Crestmont North Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Record review of Resident #26 revealed she was admitted to the facility 03/21/25. Diagnoses included PTSD. Her care plan identified potential for behaviors related to PTSD including accusatory behaviors, but did not clarify what caused the PTSD or potential triggers or situations to avoid. Review of her progress notes, care plan, assessments, and psychiatry service notes revealed no documentation of the cause, triggers, or ongoing effects of the PTSD. Interview with the Director of Nursing (DON) on 05/29/25 at 9:35 A.M. confirmed Resident #26's medical record did not contain an assessment for trauma informed care related to the resident's of PTSD and did not address the needs of the trauma survivor by minimizing triggers and/or re-traumatization. The DON said PTSD was managed with an outside counseling service who only provided their information on request alongside the facility psychiatric service. She said the surveyor would have to speak with Resident #26 to find out the source of her PTSD. Interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation, staff interview, record review, and review of facility policy, the facility failed to ensure Resident #23 was free of significant medication errors. This affected one (#23) of five residents observed for medication administration. The facility census was 68. Findings include: Review of the medical record for Resident #23 revealed an admission date of 04/22/25. Diagnoses included malignant neoplasm of oropharynx (middle section of the pharynx/ throat), rheumatoid arthritis, hypotension, and convulsions. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had impaired cognition and had a PEG tube. Review of undated care plan revealed Resident #23 was at risk for aspiration related to tube feeding as he had a malignant neoplasm of the oropharynx. Interventions included check placement of percutaneous endoscopic gastrostomy (PEG) tube prior to tube feedings, assess tube site daily for infection, flush PEG tube as ordered and notify physician of any changes.…

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, record review, facility policy review, and review of the Center for Disease Control and Prevention (CDC) guidance, the facility failed to initiate and use enhanced barrier precautions (EBP) for residents with indwelling medical devices during high contact resident care activities. The facility also failed to ensure staff followed infection control procedures during catheter care. This affected two (#12 and #23) of two residents reviewed for EBP and one (#12) of one resident reviewed for catheter care. The facility identified nine residents on EBP and two residents with catheters. The facility census was 68. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 04/22/25. Diagnoses included malignant neoplasm of oropharynx (middle section of the pharynx/ throat), rheumatoid arthritis, hypotension and convulsions. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had impaired cognition 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 record reviews and interviews, the facility failed to ensure comprehensive care plans were initiated for all resident care needs. This affected four residents (Resident #7, Resident #11, Resident #25, and Resident #48's) out of five residents reviewed for comprehensive care plans. The facility census was 56. Findings included: 1. Review of the medical record for Resident #48 revealed an admission date of 09/12/20. Diagnosis included but not limited to cerebral infarction, vascular dementia, unspecified severity with other behavioral disturbance, unspecified psychosis not due to substance or known physiological condition, dementia with behavioral disturbance, hypertension, and difficulty walking. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 had intact cognition and always incontinent of bladder and bowel. Review of the laboratory results for urinalysis culture and sensitivity dated 08/26/24 revealed Resident #48 was positive for Escherichia Coli 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.

Based on record review and interviews, the facility failed to ensure comprehensive care plans were revised to reflect new fall interventions. This affected three residents (Resident #7, Resident #25, and Resident #48) out of five residents reviewed for comprehensive care plans. Findings included: 1. Review of the medical record for Resident #48 revealed an admission date of 09/12/20. Diagnosis included but not limited to cerebral infarction, vascular dementia, unspecified severity with other behavioral disturbance, unspecified psychosis not due to substance or known physiological condition, dementia with behavioral disturbance, hypertension, and difficulty walking. Review of care plan dated 09/11/20 revealed Resident #48 had a fall on 10/31/24 and the care plan was not revised to reflect new interventions of non skid socks when out of bed to prevent falls. Interview on 11/26/24 at 8:49 A.M. with Director of Nursing (DON) confirmed care plans were not done correctly and fall interventions were not updated on the care plan. 2. Review of the medical record for Resident #25 revealed an…

