The Laurels Of Heath

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to provide assistance with personal hygiene for a resident who was dependent for care. This deficient practice affected one (#63) of eight residents reviewed for activities of daily living. The census was 112.Findings Include:Review of the medical record for Resident #63 revealed an admission date of 07/11/23 with diagnoses including but not limited to heart disease, depression, seizures, and intellectual disabilities. Review of Resident #63 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of seven out possible 15, and required moderate to dependent assistance from staff to complete activities of daily living (ADLs) tasks including personal hygiene and shaving of facial hair.Review of Resident #63's functional ability deficit care plan dated 06/06/24 revealed assistance from staff was required to complete 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 observation, medical record review, review of census information, resident interview, and staff interview, the facility failed to provide meaningful activities per resident preference. This affected one (#86) of four residents reviewed for activities. The census was 112.Findings include:Review of Resident #86's medical record revealed an admission date of 02/23/10 with diagnosis including Parkinson's disease with dyskinesia, bipolar disorder, obsessive-compulsive disorder, unspecified psychosis not due to a substance or known physiological condition, suicidal ideations, schizophrenia, and visual and auditory hallucinations. Review of Resident #86 annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident with intact cognition.Review of an activity plan of care created 02/25/20, and revised 09/09/23, revealed Resident #86 preferred to engage in activities independently. He preferred to stay in his room and sleep. He wears a headset to keep out noise, and will walk in the halls in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and facility policy review, the facility failed to implement splint/brace program for a resident with bilateral hand contractures. This deficient practice affected one (#47) of two residents reviewed for positioning and mobility. The facility census was 112.Findings Include:Review of the medical record for Resident #47 revealed an initial admission date 02/08/23 and a re-admission date 03/14/23. Diagnoses included but were not limited to bipolar disorder, anxiety, depression, suicidal behavior, and contractures.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of two out of possible 15. Resident #47 was dependent on staff for care, bathing, and transfers. Resident #47 was able to feed self, but preferred staff to assist with eating.Review of Resident #47's nutritional care plan dated 02/09/23 revealed Resident #47 was at risk for…

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

Based on record review, review of fall investigations, staff interview, and facility policy review, the facility failed to implement appropriate interventions and properly address repeated non-compliance with interventions to prevent resident falls. This deficient practice affected one (#14) of four residents reviewed for falls and accidents. The facility census was 112.Findings Include:Review of the medical record for the Resident #14 revealed an admission date of 06/12/06. Diagnoses included dementia, diabetes, anxiety disorder, and glaucoma.Review of Resident #14's quarterly Minimum Data Set (MDS) assessment, dated 07/17/25, revealed the resident had impaired cognition. Review of the plan of care dated 07/31/25 revealed Resident #14 was at risk for fall related injury and falls due to a history of falls and his requirements for assistance with activities of daily living (ADLs). Interventions included to keep the resident's call light within reach so he can call for assistance with transferring and to wear non-skid footwear when he was not in bed. Review of the plan of care dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, and facility policy review, the facility failed to properly assess a resident prior to making a diet order change, and failed to properly, accurately, and timely obtain resident weights and notify the physician of weight changes as ordered. This affected three (#49, #2, and #9) of eight residents reviewed for nutrition. The census was 112. Findings Include:1. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. His diagnoses included amyotrophic lateral sclerosis (ALS), congestive heart failure, hypertensive heart failure, type II diabetes, hyperlipidemia, dysphagia, ischemic cardiomyopathy, atherosclerotic heart disease, old myocardial infarction, nicotine dependence, and non-compliance with other medical treatment and regimen. Review of Resident #49's Minimum Data Set (MDS) assessment, dated 07/02/25, revealed he was cognitively intact. Review of Resident #49's After Visit Summary Hospital form, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, and staff interview, the facility failed to provide/offer timely dental services to residents as needed. This affected two (#49 and #6) of four residents reviewed for dental services. The census was 112. Findings Include:1. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. His diagnoses included amyotrophic lateral sclerosis (ALS), congestive heart failure, hypertensive heart failure, type II diabetes, hyperlipidemia, dysphagia, ischemic cardiomyopathy, atherosclerotic heart disease, old myocardial infarction, nicotine dependence, and non-compliance with other medical treatment and regimen. Review of Resident #49's Minimum Data Set (MDS) assessment, dated 07/02/25, revealed he was cognitively intact.Review of Resident #49's dental progress notes, dated 01/19/24, confirmed Resident #24 was edentulous from a medical procedure that occurred earlier in the month at the hospital. The note also revealed they would complete…

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 implement restorative programs following completion of therapy services as recommended. This affected one (#11) of two residents reviewed for therapy services. The facility census was 112. Findings Include:Review of Resident #11's medical record revealed an initial admission date of 08/19/24 with a re-admission date 05/24/25. Diagnoses including but were not limited to orthopedic care, fracture of the left femur, high blood pressure, spinal stenosis, and dementia.Review of Resident #11's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of nine out of a possible 15, and was independent with ambulation, transfers, and personal hygiene. Resident #11 had a history of falls.Review of Resident #11's progress notes dated 05/19/25 at 8:16 A.M. revealed Resident #11 reported to the day shift nurse during morning medication administration that…

