Walnut Creek Nursing Center

Based on observation, staff interviews, and review of the facility policy, the facility failed to ensure residents were served food to meet their needs. This affected one (Resident #104) out of three residents reviewed for proper diets. The facility census was 107.Findings include:Review of the medical record for Resident #104 revealed an admission date of 05/17/22 with diagnoses of vascular dementia, moderate, with other behavioral disturbance, chronic obstructive pulmonary disease, unspecified, essential (primary) hypertension, and adult failure to thrive. Review of the physician order dated 01/13/25 revealed Resident #104 was ordered to receive a regular diet, mechanical soft texture, regular consistency with regular texture food / snacks as desired with supervision. Review of the Care Plan dated 06/09/25 revealed Resident #104 was at risk for malnutrition/alteration in nutritional status related to dementia with behaviors, history of failure to thrive, depression/anxiety, diabetes, chronic obstructive pulmonary disease (COPD), and cerebrovascular accident. The resident received…

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, review of facility's Self-Reported Incidents (SRI) and investigation, resident interviews, review of personnel file, and staff interviews, the facility failed to ensure the residents were treated with respect and dignity. This affected two (#34 and #40) of five residents reviewed for abuse and dignity. Findings include: Review of the medical record for Resident #34 revealed an admission to 08/30/24 with medical diagnoses of Parkinson's disease, chronic obstructive pulmonary disease (COPD), and depression. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact and was dependent upon staff for toilet hygiene, bathing, bed mobility, and transfers. Resident #34 was always incontinent with bladder and bowel. Review of the facility's SRI number 265729, dated 09/26/25 at 5:08 P.M., revealed on 09/25/25 at 7:30 P.M., Resident #34 stated Certified Nursing Assistant (CNA) #210 failed to provide cares/services for Resident #34 as requested. 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 reviews, resident and staff interviews, review of facility Self-Reported Incidents (SRIs) and investigation, and policy review, the facility failed to ensure staff immediately reported allegations of abuse to administration and failed to complete a thorough investigations into allegations of abuse. This affected two (#34 and #105) of five residents reviewed for abuse. The facility census was 103.Findings include: Review of the medical record for Resident #34 revealed an admission to 08/30/24 with medical diagnoses of Parkinson's disease, chronic obstructive pulmonary disease (COPD), and depression. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact and was dependent upon staff for toilet hygiene, bathing, bed mobility, and transfers. Resident #34 was always incontinent with bladder and bowel. Review of the facility's SRI number 265729 and investigation, dated 09/26/25 at 5:08 P.M., revealed on 09/25/25 at 7:30 P.M., Resident #34 stated…

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 review of facility policy, the facility failed to ensure staff had there hair contained in food preparation areas and failed to ensure food was stored properly. This had the potential to 98 out of 98 residents who receive their meals/food from the kitchen, the facility identified one resident (#30) that did not receive food from the kitchen. The census was 99. Findings include: Observations of the kitchen on 05/21/25 at 2:14 P.M. revealed Dietary Aide (DA) #150 preparing meals trays and DA #160 arranging drink cups and preparing drinks. Neither DA #150 or DA #160 had were wearing hairnets or had their hair contained. Interview with DA #150 on 05/21/25 at 2:19 P.M. confirmed she was not wearing a hairnet. DA #150 stated her hairnet must have fell off. Interview with Dietary Director (DD) #170 on 05/21/25 at 2:29 P.M. confirmed DA #150 and DA #170 were not wearing hairnets and did not have their hair contained in the food preparation area. DD #170 stated hairnets were required at all times in the kitchen. Further observation on 05/21/25 at…

