and was at risk for chewing issues and mouth pain related to denture use, that resident needs assistance with denture care, and that a care plan would be developed to avoid complications and minimize risks related to denture use. Review of care plan for Resident #66 dated 11/12/19 revealed resident had a self…

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, and staff and family interviews, the facility failed to ensure staff implemented a wheelchair cushion used as a positioning device and a finger splint ordered to treat a fractured finger. This affected one (#223) of one residents reviewed for position/mobility during the annual survey. The facility census was 75. Findings include: Review of the medical record revealed Resident #223 was admitted to the facility on [DATE] with diagnoses including heart failure, dementia with behavioral disturbance, wandering, rheumatoid arthritis, major depressive disorder, anxiety disorder, and atrophy. Review of the five-day admission Minimum Data Set (MDS) dated [DATE] revealed Resident #223 severely cognitively impaired with delirium inattention and disorganized thinking behaviors noted continuously. Review of Section G- Functional Status revealed the resident required extensive two-person assistance with bed mobility, toileting, personal hygiene, supervision with two-person…

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, observations, resident and staff interview, and review of the facility policy, the facility failed to ensure fall prevention measures were in place in accordance with the resident's care plan. This affected one (#7) of three residents reviewed for accidents. The census was 75. Findings include: Review of record revealed Resident #7 was admitted [DATE] with diagnoses which included low back pain and other chronic pain. Review of Minimum Data Set (MDS) for Resident #7 dated 11/17/19 revealed resident had cognitive impairment and required limited assistance with activities of daily living. Review of fall risk assessment for Resident #7 dated 09/18/19 revealed resident was at risk for falls. Review of care plan for Resident #7 dated 09/18/19 revealed resident was at risk for falls or fall related injury related to impaired mobility, muscle weakness, and impaired cognition. Interventions included the following: assess the risk level for falls on admission and as needed, encourage…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and resident and staff interview, and review of facility policy the facility failed to assess and manage resident pain. This affected one (#7) of 18 residents sampled. The census was 75. Findings include: Review of record revealed Resident #7 was admitted [DATE] with diagnoses which included low back pain and other chronic pain. Review of Minimum Data Set (MDS) for Resident #7 dated 11/17/19 revealed resident had cognitive impairment, required limited assistance with activities of daily living, and was coded as negative for receiving pain medications, negative as receiving non-pharmacological interventions for pain, and rated her pain during the assessment window as a seven on a scale of zero to 10 with 10 being the worst pain. Review of November 2019 physician orders for Resident #7 revealed no orders for pain medication. Review of care plan for Resident #7 dated 11/19/19 revealed resident was at risk for pain related to decreased mobility, diagnoses of chronic pain and generalized pain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to adequately monitor resident blood sugar per the physician's order related to insulin administration. This affected one (#27) of six residents reviewed for medications. The census was 75. Findings include: Review of record for Resident #27 revealed as admission date of 05/01/17 with a diagnosis of diabetes. Review of Minimum Data Set (MDS) dated [DATE] for Resident #27 revealed resident had mild cognitive impairment and required supervision with activities of daily living. Review of November 2019 physician orders for Resident #27 revealed an order for insulin be administered per a sliding scale and that if blood sugar was above 450 to administer 12 units of insulin and then to recheck the blood sugar in one hour and notify the physician. Review of the Medication Administration Record (MAR) for November 2019 for Resident #27 revealed the resident's blood sugar (BS) was over 450 on the following dates/times: 11/01/19 at 3:30 P.M.- BS was…

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.