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, review of pest control records, and facility policy review, the facility failed to maintain an effective pest control program. This deficient practice affected three (#3, #52, and #93) of 112 residents observed for environment and pest control. The facility census was 112.Findings Include:An observation on 09/08/25 at 10:15 A.M. revealed Resident #105 sitting at edge of the bed looking out the window. There were multiple house flies noted on the windowsill and bed covers.An observation on 09/08/25 at 11:25 A.M. revealed Resident #52 sitting in a wheelchair in her room awaiting lunch meal service. There were several house flies observed in the room. Resident #52 would occasionally swat at one house fly as it flew around her face.An observation on 09/08/25 at 2:21 P.M. revealed Resident #3 resting in bed with the bed covers pulled up to his chest area. There were multiple house flies on the bed covers and windowsill.An observation on 09/09/25 at 11:00 A.M. revealed Resident #3 sitting up in bed with the bed covers pulled up to cover…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview, the facility failed to maintain toilet rails, thresholds, walls, floors and dressers. This affected six (Resident's #2, #3, #4, #5 #8, and #9) of 117 residents in the facility.Findings include:Observations 07/09/25 between 9:33 A.M. and 10:27 A.M. revealed:- Resident #3's bathroom toilet had handrails attached to the bolts that held the toilet seat on the toilet. The rails moved when touched. The right railed moved approximately six inches and the left rail four inches. The toilet water was a milky pink color. The bathroom had an incontinence odor. The door frames entering the room and bathroom were scraped heavily with the paint off. The sink bowl was dirty a rusty color. There were seven broken tiles on the bathroom walls.- The community shower room between three and four the handrails attached to the toilet moved two to four inches when touched. There was molding off the wall between on the right exiting the shower. The linoleum type tile blocks at the threshold of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, record review and interview, the facility failed to ensure call bells were within reach. This affected three (Resident's #1, #3 and #4) of six residents observed. The census was 117.Findings include:1. Review of Resident #3's medical record revealed an admission date of 08/22/22 with diagnoses including Alzheimer's disease, dementia, chronic obstructive pulmonary disease, dysphasia, and osteoarthritis.Review of Resident #3's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had severely impaired cognition. He was independent of eating and required supervision or touching assistance for toilet transfers.Observation 07/09/25 at 10:10 A.M. of Resident #3 revealed the resident was in bed without a call bell/light near him. The call bell was plugged in the wall side of bed one and hanging on the floor. The resident was in bed two. There was not a call bell plugged into the wall on the bed two side. There was not a call bell in sight in the room for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of job description the facility failed to ensure the social worker assisted the resident to address his preferences of transferring to a different facility. This affected one resident (#2) of one residents reviewed for transfers. The facility census was 117.Findings include:Review of Resident #2's medical record revealed an admission date of 02/15/23 and diagnoses including paraplegia, unspecified protein-calorie malnutrition, generalized anxiety, and chronic respiratory failure.Review of Resident #2's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #2's care conference note dated 08/15/24 revealed the resident wanted to transfer to a facility in Cleveland or [NAME]. The resident's mother was to research the facilities and report to the social worker.Review of Resident #2's care conference note dated 11/13/24 revealed the resident wanted to go to a facility in [NAME]. The social worker was to search…

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 interview, the facility failed to ensure residents were provided drinking water. This affected three (Resident's #1, #3 and #4) of five residents observed for water availability. The census was 117.Findings include: 1. Review of Resident #3's medical record revealed an admission date of 08/22/22 with diagnoses including Alzheimer's disease, dementia, chronic obstructive pulmonary disease, dysphasia, and osteoarthritis.Review of Resident #3's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had severely impaired cognition. He was independent of eating and required supervision or touching assistance for toilet transfers.Observation 07/09/25 at 10:10 A.M. of Resident #3 revealed the resident was in bed without water or beverages on his overbed table or available in the room.Interview 07/09/25 at 10:10 A.M. with Licensed Practical Nurse (LPN) #15 verified the resident did not have water in reach. LPN #15 asked him if he wanted water and he said yes,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview, observation medical record review, review of facility policy, and review of facility investigation, the facility failed to ensure Resident #127 did not elope from the facility for an extended period of time. This affected one resident (#127) of three residents reviewed for elopement. The facility census was 122. Findings include: Review of Resident #127's medical record revealed an admission date of 07/06/25 with diagnoses including chronic obstructive pulmonary disease, cachexia, panic disorder, depression, dementia, and mild cognitive impairment. Review of Resident #127's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. Review of Resident #127's plan of care initiated 06/11/24 revealed the resident was at risk for exit seeking and elopement related to impaired cognition, enjoying being outside and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on a Facility-Reported Incident (FRI) review, medical record review, facility investigation review, observation, staff interviews, and facility policy review, the facility failed to ensure money was timely returned to the resident or resident representative to prevent misappropriation. This affected one resident (Resident #135) of two residents reviewed for misappropriation. The facility census was 128. Findings Include: Review of Resident #135's medical record revealed admission date of [DATE] and discharge date [DATE] with diagnoses including but not limited to metabolic encephalopathy, heart attack, kidney failure, chronic obstructive pulmonary disease (COPD), and adult failure to thrive. Resident #135 required assistance from staff to complete activities of daily living (ADL) tasks. Resident #135 had intact cognition with a brief interview mental status (BIMS) score of 14 out of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interviews and facility policy review the facility failed to ensure respiratory equipment used for sleep apnea, continuous positive airway pressure (CPAP), mask and tubing were cleaned routinely. This affected one resident (Resident #133) of three residents reviewed for use of respiratory care. The facility census was 128. Findings Include: Review of Resident #133's medical record revealed admission date 09/15/22 and discharge date [DATE] with diagnoses including but not limited to unspecified dementia, spina bifida, sleep apnea, depression and anxiety. Resident #133 required staff assistance to complete activities of daily living (ADL) tasks related to having bilateral lower extremity impairment and used a wheelchair for mobility. Resident #133 had moderate cognitive impairment with a brief interview mental status (BIMS) score of 13 out of a possible 15 and Resident #133 used oxygen therapy and used a non-invasive ventilator (CPAP) for breathing assistance while sleeping. dated…