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 review of facility policy, the facility failed to ensure fall interventions were in place for a resident who was at risk for falls and had recent falls. This affected one (#69) of the three residents reviewed for accidents. The census was 95. Findings include: Review of Resident #69's medical record revealed an admission date of 11/05/24. Diagnoses listed included psychotic disorder, cognitive disorder with Lewy bodies, anxiety disorder, depressive disorder, and muscle weakness. Review of a care plan for Resident #69 dated 11/18/24, revealed the resident was at risk for falls and potential injury related to dementia, impaired balance, impaired cognition, medications, poor decision-making skills, unsteady gait, history of falls, and keeps eyes closed when walking. An intervention of anti-rollbacks to the resident's wheelchair was implemented on 02/03/25. Review of a significant change Minimum Data Set (MDS) assessment for Resident #69 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 record review, staff interview, and facility policy review, the facility failed to ensure medications were administered per physician's order. This affected one (#71) resident out of the five residents reviewed for medications. The facility census was 95. Findings Include: Review of medical record for Resident #71 revealed an admission date 09/04/25. Diagnoses included acute respiratory failure, obstructive and reflux uropathy, acute and chronic respiratory failure, pleural effusion, chronic obstructive pulmonary disease, morbid obesity, and sleep apnea. Review of a physician order for Resident #71 dated 12/04/24 and discontinued on 01/24/25, revealed the resident had an order for Midodrine five milligrams (mg) by mouth every eight hours as needed (PRN) for hypotension related to systolic blood pressure less than 100 millimeters or mercury (mm/Hg), and do not give the medication four hours before bedtime. Review of a physician order for Resident #71 dated 01/01/25, revealed the resident was ordered to have a blood pressure taken twice daily (morning and night) and check…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure abnormal involuntary movement scale (AIMS) assessments were completed as ordered. This affected two (#69 and #76) of the five residents reviewed for unnecessary medications. The facility also failed to ensure an ordered stop date for an as needed (PRN) antianxiety medication was implemented. This affected one (#69) of the five residents reviewed for unnecessary mediations. The census was 95. Findings include: 1. Review of Resident #69's medical record revealed an admission date of 11/05/24. Diagnoses listed included psychotic disorder, cognitive disorder with Lewy bodies, anxiety disorder, depressive disorder, and muscle weakness. Review of a monthly medication review (MMR) dated 11/26/24, revealed Resident #69 was currently receiving the antipsychotic medication Risperdal and recommended an AIMS assessment be completed due to this antipsychotic therapy requiring an AIMS assessment. The MMR was signed by…

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, interviews, and facility policy, the facility failed to ensure the proper storage of medications when outdated and expired medications were being stored in the medication carts. This affected two (#47 and #70) residents of the five residents reviewed for medications. The facility census was 95. Findings Include: Review of medical record for Resident #70 revealed an admission date 03/21/24. Diagnoses included depression, type two diabetes, anemia, and hypertension. Review of record for Resident #47, revealed an admission date 11/19/24. Diagnoses included heart failure, depression and atrial fibrillation. Observation of the 100-hall medication cart on 03/19/25 at 10:55 A.M. with Licensed Practical Nurse (LPN) #117, revealed an Insulin Aspart (fast acting insulin) 100 units per milliliter belonging to Resident #70 with an open date of 02/06/25. Interview with LPN #117 at the same time verified Resident #70's insulin was opened 02/06/25. Observation of the 200-hall medication cart on 03/19/25 at 11:24 A.M. with LPN #32, revealed a container Potassium Chloride 10…

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, review of online resources from Centers for Disease Control and Prevention (CDC), and review of facility policy, the facility failed to timely implement Enhanced Barrier Precautions (EBP). This affected three (#14, #17, and #46) residents of five reviewed for Transmission-Based Precautions (TBP). The census was 95. Findings include: 1. Review of Resident #17's medical record revealed an admission date of 04/16/18. Diagnoses listed included malnutrition, cerebral palsy, chronic kidney disease stage 3, dysphagia, and atherosclerotic heart disease. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #17 was cognitively intact, was receiving Hospice services and did not have any pressure ulcers. Further review of Resident #17's medical record, revealed a stage III (full-thickness skin loss in which adipose [fat] is visible) pressure ulcer to the resident's sacrum was identified on 01/31/25 and treatments were…

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 records review, staff interview, observation, review of facility policy, and review of Centers of Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) while caring for a resident who was positive with Coronavirus Disease 2019 (COVID-19). This affected one (#1) out of three residents reviewed for infection control. The census was 90. Findings include: Review of Resident #1's medical record revealed an admission date of 07/24/24. Diagnoses listed included cerebral atherosclerosis, hypertension, vascular dementia, and chronic kidney disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitive impaired and receiving Hospice services. Review of physician orders revealed an order dated 01/13/25 for contact and droplet precautions due to COVID-19. Review of progress notes dated 01/13/25 at 12:36 P.M. revealed Resident #1 tested positive for COVID-19 with 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 medical record review and staff interviews, the facility failed to ensure physician orders were followed and parameters were met prior to the administration of insulin resulting in significant medication errors. This affected one resident (#10) of three residents reviewed for medication administration. Facility census was 85. Findings include: Review of medical record for Resident #10 revealed admission date of 06/21/24. Diagnoses include diabetes mellitus with skin complications, congestive heart failure, peripheral vascular disease, and hypertension. Resident #10 was admitted to hospice on 08/26/24 for a diagnosis of senile asthenia. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 had a Brief Interview Mental Status (BIMS) score of seven out of 15. Resident #10 required extensive two-person assistance for transfers, one person assistance for bed mobility, dependent for toileting and independent for eating. Medications documented injections were received seven of seven days…