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

Based on observations, staff interviews and facility policy, the facility failed to store resident food properly in the unit refrigerator on Unit 3. This had the potential to affect all of the residents on Unit 3 (17 residents on J Hall and 23 residents on K Hall). The facility census was 116. Findings include: Observation on 10/17/24 at 4:55 P.M. revealed that the Unit 3 refrigerator for resident food storage contained one container of unlabeled and undated food. Spillage was observed on the walls and floors of the Unit 3 refrigerator. A pool of orange liquid was observed on the bottle right of the fridge, and a soaked rag was on top of the orange liquid. On the left side of the fridge, the bottom drawer contained a pool of clear liquid. A soggy undated sandwich in a sandwich bag was observed floating in a pool of clear liquid, along with one health shake and one milk carton. The health shake carton and milk carton were observed to be soft and wet to the touch. Interview with State Tested Nursing Assistant (STNA) #235 on 10/17/24 at 5:00 P.M. confirmed that the unit 3 refrigerator…

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, observation, interview, the facility failed to provide dignity in dining for Resident #37 while being assisted with her lunch meal. This affected one resident (Resident #37) out of three residents reviewed for meal assistance. The facility census was 116. Findings include: Resident #37 was admitted to facility on 12/22/15 with diagnoses that included Alzheimers dementia, heart failure, and glaucoma. Her diet order as of 08/23/23 was regular diet, pureed texture with thin liquids. Review of Resident #37's Minimum Data Set (MDS) assessment on 08/01/24 revealed that Resident #37 required supervision and or touch assistance for eating. Review of Resident #37's care plan dated 08/12/19 and revised on 08/13/24 revealed that Resident #37 received assistance with eating from nursing staff as needed. Observations on 10/17/24 from 12:35 P.M. to 12:52 P.M. revealed that Resident #37 did not immediately initiate feeding herself her meal. On 10/17/24 at 12:53 P.M., Resident #37 was observed dipping her fork into her milk, then dipping her fork into her water, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, review of the wound nurse practitioner (NP) progress notes, and interviews the facility failed to ensure wound notes were accurately documented to reflect current treatment orders for skin alterations. This affected one resident (#1) of three record reviewed. Findings included: 1. a. Closed medical record revealed Resident #1 was admitted to the facility initially on 03/07/24 and re-admitted on [DATE] with diagnoses including tracheostomy, embolism and thrombosis of deep veins of left upper extremity, acute respiratory failure, quadriplegia, dependence on respirator, and Raynaud's. Review of Resident #1's Wound NP #500's progress note dated 07/26/24 revealed new orders to cleanse the right scapula wound with 3% acetic acid. Review of Resident #1's orders revealed no evidence 3% acetic acid was ordered to cleanse the wound. Interview on 09/10/24 at 4:35 P.M., with the Director of Nursing (DON) and Wound Licensed Practical Nurse (WLPN) #224 revealed the facility never…

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, interview, and facility policy review, the facility failed to implement a comprehensive and effective water management program to identify areas in facility at risk for Legionella growth. This affected one resident (#122), who contracted Legionella while residing in the facility and had the potential to affect all 120 residents residing in the facility. The facility census was 120. Findings Include: Record review revealed Resident #122 was admitted to the facility on [DATE] with diagnoses including quadriplegia, dependence on respirator, chronic bronchitis, moderate protein calorie malnutrition, acute embolism and thrombosis, acute respiratory failure with hypoxia, edema, dysphagia, hypertension, pleural effusion, anemia, anxiety disorder, insomnia, sepsis, urinary tract infection, pneumonia, acute kidney failure, major depressive disorder, neuromuscular dysfunction of bladder, bradycardia, Raynauds' syndrome, post traumatic stress disorder (PTSD), osteoarthritis, and other psychoactive…

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, resident interview, staff interview and policy review, the facility failed to ensure residents who were dependent on staff for personal care received the assistance they needed to be bathed/ showered as scheduled and as per their preference. This affected three residents (#4, #15, and #64) of three residents reviewed for activities of daily living (ADL) assistance. Findings include: 1. A review of Resident #4's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included chronic obstructive pulmonary disease, atrial fibrillation, hypertension, chronic pain, osteoarthritis, and unsteadiness on his feet. A review of Resident #4's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he did not have any communication issues and was cognitively intact. He was not known to display any behaviors or reject care during the seven days of the assessment period. A bathing activity was not indicated to have occurred during the seven days of the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and policy review, the facility failed to ensure a rationale was provided when the physician declined the pharmacist's recommendation. This affected four (#14, #39, #51, and #114) out of five residents reviewed for unnecessary medications. The facility census was 122. Findings include: Review of Resident #39's medical record revealed Resident #39 was admitted to the facility on [DATE]. Resident #39's diagnoses included hemiplegia, aphasia, type two diabetes, gastro esophageal reflux disease (GERD), depression, unspecified atrial fibrillation, obstructive sleep apnea, anxiety, and bells palsy. Review of the annual Minimum Data Set (MDS) assessment, dated 11/28/23, revealed Resident #39 had mild cognitive impairment and received insulin. Review of Resident #39's pharmacy recommendation, dated 04/13/23, revealed Resident #39 frequently required insulin per sliding scale and Resident #39's most recent hemoglobin A1C was eight percent on 01/11/23. Resident #39 also…

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 menu spreadsheets, observation, staff interview, and review of a diet list, the facility failed to ensure residents on a mechanical soft diet and no added salt diet received meals according to the menu. This affected 34 (Residents #1, #2, #4, #6, #14, #19, #22, #27, #31, #32, #33, #37, #38, #39, #49, #50, #52, #54, #58, #60, #61, #64, #66, #68, #70, #71, #75, #88, #97, #105, #109, #227, #275, #328) of 34 residents who were on a mechanical soft diet and/or no added salt diet. The facility census was 122. Findings include: Review of the menu spreadsheet for the lunch meal on 01/10/24 revealed residents on a mechanical soft diet were supposed to receive ground sweet and sour chicken, fluffy steamed rice, seasoned carrots, a croissant, and sherbet. Residents on a no added salt diet were supposed to receive sweet and sour chicken, fluffy steamed rice, stir fried vegetables, an egg roll, and sherbet. Observation on 01/10/24 at 12:00 P.M. of the steamtable at lunch service revealed there was no fluffy steamed rice or steamed carrots. No croissants were observed on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure staff practiced proper infection prevention precautions to prevent the spread of respiratory syncytial virus (RSV). This had the potential to affect all 32 residents (#3, #4, #6, #23, #25, #29, #31, #35, #39, #42, #43, #45, #50, #53, #55, #56, #59, #60, #65, #70, #72, #74, #81, #82, #85, #87, #92, #94, #96, #101, #113, #324) who were negative for RSV and resided on the K hall and C hall. The facility census was 122. Findings include: 1. Review of Resident #54's medical record revealed the Resident #54 was admitted on [DATE] with diagnoses which included ischemic cardiomyopathy, congestive heart failure, hypertension, mild protein calorie malnutrition, atrial fibrillation. and depression. Review of the quarterly Minimum Data Set 3.0 assessment, dated 12/22/23, revealed Resident #54 was cognitively intact. Review of Resident #54's physician orders revealed the resident tested positive…