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, observations and staff interview the facility failed to ensure residents were administered as ordered resulting in two medication errors out of 25 opportunities or an eight percent (%) medication error rate. This affected two (#18 and #19) out of of four residents observed for medication administration. The facility census was 88. Findings include: 1. Review of medical record for Resident #18 revealed admission date of 04/18/23. Diagnoses include alcoholic hepatic failure without coma, traumatic subdural hemorrhage, bipolar disorder, chronic obstructive pulmonary disorder, depression and chronic respiratory failure. The resident remained in the facility. Observation of medication pass on 01/18/24 at 8:15 A.M. with Licensed Practical Nurse (LPN) #118 for Resident #18 revealed she was given Amlodipine (blood pressure) 10 milligrams (mg), Keppra (seizures) 750 mg, Lisinopril (blood pressure) 20 mg, Metformin (diabetes) 500 mg, Senna (laxative) 8.6 mg and Zyprexa (antipsychotic) 2.5 mg. Further review of Resident #18's physician orders revealed an order…

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 reviews, observations, staff interview and review of medication information from Medscape, the facility failed to ensure antipsychotic and/or blood pressure medications were administered as physician ordered resulting in significant medication errors. This affected three (#15, #13, #18) of four residents reviewed for medication administration. The facility census was 88. Findings include: 1. Review of medical record for Resident #18 revealed admission date of 04/18/23. Diagnoses include alcoholic hepatic failure without coma, traumatic subdural hemorrhage, bipolar disorder, chronic obstructive pulmonary disorder, depression and chronic respiratory failure. Observation of medication pass on 01/18/24 at 8:15 A.M. with Licensed Practical Nurse (LPN) #118 for Resident #18 revealed she was given Amlodipine (blood pressure) 10 milligrams (mg), Keppra (seizures) 750 mg, Lisinopril (blood pressure) 20 mg, Metformin (diabetes) 500 mg, Senna (laxative) 8.6 mg and Zyprexa (antipsychotic) 2.5 mg. Further review of Resident #18's physician orders revealed an order 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 Quality Assessment and Assurance (QAA) record review, staff interview, and policy review, the facility failed to ensure QAA meetings were conducted at least quarterly and all required members were in attendance. This had the potential to affect all 85 residents of the facility. The facility census was 85. Findings included: Review of the QAA meeting information revealed the facility conducted a QAA meeting first and second quarter of 2023 with all required members present at the meetings. Review of the Ad hoc QAA meeting attendance sheet, dated 11/08/23, revealed the medical director was not present for the meeting. Further review of the QAA meeting information revealed no documentation to support the facility conducted a QAA meeting in the fourth quarter of 2022. Interview on 11/16/23 at 3:46 P.M. with Registered Nurse (RN) #501 confirmed the Medical Director was not present for the Ad Hoc QAA meeting on 11/08/23. RN #501 also confirmed there was no documentation to support the facility conducted a QAA meeting in the fourth quarter of 2022. Review of the policy titled,…

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 reviews, staff interviews, and review of the Resident Assessment Instrument (RAI) Manual 3.0, the facility failed to compete quarterly Minimum Data Set (MDS) assessments within the required time frame. This affected four (#21, #39, #46 and #77) of the 19 residents reviewed for timely completion of MDS assessments. The facility census was 85. Findings included: 1) Review of the medical record for Resident #39 revealed an admission date of 01/26/17 with medical diagnoses of dementia, diabetes mellitus (DM), hypertension (HTN), and hypothyroidism. Review of the medical record for Resident #39 revealed a quarterly MDS assessment with assessment reference date (ARD) of 08/19/23 which indicated Resident #39 was cognitively intact and required supervision with bed mobility, transfers, dressing, and toileting. Review of the quarterly MDS revealed a completion date of 09/20/23. 2) Review of the medical record for Resident #46 revealed an admission date of 01/18/18 with medical diagnoses of DM, Alzheimer's disease, chronic obstructive pulmonary disease, HTN, and…