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

Based on observation and staff interview, the facility failed to maintain a clean and sanitary environment. This had the potential to affect all 19 (#9, #10, #23, #27, #43, #64, #66, #71, #72, #74, #84, #87, #92, #103, #110, #116, #118, #326, and #475) residents who the facility identified as independently mobile and able to use the pool table in the K hallway. The facility census was 122. Findings include: Observation of the pool table in the K hallway common area on 01/09/24 at 3:00 P.M. revealed there was a red chunky substance on the table surface. Observation of the pool table in the K hallway common area on 01/10/24 at 8:30 A.M. revealed there was a red chunky substance on the table surface. Observation of the pool table in the K hallway common area on 01/10/24 at 1:00 P.M. revealed there was a red chunky substance on the table surface. Observation of the pool table in the K hallway common area on 01/11/24 at 8:00 A.M. revealed there was a red chunky substance on the table surface. Observation of the pool table in the K hallway common area and interview with Registered 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, family interview, and staff interview, the facility failed to ensure Resident #102's primary language of Spanish was addressed in the comprehensive care plan. This affected one (Resident #102) out of one resident reviewed for communication. The facility census was 122. Findings include: Review of the medical record for Resident #102 revealed Resident #102 was admitted on [DATE] with diagnoses which included chronic respiratory failure, emphysema, seizures, anoxic brain damage, persistent vegetative state, tracheostomy, gastrostomy, and type two diabetes. Review of Resident #102's Quarterly Minimum Data Set (MDS) assessment, dated 11/17/23, revealed the brief interview for mental status (BIMS) was unable to be completed due to Resident #102's inability to communicate with speech. Staff reported Resident #102 had severely impaired cognition. Review of Resident #102's care plan revealed Resident #102 had impaired social interaction/social isolation. Resident #102 was unable 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 medical record review, observation, interview, and review of facility policy, the facility failed to ensure activities were provided as care planned and preferred in order to meet the needs of the residents. This affected two residents (#24 and #108) of three residents reviewed for activities. The facility census was 122. Findings include: 1. Review of the medical record for Resident #108 revealed an admission date of 11/15/23 with diagnoses including hemiplegia and hemiparesis affecting left non-dominant side, burn of unspecified degree of right and left lower leg, contractures of left and right knee, dysphagia, depression, and unspecified severe protein-calorie malnutrition. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 11/22/23, revealed Resident #108 had severely impaired cognition. He had impaired range of motion on both sides of his upper and lower extremities. For activities, it was important for him to listen to music, to have books, newspapers and magazines, to be around pets, and to do things in groups. Review of Resident #108's plan 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 medical record review, observation, and staff interview, the facility failed to ensure fall interventions were implemented as ordered. This affected one resident (#104) of four residents reviewed for falls. The facility census was 122. Findings include: Review of the medical record for Resident #104 revealed an admission date of 03/24/23 with diagnoses including cerebral infarction, occlusion and stenosis of carotid artery, anxiety disorder, depression, hemiplegia, type two diabetes mellitus, and protein-calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/01/23, revealed Resident #104 had severely impaired cognition. Review of the plan of care, dated 03/24/23, revealed Resident #104 was at risk for falls and fall related injuries related to weakness, psychotropic medications, requiring assistance with transfers, history of falls, and hemiplegia to left side. Interventions included anticipating and meeting needs, assessing risk for falls, bed in low position while in bed, encouraging appropriate footwear, keeping environment safe,…

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

Based on medical record review and staff interview, the facility failed to adequately obtain/monitor resident blood pressures in order to ensure antihypertensive medication was administered as ordered. This affected one resident (#114) of five residents who were reviewed for unnecessary medications. The facility census was 122. Findings include: Review of the medical record for Resident #114 revealed an admission date of 10/21/23 with diagnoses including Alzheimer's disease, paranoid personality disorder, chronic obstructive pulmonary disease, delusional disorders, hallucinations, and chronic kidney disease stage three. Review of the comprehensive Minimum Data Set 3.0 assessment, dated 10/28/23, revealed Resident #114 had severely impaired cognition. Review of the plan of care for Resident #114 revealed he was at risk for cardiac complications related to multiple cardiovascular diseases including hypertension, chronic heart failure, and hyperlipidemia. Interventions included administering medications as ordered, completing vital signs as ordered, and observing and reporting any…

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, and staff interview, the facility failed to ensure residents were provided adaptive equipment at meals as needed. This affected one (Resident #39) out of six residents reviewed for nutrition. The facility census was 122. Findings include: Review of Resident #39's medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses which included hemiplegia, aphasia, type two diabetes, gastro esophageal reflux disease (GERD), depression, unspecified atrial fibrillation, obstructive sleep apnea, anxiety, and bells palsy. Review of Resident #39's Annual Minimum Data Set assessment, dated 11/28/23, revealed Resident #39 received a therapeutic, mechanically altered diet. Observation of Resident #39's meal tray ticket for the lunch meal on 01/08/24, revealed the resident was to have a divided plate. Observation of Resident #39's lunch tray on 01/08/24 at 12:58 P.M., revealed the resident was eating the meal while in bed. The meal was served on 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.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview and record review the facility failed to initiate antibiotic treatment orders when Resident #132's diabetic ulcer became infected. This affected one resident (Resident #132) of three residents reviewed for infections. The facility census was 117. Findings include: Review of the medical record for Resident #132 revealed an admission date of 10/26/23 with diagnoses including diabetic ulcer to his left planter first digit, diabetes mellitus type two, and chronic kidney disease. Review of Resident #132's Skin and Wound assessment, dated 10/27/23 revealed the resident was admitted with a diabetic ulcer to his left plantar digit (hallux) measuring 3.5 centimeters (cm) length by 2.5 cm width, and 0.2 cm deep. At the time of admission, the assessment stated there were no signs of infection. Review of Resident #132's podiatry consult dated 11/13/23 revealed the resident was seen regarding his ulcer and a wound culture was done. The consult stated 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 interview and record review the facility failed to obtain ordered lab work for Resident #132. This affected one resident (#132) of three residents reviewed for laboratory testing The facility census was 117. Findings include: Review of the medical record for Resident #132 revealed an admission date of 10/26/23 with diagnoses including diabetic ulcer to his left planter first digit, diabetes mellitus type two, and chronic kidney disease. Review of the Certified Nurse Practitioner (CNP) #47's progress note dated 11/14/23 revealed Resident #132 was a patient with chronic kidney disease, stage three. The note stated that the facility will monitor his kidney function this week and follow with Nephrology. Review of CNP #47's progress note dated 11/17/23 revealed the practitioner was seeing Resident #132 today in an acute visit for complaints of generalized malaise. The patient tested positive for COVID-19. The patient was having some symptoms, appeared ill, tired, and was resting more often. He complained of generalized weakness and had a little scratchy throat. CNP #47 went 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.