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

Based on medical record review, staff interview, and review of the Resident Assessment Instrument (RAI) 3.0 manual, the facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required timeframe. This affected two (#40 and #57) of the 19 residents reviewed for timely completion of MDS assessments. The facility census was 85. Findings include: 1) Review of the medical record for Resident #40 revealed an admission date of 08/09/18 with medical diagnoses of Alzheimer's disease, hypertension (HTN), heart failure, and chronic kidney disease stage III. Review of the medical record for Resident #57 revealed an annual MDS with assessment reference date (ARD) of 10/14/23 which indicated Resident #40 had severe cognitive impairment and required set-up to supervision with transfers, bed mobility, toileting and eating. Further review of the MDS revealed a completion date of 11/10/23. 2) Review of the medical record for Resident #57 revealed an admission date of 09/07/23 with medication diagnoses of congestive heart failure (CHF), HTN, diabetes mellitus, and…

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

Based on medical record review, staff interview and review of the Resident Assessment Instrument (RAI) 3.0 manual, the facility failed to ensure resident interviews were conducted for cognition Brief Interview for Mental Status (BIMS) and for mood 9-Item Patient Health Questionnaire (PHQ-9) as required by RAI manual. This affected two (#57 and #77) of the 19 residents reviewed for Minimum Data Set (MDS) assessment accuracy. The facility census was 85. Findings include: 1) Review of the medical record for Resident #57 revealed an admission date of 09/07/23 with medical diagnoses of congestive heart failure (CHF), hypertension (HTN), diabetes mellitus, and chronic obstructive pulmonary disease. Review of the medical record for Resident #57 revealed an admission MDS assessment with assessment reference date (ARD) 09/25/23 which indicated the facility did not complete resident interviews for BIMS or PHQ-9 and the resident interviews were dashed. Review of the MDS assessment revealed staff interviews were not conducted to determine Resident #57's BIMS or PHQ-9. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to accurately fill out a Preadmission Screening and Resident Review (PASARR) for Residents. This affected one (#68) of the five residents reviewed for PASARR. The facility census was 85. Findings include: Resident #68 was admitted to the facility on [DATE] with a diagnosis of acute kidney failure, amnestic disorder due to known physiological condition, metabolic encephalopathy, need for assistance with personal care, muscle weakness, bipolar disorder, alcohol dependence with alcohol-induced persisting dementia, non-pressure chronic ulcer of right heel and midfoot, schizoaffective disorder, and pseudobulbar affect. Review of the Minimal Data Set (MDS) assessment 3.0 dated 09/25/23 revealed Resident #68 had moderate cognitive impairment. Her functional status is listed as totally dependent for transfers, bed mobility, and toileting. The MDS also revealed Resident #68 was incontinent of urine and bowel and assessed with no pressure ulcers. 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 reviews, staff interviews, and review of the Resident Assessment Instrument (RAI) manual 3.0, the facility failed to develop and implement comprehensive person-centered care plans. This affected three (#31, #77, and #87) of the 19 residents reviewed for comprehensive person-centered care plans. The facility census was 85. Findings included: 1) Review of the medical record for Resident #31 revealed an admission date of 08/18/23 with medical diagnoses of malignant neoplasm of prostate, secondary malignant neoplasm of bone, non-pressure chronic ulcer of left foot, and hypertension (HTN). Review of the admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 08/25/23 for Resident #31, revealed the resident had moderate cognitive impairment and required limited staff assistance with bed mobility, transfers, dressing, and toileting. The MDS assessment did not indicate Resident #31 had any skin issues. Review of a physician's progress noted dated 10/23/23 for Resident #31,…

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, record review, staff and resident interviews, and review of facility policy, the facility failed to provide dependent residents with bathing needs. This affected two (#01 and #37) of the four residents reviewed for activities of daily living (ADLs). The facility census was 85. Finding included: 1) Review of the medical record for Resident #01 revealed the resident had an original admission date of 06/07/22. Diagnoses included, but not limited to, cerebral palsy, Parkinson's disease, chronic obstructive pulmonary disease (COPD), diabetes type 2, morbid obesity, malignant neoplasm of bladder, gastroesophageal reflux, schizoaffective disorder, chronic diastolic heart failure, chronic kidney disease, bipolar disorder, anxiety, gout, and auditory hallucination. Review of the comprehensive plan of care dated 05/30/23 for Resident #01, revealed the resident had an ADL self- care performance deficit related to activity intolerance, fatigue, and impaired balance with an intervention to 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 medical record review, staff interviews, and policy review, the facility failed to complete weekly skin assessments and the facility failed to complete wound treatments as ordered by the physician for a resident's surgical site. This affected one (#31) of the six residents reviewed for wound care. The facility census was 85. Finding included: Review of the medical record for Resident #31 revealed an admission date of 08/18/23 with medical diagnoses of malignant neoplasm of prostate, secondary malignant neoplasm of bone, non-pressure chronic ulcer of left foot, and hypertension. Review of a skin evaluation assessment dated [DATE] for Resident #31 revealed the resident had skin issues to the toes on the resident's right foot. The medical record revealed no documented evidence that the facility completed any weekly skin assessments after the resident's admission on [DATE]. Review of the admission Minimum Data Set (MDS) for Resident #31 revealed an assessment reference date (ARD) of 08/25/23 which indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to complete weekly skin assessments and monitoring of pressure ulcer as per facility policy. This affected one (#77) of the two residents reviewed for pressure ulcers. The facility census was 85. Findings included: Review of the medical record for Resident #77 revealed an admission date of 05/31/23 with medical diagnoses of schizophrenia, moderate protein calorie malnutrition, and hypertension. Review of the weekly skin assessments from 06/02/23 to 06/25/23 for Resident #77, revealed the facility completed the weekly skin assessments. There were no documented weekly skin assessments or monitoring of the resident's Stage IV pressure ulcer to coccyx after 06/25/23 and before the resident was seen by the wound physician on 08/21/23. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 09/07/23 for Resident #77, revealed the resident was dependent on staff or required extensive staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to ensure a resident's tube feeding was administered per physician orders. This affected one (#25) of two residents reviewed for tube feeding. The facility census was 85. Findings include: Review of medical record for Resident #25, revealed the resident was admitted on [DATE] with diagnoses that included, but not limited to, hemiplegia and hemiparesis following cerebral infarction, diabetes mellitus, morbid obesity, unspecified severe protein-calorie malnutrition, major depression, anxiety disorder, osteoarthritis, dysphagia oropharyngeal phase, gastroparesis, cerebral palsy, celiac disease, and gastrostomy. Review of the Minimum Data Set (MDS) assessment 3.0 dated 09/07/23 for Resident #25, revealed a Brief Interview for Mental Status (BIMS) score 15, implying no cognitive impairment. Further review revealed no behaviors exhibited, no rejection of care and no wandering. Resident #25 received 51 percent or more total calories…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and review of facility policy, the facility failed to administer and document as needed (PRN) psychotropic medications for an appropriate indication, failed to implement non-pharmacological interventions prior to administration of PRN psychotropics and failed to timely evaluate and monitor the effectiveness of antipsychotic medications for residents. This affected three (#26, #37 and #46) of the six residents reviewed for unnecessary medication use. The facility census was 85. Finding Include: 1) Record review of Resident #26 revealed an original admission dated of 07/14/2023 with diagnosis's including but not limited to: metabolic encephalopathy, vascular dementia, bipolar disorder, adult failure to thrive, chronic atrial fibrillation, type two diabetes, sleep apnea, hallucination, and orthostatic hypotension. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] for Resident #26 revealed no behaviors, rejection of care or wandering. 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, observation, and staff interview, the facility failed to ensure a Frazier Water Protocol (protocol to allow residents with dysphagia to freely consume thin liquid water with supervision) was followed per resident preference and as physician ordered. This affected one (#21) of one residents reviewed for hydration. The facility census was 85. Findings include: Review of Resident # 21's medical record revealed an admission date of 06/09/2020. Diagnoses included, but not limited to, chronic kidney disease, dysphagia, aphasia, anoxic brain damage, unspecified atrial fibrillation, hypertension, blindness in right eye, type II diabetes, muscle weakness and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 required partial or moderate assistance with eating. Review of a physician order dated 05/10/21 revealed Resident #21 was ordered a Frazier Water Protocol after meals for dysphagia. Additionally, Resident #21 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, review of the facility's Self-Reported Incident (SRI), and policy review, the facility failed to protect the resident's right to be free from sexual abuse. This affected one (Resident #1) of three residents reviewed for sexual abuse. The facility census was 92. Findings include: Closed medical record review for Resident #1 revealed an admission date of 04/14/22. Diagnoses included chronic obstructive pulmonary disease, hemiplegia and hemiparesis affecting the left dominant side, dementia, depression, and Alzheimer's disease. Resident #1 was sent to the emergency room on [DATE] at 4:21 P.M. and the family will transfer Resident #1 to another facility upon discharge from the hospital. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired with a Brief Interview of Mental Status (BIMS) score of seven. Resident #1 required extensive assistance from staff with bed mobility, transfers, and toilet…