Based on interview, record review, and policy review the facility failed to ensure antibiotic stewardship procedures were followed regarding wound cultures obtained during consultation appointments. This affected one resident (Resident #132) of three residents reviewed for antibiotic stewardship. The facility census was 117. Findings include: Review of the medical record for Resident #132 revealed an admission date of 10/26/23 with diagnoses including diabetic ulcer to his left planter first digit, diabetes mellitus type two, and chronic kidney disease. Review of Resident #132's Skin and Wound assessment, dated 10/27/23 revealed the resident was admitted with a diabetic ulcer to his left plantar digit (hallux) measuring 3.5 centimeters (cm) length by 2.5 cm width and 0.2 cm deep. At the time of admission, the assessment stated there were no signs of infection. Review of Resident #132's podiatry consult, dated 11/13/23 revealed the resident was seen regarding his ulcer and a wound culture was completed. The consult stated the results would be ready in three to four days. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of shower documentation, and staff interview, the facility failed to ensure residents unable to carry out activities of daily living (ADL) received assistance with grooming and personal hygiene. This affected four of four residents reviewed for ADL's (Residents #16, #49, #105, and #368). The census was 125. Findings include: 1. Review of Resident #105's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included schizophrenia, dementia, diabetes, and legal blindness. Review of the annual minimum data set (MDS) assessment dated [DATE] revealed his cognition was intact. He required extensive assistance of one staff member for transfers, dressing, toilet use, bathing and personal hygiene. Plan of care dated 02/23/20 revealed a self care performance deficit with ADL's. Review of the bath schedule revealed Resident #105 was to receive a shower on Tuesdays and Thursdays. Review of the documentation revealed no shower was documented between 12/01/21 to 12/08/21,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview and facility policy review, the facility failed to ensure one resident (Resident #57) received tracheotomy care in a manner to prevent potential infection. Additionally, the facility failed to ensure three resident's (Residents #24, #39, #115) oxygen equipment was stored in a sanitary manner. This affected one of one resident reviewed for tracheotomy/ventilator use and three of four residents reviewed for oxygen use. Findings Included: 1. Review of Resident #57's medical record revealed an original admission date of 12/19/20 with the latest readmission of 04/07/20. Diagnoses included chronic respiratory failure with hypoxia, status tracheotomy, dependence on ventilator, chronic obstructive pulmonary disease, metabolic encephalopathy, diabetes mellitus, dysphagia, status gastrostomy, hypertension, anemia, mood disorder, insomnia, chronic pain, anxiety, carcinoma of skin of face, basal cell carcinoma of skin of face, dependence on supplement oxygen and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, staff interview, and facility policy review, the facility failed to follow infection control and COVID-19 policies and procedures. This affected eight (Residents #10, #27, #38, #58, #61 #67, #99, and #109) of nine residents reviewed for infection control procedures. The census was 125. Findings include: 1. Observations on 01/03/22 from 12:20 P.M. to 12:45 P.M. revealed Business Office Manager (BOM) #261 enter into Resident #10 and Resident #61 room. Residents #10 and #61 had a personal protective equipment (PPE) cart and sign on the door to indicate that they were on droplet/contact isolation precautions. BOM #261 entered the room with eye protection, N95 mask, gown and gloves to deliver the trays. When she left the room, she did not change her mask, nor did she clean her face shield. She went in six different rooms before she changed her mask and cleaned her face shield (after being asked about the proper procedures for coming out of a room that was on isolation…

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 provide beneficiary notices for skilled services being discontinued in a timely manner. This affected two (Residents #47 and #58) of three resident beneficiary notices reviewed. The census was 125. Findings Include: Review of Resident #47 beneficiary notice letter revealed his skilled services started on 10/20/21. The end date of his skilled services was scheduled to be 11/27/21. In review of his medical records, the facility did not have evidence that Resident #47's responsible party signed the beneficiary notice form. There was evidence that it was sent to Resident #47 responsible party via mail, but they never received a signed copy. Also, according to Resident #47's progress notes, the facility contacted Resident #47's responsible party to explain about the date when the skilled services would end, their appeal rights, and contact information for those appeals. The date of this communication was on 11/26/21, one day prior to the skilled services ending. Review of Resident #58 beneficiary notice letter…