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, observations and staff and resident interviews, the facility failed to provide wound care treatment as ordered by the physician. This affected two (#110 and #176) residents out of the three reviewed for wound care. The facility census was 92. Findings include: 1. Review of the medical record for Resident #110 revealed an admission date of 05/19/23 with medical diagnoses of morbid obesity, hypertension, and depression. Review of the medical record for Resident #110 revealed a significant change Minimum Data Set (MDS) assessment, dated 06/19/23, which indicated Resident #110 was cognitively intact and required extensive staff assistance with bed mobility, transfers, toileting, and was dependent upon staff for bathing. The MDS did not contain documentation to support Resident #110 had any pressure ulcers or skin issues. Review of the medical record revealed a wound physician note, dated 09/07/23, which stated Resident #110 had chronic ulcers of right foot. Further review of the medical record revealed a wound physician note, dated 09/21/23, which stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the facility failed to ensure call lights were answered in a timely manner by any staff available and trained to complete the task. This affected three resident rooms (#301, #308 and #310) of three resident rooms reviewed for call light response. Findings include: Observation on 05/18/21 at 8:24 A.M. revealed room call lights for rooms 301, 308 and 310 were activated for assistance. Observation on 05/18/21 at 8:27 A.M. of Registered Nurse (RN) #106 and License Practical Nurse (LPN) #204 continued standing at the medication cart and prepared medications. At 08:29 AM continued to sound for room [ROOM NUMBER], 308 and 310 alerting staff members of activation. Observation on 05/18/21 at 8:30 A.M. the Director of Nursing (DON) and Unit Manager #105 walked onto the unit and by the rooms with the call light activated. Neither staff responded to the call lights. At 08:34 A.M. the call lights for room [ROOM NUMBER], 308 and 310 continued to sound in the hallway and on the call…

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, family interview, observation, and review of the Centers for Disease Control (CDC) guidelines, the facility failed to ensure residents who were recently admitted to the facility were put on quarantine status. This affected three residents (#140, #258, and #292 ) of four reviewed for newly admissions. The facility Census was 99. Findings include: 1. Medical record review revealed Resident #140 was admitted to the facility on [DATE] with diagnoses including heart beat irregularity, high blood pressure, and falls. There was no evidence the resident had received the COVID-19 vaccination. Observation on 05/10/21 at 10:30 A.M. revealed Resident #140 was in a private room. There was no isolation cart with personal protective equipment (PPE) outside of the resident's door, or a sign on the door indicating the resident was on quarantine status. Interview with Registered Nurse (RN) #105 on 05/10/21 at 2:30 P.M. revealed Resident #140 had received the first vaccination for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review the facility failed to notify the resident and the contact party of a room change. This affected two residents (#63 and #75) of 20 residents reviewed. The facility census was 99. Findings include: 1. Review of Resident #63's medical record revealed an admission date of 09/05/20. Diagnoses included chronic pulmonary disease, major depressive disorder, anxiety, and chronic pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 was cognitively intact, had no behaviors, and required extensive assist with one-person physical assist. Resident #63 had a responsible party emergency contact. Further review of the medical record revealed there was no notification to the resident or the responsible party prior to a room change. Interview on 05/10/21 at 11:25 A.M., Resident #63 reported he was moved a week ago due to an incident happening with the former roommate. He was not given a notice in advance of his room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the Notice of Medicare Non Coverage forms, and staff interview the facility failed to ensure timely notification was made to the resident or residents representative of the discontinuation of skilled services. This affected two residents (#08 and #05) of three reviewed for beneficiary notice. The facility census was 99. Findings include: 1. Review of the medical record for Resident #08 revealed an admission date on 07/25/20. Diagnoses included Covid-19 (history), history of falls, restless leg syndrome, hypertension, schizoaffective disorder, insomnia, major depressive disorder, and vascular dementia. Review of the document titled Notice of Medicare Non Coverage (NOMNC) revealed skilled services would end for Resident #08 on 02/04/21. Further review of the document revealed the resident or the resident representative had not signed the required document. Additionally, a letter attached to the NOMNC on the facility letter head dated 03/11/21 stated this letter was 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 record review, interview, and policy review the facility failed to report an allegation of resident to resident abuse. This affected two residents (#61 and #63) of 21 reviewed for abuse. The facility census was 99. Findings include: 1. Review of the medical record revealed Resident #61 was admitted on [DATE]. Diagnoses included Alzheimer's Disease, mixed receptive language, cognitive communication deficit and alcohol dependence. Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 was moderately impaired with no physical or verbal behaviors exhibited. Review of the nurse notes dated 12/26/20 revealed Resident #61 was upset with staff and stated he was going home. Resident #61 was unable to be redirected by staff. Review of the nurse notes dated 05/06/21 revealed Resident #61 was using profanity towards staff and throwing objects off of the bedside table. Review of the Care Plan revealed Resident #61 was verbally abusive towards staff, exhibited verbal aggression…

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, interview, and policy review the facility failed to thoroughly investigate an allegation of resident to resident abuse. This affected two residents (#61 and #63) of 21 reviewed for abuse. The facility census was 99. Findings include: 1. Review of the medical record revealed Resident #61 was admitted on [DATE]. Diagnoses included Alzheimer's Disease, mixed receptive language, cognitive communication deficit and alcohol dependence. Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 was moderately impaired with no physical or verbal behaviors exhibited. Review of the nurse notes dated 12/26/20 revealed Resident #61 was upset with staff and stated he was going home. Resident #61 was unable to be redirected by staff. Review of the nurse notes dated 05/06/21 revealed Resident #61 was using profanity towards staff and throwing objects off of the bedside table. Review of the Care Plan revealed Resident #61 was verbally abusive towards staff, exhibited…

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, and policy review, the facility failed to ensure residents were provided a written notice of reason for the transfer. This affected one resident (#257) of two residents reviewed for transfer. The facility census was 99. Findings include: Review of the medical record for Resident #257 revealed an admission date on 04/15/21. Diagnoses included cystitis (urinary tract infection), repeated falls, injury of falling, acid reflux, [NAME] cell (skin cancer) carcinoma, and hearing loss. Review of the admission Minimum Data Set, dated [DATE] revealed the resident had intact cognition. The resident required extensive assistance of two people for bed mobility, supervision for transfers, and extensive assistance for toileting with one staff member. The resident was coded as having one fall with no injuries in the look back period. Review of the plan of care dated 04/15/21 revealed the resident was at high risk for falls. Interventions included anticipate and meet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and review of the Resident Assessment Instrument (RAI), the facility failed to timely complete resident minimum data set (MDS) assessments as required. This affected three (#49, #55 and #27) of three residents reviewed for timely completion and submission of the MDS to Centers of Medicare and Medicaid. Facility census was 88. Findings include: 1. Review of medical record for Resident #49 revealed an admission on [DATE] with diagnoses including high blood pressure, abnormal heart rhythm, heart failure and heart disease. Review of the admission MDS dated [DATE] for Resident #49 revealed the assessment was completed on 08/02/21 instead of 07/30/21 as required by the RAI manual. 2. Review of the medical record for Resident #55 revealed an admission on [DATE] with diagnoses including metabolic encephalopathy, diabetes, major depressive disorder, and anxiety. Review of the admission MDS assessment dated [DATE] for Resident #55 revealed the assessment was completed 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 medical record review, observation, and interview the facility failed to accurately code the Minimum Data Set (MDS) reflecting the current health care status. This affected one resident (#48) of three residents reviewed for MDS accuracy. The facility census was 99. Findings include: Review of medical record for Resident #48 revealed an initial admission date on 02/26/17 with discharge on [DATE] and a readmission on [DATE] due to fecal impaction and urinary tract infection. Diagnoses included peripheral vascular disease, cellulitis of left lower leg, chronic gout, peripheral neuropathy, benign prostatic hyperplasia with urinary tract infections, chronic kidney disease edema, dysphagia, metabolic encephalopathy, chronic pain, convulsion, hypertension, neuromuscular dysfunction of bladder. Review of the plan of care 01/08/19 revealed the resident had an indwelling catheter due to neurogenic bladder. Interventions include change catheter as ordered, monitor intake and output per policy, and resident uses an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and policy review the facility failed to develop and implement a baseline plan of care and provide a summary to the resident within 48 hours after admission. This affected one resident (#247) of one resident reviewed for baseline plan of care. The facility census was 99. Findings include: Medical record review for Resident #247 revealed an admission date of 05/05/21. Diagnoses included abdominal aortic aneurysm without rupture, anxiety, anorexia, hypertension, chronic obstructive pulmonary disease, and lung cancer. Resident is the responsible party listed in the electronic health record. Review of the baseline plan of care dated 05/05/21 revealed a partially completed document without any signatures of facility staff members, resident or the resident representative. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition. Resident #247 required limited assistance for bed mobility and transfers. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review the facility failed to ensure the type and location of dialysis site access was addressed in the comprehensive care plan. This affected one resident (#38) of two residents who received dialysis. The census was 99. Findings Include: Review of the medical record for Resident #38 revealed an admission date of 04/28/15. Diagnoses included end stage renal disease on hemodialysis, diabetes mellitus type two, and vascular dementia. Review of the active physician orders revealed an order dated 02/23/21 for Resident #38 to receive hemodialysis on Tuesday and Thursday. Further review of the active physician orders revealed there were no orders indicating Resident #38's type and location of dialysis site access. Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #38 was cognitively intact and received dialysis. Review of Resident #38's comprehensive care plan revealed a focus of Resident #38 need for dialysis related to end…