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 the facility failed to provide a resident personal privacy during a medical treatment. This affected one of 125 residents (Resident #57). Findings Included: Review of Resident #57's medical record revealed the latest readmission of 04/07/20. Diagnoses included chronic respiratory failure with hypoxia, status tracheotomy, dependence on ventilator, chronic obstructive pulmonary disease, metabolic encephalopathy, diabetes mellitus, dysphagia, status gastrostomy, hypertension, anemia, mood disorder, insomnia, chronic pain, anxiety, carcinoma of skin of face, basal cell carcinoma of skin of face, dependence on supplement oxygen and constipation. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had no speech, sometimes understood others, rarely/never made herself understood and had a severe cognitive impairment. The resident was dependent on two staff for activities of daily living (ADL). 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 and staff interview, the facility failed to provide a homelike environment for residents. This was observed in two of ten hallways (L and M hallways) and affected 43 residents residing on the affected hallways. The census was 125. Findings include: On 01/06/22 from 3:00 P.M. to 3:11 P.M. tour of the L and M hallways with Licensed Practical Nurse (LPN) #288 revealed the following: 1. Room L 7: Wall with multiple areas and chipped paint 2. Room L-2: Wall gouged into drywall behind and beside head board 3. Room L-5: Wall scuffed and gouged behind head board 4. Room M-6: Wall had multiple places in room that were patched and not painted 5. On the M hallway on both sides there was wall paper torn in multiple places and black scuffed areas observed 6. The L/M lounge area had walls scuffed and chipped. Interview with LPN #288 verified the above observations at the time of the tour.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to update resident Pre-admission Screening and Resident Review (PASRR) records after a significant change. This affected two (Resident #16 and Resident #46) of six resident PASRR forms reviewed. The census was 125. Findings Include: 1. Record review revealed Resident #16 was admitted to the facility on [DATE]. His diagnoses were unspecified dementia with behavioral disturbances, hypertensive heart disease, congestive heart disease, type II diabetes, atrial fibrillation, peripheral vascular disease, adjustment disorder (05/03/21), unspecified psychosis, major depressive disorder, dysphagia, vitamin D deficiency, dry eye syndrome, osteoarthritis, hypokalemia, and personal history of transient ischemic attack. According to his Minimum Data Set (MDS) 3.0 assessment (dated 10/05/21) revealed he was cognitively intact, based on his Brief Interview for Mental Status (BIMS) score of 15. Review of Resident #16 medical records revealed under section C…

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 maintain an updated and accurate Pre-admission Screening and Resident Review (PASRR) for residents when they are first admitted to the facility. This affected two (Resident #6 and Resident #73) of six residents PASRR forms reviewed. The census was 125. Findings Include: 1. Record review revealed Resident #6 was admitted to the facility on [DATE]. His diagnoses were dementia with behavioral disturbances, chronic obstructive pulmonary disease, type II diabetes, chronic kidney disease, anemia, dysphagia, chronic respiratory failure, schizoaffective disorder, schizophrenia, anxiety disorder, major depressive disorder, bipolar disorder, osteoarthritis, vitamin D deficiency, peripheral vascular disease, hyperlipidemia, type II diabetes, and shortness of breath. According to his Minimum Data Set (MDS) 3.0 assessment (dated 12/22/21), he had no cognitive impairment, due to his Brief Interview for Mental Status (BIMS) score being 13. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to report a significant change of a resident Pre-admission Screening and Resident Review (PASRR) records to the state mental health agency. This affected two (Resident #16 and Resident #46) of six resident PASRR forms reviewed. The census was 125. Findings Include: 1. Record review revealed Resident #16 was admitted to the facility on [DATE]. His diagnoses were unspecified dementia with behavioral disturbances, hypertensive heart disease, congestive heart disease, type II diabetes, atrial fibrillation, peripheral vascular disease, adjustment disorder (05/03/21), unspecified psychosis, major depressive disorder, dysphagia, vitamin D deficiency, dry eye syndrome, osteoarthritis, hypokalemia, and personal history of transient ischemic attack. According to his Minimum Data Set (MDS) 3.0 assessment (dated 10/05/21) revealed he was cognitively intact, based on his Brief Interview for Mental Status (BIMS) score of 15. Review of Resident #16'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 activity record documentation and staff interview, the facility failed to provide on-going activities. This affected one of two residents reviewed for activities (Resident #24). The census was 125. Findings include: Review of Resident #24's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included dementia, diabetes, chronic kidney disease, schizophrenia and atrial fibrillation. Review of the annual minimum data set assessment dated [DATE] revealed his cognition was intact, he required extensive assistance of two or more staff members for bed mobility, transfers, toilet use and extensive assistance of on staff member for dressing and personal hygiene. Review of the activity plan of care dated 03/02/21 revealed he prefers to engage in activities independently in the room but is willing to attend programs as interested. He likes to sit in lobby and people watch sometimes, and wheel up and down the halls. He likes to watch TV, read, participate in socials and listen to music.…

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, staff and resident interviews, facility failed to ensure Resident #46 had eyeglasses in functional working condition when her glasses were broken. This affected one resident of one reviewed for assistive devices. Facility census was 125. Findings include: Review of the medical record for the Resident #46 revealed an admission date of 10/08/21. Diagnoses included traumatic brain injury, hemiplegia, post traumatic seizures, dysphagia, hypertension, major depression disorder, anxiety disorder, fibromyalgia, muscle wasting, spinal stenosis, post-traumatic stress disorder, contracture of the left wrist, shoulder and hand. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 was cognitively intact with a BIMS of 15 and required extensive assistance of two staff members and was totally dependent for transfers. Resident #46 was incontinent of bladder and incontinent of bowels. Resident #46's vision was impaired and the resident wore corrective lenses. Review…

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 and staff interview, the facility failed to ensure pressure ulcer interventions were maintained. This affected one (Resident #109) of three residents reviewed for pressure ulcers. Findings include: Record review revealed Resident #109 was admitted to the facility on [DATE] with diagnoses that included ASHD, diabetes, morbid obesity and hypothyroidism. Review of the significant change minimum data set (MDS) assessment dated [DATE] revealed her cognition was not intact. She required extensive assistance of two or more staff members, dressing, toilet use and personal hygiene. A stage II pressure ulcer was identified (Stage II pressure ulcer is defined as partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister). Review revealed a pressure ulcer risk assessment dated [DATE] which identified Resident #109 as low risk for development of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and staff interview, the facility failed to ensure one resident (Resident #57) physician ordered contracture prevention device was in place as ordered. This affected one of one resident reviewed for limited range of motion. Findings Include: Review of Resident #57's medical record revealed an original admission date of 12/19/20 with the latest readmission of 04/07/20. Diagnoses included chronic respiratory failure with hypoxia, status tracheotomy, dependence on ventilator, chronic obstructive pulmonary disease, metabolic encephalopathy, diabetes mellitus, dysphagia, status gastrostomy, hypertension, anemia, mood disorder, insomnia, chronic pain, anxiety, carcinoma of skin of face, basal cell carcinoma of skin of face, dependence on supplement oxygen and constipation. Review of Resident #57's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had no speech, sometimes understood others, rarely/never made herself understood and had…

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 accurately monitor and treat one resident (Resident #81) constipation with known history of small bowel obstruction. This affected one of one resident reviewed for bowel and bladder incontinence. Findings Included: Review of Resident #81's medical record revealed an original admission date of 10/30/20 with the latest readmission of 11/17/21. Diagnoses included partial intestinal obstruction, constipation, diabetes mellitus, severe morbid obesity, chronic pain, hypertension, hyperlipidemia, benign prostatic hyperplasia, anemia, peripheral vascular disease, chronic pulmonary embolism, major depressive disorder, insomnia, mixed irritable bowel syndrome, gastro-esophageal reflux disease, post-traumatic stress disorder, malignant neoplasm of prostate, lymphedema, dry eye syndrome, presbyopia, osteoarthritis, spinal stenosis and vitamin D deficiency. Review of the acute care Discharge summary dated [DATE] revealed Resident #81 was admitted 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 one resident's (Resident #57) enteral feeding formula was labeled and not spoiled. This affected one of one resident reviewed for enteral feeding. Findings Included: Review of Resident #57's medical record revealed an original admission date of 12/19/20 with the latest readmission of 04/07/20. Diagnoses included chronic respiratory failure with hypoxia, status tracheotomy, dependence on ventilator, chronic obstructive pulmonary disease, metabolic encephalopathy, diabetes mellitus, dysphagia, status gastrostomy, hypertension, anemia, mood disorder, insomnia, chronic pain, anxiety, carcinoma of skin of face, basal cell carcinoma of skin of face, dependence on supplement oxygen and constipation. Review of Resident #57's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had no speech, sometimes understood others, rarely/never made herself understood and had a severely cognitive…

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 policy review, the facility failed to ensure medications were stored properly. Multiple stock medications were expired in Unit 3's Medication Room. This affected one of two medication storage rooms observed for medication storage and had the potential to affect all residents in the facility. The facility census is 125. Findings include: An observation, on [DATE] at 8:02 AM, revealed Unit 3's Medication Room contained the stock medications for the unit. The following stock medications were observed to be expired: One bottle of Vitamin B6 with an expiration date of 10/21. Three bottles of Vitamin B12 with an expiration date of 08/21. Two bottles of Niacin with an expiration date of 08/21. One bottle of Vitamin C with an expiration date 08/21. An interview with Registered Nurse (RN) #271, on [DATE] at 8:12 A.M., revealed no stock medications in the medication room should be expired. RN #271 stated the medications should have been discarded at the time of expiration. 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 record review and interviews of staff, residents, and the certified nurse practitioner, the facility failed to obtain laboratory services according to physician orders. This affected two residents (Residents #46 and #105) of two reviewed for laboratory orders. Facility census was 125. Findings include: 1. Review of the medical record for Resident #46 revealed an admission date of 10/08/21. Diagnoses included traumatic brain injury, hemiplegia, post traumatic seizures, dysphagia, hypertension, major depression disorder, anxiety disorder, fibromyalgia, muscle wasting, spinal stenosis, post-traumatic stress disorder, contracture of the left wrist, shoulder and hand. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 was cognitively intact with a BIMS of 15 and required extensive assistance of two staff members and was totally dependent for transfers. Resident #46 was incontinent of bladder and incontinent of bowels. Resident #46's vision was impaired and 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.