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 interview the facility failed to ensure the comprehensive care was revised to include an accurate dialysis schedule, accurate medication usage, and constipation issues. This affected two residents (#38 and #48) of 29 residents reviewed for comprehensive care plans. The census was 99. Findings Include: 1. Review of the medical record for Resident #38 revealed an admission date of 04/28/15. Diagnoses included end stage renal disease on hemodialysis, diabetes mellitus type two, and vascular dementia. Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #38 was cognitively intact and received dialysis. Review of the active physician orders revealed an order dated 02/23/21 for Resident #38 to receive hemodialysis on Tuesday and Thursday. Review of the comprehensive care plan revealed a focus of Resident #38 needs for dialysis related to end stage renal disease. Further review of the comprehensive care plan revealed Resident #38 received…

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 discharge summary was provided to residents upon discharge. This affected one resident (#89) of four residents reviewed for discharge/hospitalization. The facility census was 99. Findings Include: Review of the medical record for Resident #89 revealed an admission date of 03/29/21. Diagnoses included diabetes mellitus type two, hypertension, and cerebral infarction. Review of the admission minimum data set assessment dated [DATE] revealed Resident #89 had moderate cognitive impairment and required extensive assistance with activities of daily living. Review of the health status note dated 04/14/21 at 12:11 P.M. revealed Resident #89 discharged home and all belongings and medication went with the resident. Review of the medical record for Resident #89 revealed no evidence of a discharge summary having been provided to Resident #89 upon discharge. Interview with the Unit Manager #701 on 05/18/21 at 11:50 A.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review the facility failed to ensure residents were provided timely incontinence care. This affected two residents (#60 and #71) of two residents reviewed for incontinence care of 44 incontinent residents. The facility census was 99. Findings Include: 1. Review of the medical record for Resident #60 revealed an admission date of 04/10/18. Diagnoses included chronic kidney disease stage three, diabetes mellitus type two, and neuromuscular dysfunction of bladder. Review of the annual minimum data set assessment dated [DATE] revealed Resident #60 was cognitively intact, required limited assistance with activities of daily living, required total dependence assistance with bathing, and was always incontinent of bowel and bladder. Interview with Resident #60 on 05/11/21 at 11:18 A.M. revealed she was left wet in her bed for extended periods of time. Interview with State Tested Nurse Aide (STNA) #332 on 05/17/21 at 2:08 P.M. revealed she worked on day shift and frequently…

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, interview, and policy review the facility staff failed to monitor a dialysis access site. This affected one resident (#38) of two residents who received dialysis. The census was 99. Findings Include: Review of the medical record for Resident #38 revealed an admission date of 04/28/15. Diagnoses included end stage renal disease on hemodialysis, diabetes mellitus type two, and vascular dementia. Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #38 was cognitively intact and received dialysis. Review of the active physician orders revealed an order dated 02/23/21 for Resident #38 to receive hemodialysis on Tuesday and Thursday. Review of the active physician orders revealed they had no documentation of the type and location of the residents dialysis access site as well as any orders to monitor the dialysis access site. Review of the Medication Administration Record and Treatment Administration Record dated 04/01/21 through 05/17/21 revealed no…

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

Based on observation, staff interview, and policy review the facility failed to ensure medication was stored in a secure manner away from resident access. This had the potential to affected seven residents (#31, #26, #28, #55, #74, #44 #255) who the facility identified as independently mobile and confused of 15 who resided on the memory care unit and six residents (#246, #251, #5, #8, #24, #34) of 47 residents residing on the 100 and 200 halls. The facility census was 99. Findings include: 1. Observation on 05/10/21 at 12:05 P.M. of the nursing supply room located on the 100 hall. The door to the supply room was unlocked. Inside the room, was a metal storage cabinet unlocked that contained multiples of nasal decongestant, ear drops, deep sea nasal spray, milk of magnesia, polyethylene laxative, calcium antacid, metricida plus 30 chemical, aspirin 81 milligram (mg) 36 bottles, ferrous sulfate elixir, antacid liquid, Mucinex expectorant, and MiraLAX single use packets for the facility stock supply. Interview on 05/10/21 at 12:10 P.M., with LPN #212 verified the metal cabinet should be…

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