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

Based on record review and interviews, the facility failed to ensure residents were timely assessed for risk of falls to ensure appropriate interventions were in place to prevent falls. This affected three residents (Resident #11, Resident #21, and Resident #48) out of five residents reviewed for accident hazards. Findings included: 1. Review of the medical record for Resident #48 revealed an admission date of 09/12/20. Diagnosis included but not limited to cerebral infarction, vascular dementia, unspecified severity with other behavioral disturbance, unspecified psychosis not due to substance or known physiological condition, dementia with behavioral disturbance, hypertension, and difficulty walking. Review of the falls risk assessment revealed Resident #48's latest fall risk assessments were completed on 10/02/24 and 10/31/24. Prior to 10/31/24 the resident was not assessed for falls since 03/08/21. Interview on 11/26/24 at 8:49 A.M. with Director of Nursing (DON) confirmed falls risk assessments were not being completed as required. 2. Review of the medical record for Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure residents were administered medication per physician orders. This affected two residents (#7 and #48) out of three residents reviewed for medication administration. Findings included: 1. Review of the medical record revealed Resident ##7 revealed an admission date of 10/17/19. Diagnosis included but not limited to cerebral infarction, unspecified dementia with behavioral disturbance, type two diabetes, major depressive disorder, and seizures. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had intact cognition. Review of the laboratory results for urinalysis culture and sensitivity dated 08/04/24 revealed Resident #7 was positive for Staphylococcus Haemolyticus of the urine and had a urinary tract infection (UTI). Review of the physician order dated 08/04/24 revealed an order for Macrobid (antibiotic) 100 milligrams (mg) every twelve (12) hours for five (5) days. Review of the medication…

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 maintain the kitchen area in a clean and sanitary condition. This had the potential to affect 57 of 58 residents who resided in the facility. The facility identified one resident (#30) who did not receive food from the kitchen. Findings include: Observation during the tour of the kitchen with Assistant Dietary Manager #624 on 08/22/22 at 8:30 A.M. revealed the following: - An accumulation of dust on the evaporator fans hanging from the ceilings of both the walk in freezer and walk in refrigerator. There was so much dust on them you could see strings of dust blowing from the fans. Food items were stored in both of these areas. - Four sealed boxes (one each of broccoli, Brussel sprouts, oriental blend, and carrots) sitting on the floor of the walk-in freezer. - One undated and resealed bag of three breaded chicken patties; one undated and resealed bag of ten lasagna rolls; one undated and resealed half full bag of diced chicken; and one undated and resealed bag of eight country fried steak patties sitting…

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

Based on observation, interview and policy review, the facility failed to maintain a clean and sanitary environment for residents, employees and visitors. This affected all 58 residents in the facility. Findings include: General observations made on 08/22/22 at 9:15 A.M. revealed the carpeted hallways were significantly stained and worn. Observation of the smoking area on 08/22/22, 08/23/22 and 08/24/22 revealed two long wrought iron couches. One couch had no cushions. The other wrought iron couch had three discolored cushions. The cushions were lumpy and not flat. The smokers from the secured unit were observed being led to the designated smoking area. There were nine residents identified as smokers who resided on the secured unit (#11, #20, #27, #44, #48, #51, #54, #156 and #207). Four Residents (#20, #27, #54 and #156) were identified as ambulatory and would need a seat during smoking. Interview with Resident #26 on 08/22/22 at 12:08 P.M. reported his wheelchair was not cleaned. Observation of Resident #26's wheelchair at the time of the interview revealed the rungs under 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 record review and interview, the facility failed to ensure a representative of the Office of the State Long-Term Care Ombudsman was notified of facility initiated discharges. This affected 18 residents (Residents #18, #51, #206, #207, #208, #209, #210, #211, #212, #213, #214, #215, #216, #217, #218, #219, #220 and #221.) The census was 58. Findings include: Interview on 08/24/22 at 11:45 A.M. with Social Services (SS) #608 revealed the facility had not been notifying the State Long-Term Care Ombudsman of facility-initiated discharges. SS #608 verified the last notification to the Ombudsman was on 02/02/21 for January 2021 facility discharges. Review of a facsimile transmittal report, dated 02/02/21, addressed to Ombudsman from the facility regarding discharge notification revealed a list of discharges from the facility during January 2021. Review of the facility admission/discharge report, dated 08/24/22, for residents discharged from 02/01/21 to 08/24/22 revealed the following residents received a facility-initiated discharge to an acute care hospital: - Resident #206 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 observation, interview, record review and policy review, the facility failed to develop individualized care plans for Residents #14, #35, #37, #42 and #48 related to smoking, wounds, and pain. This affected five of 24 resident care plans reviewed. Findings include: 1. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, cerebral ischemia, adult failure to thrive, surgical amputation of left big toe, major depressive disorder, chronic pain, insomnia, lumbago and sciatica, syncope and collapse. Review of the smoking assessment dated [DATE] indicated Resident #35 was a daily smoker and did not need the facility to store his lighter or cigarettes. On 08/22/22 at 11:29 A.M. Resident #35 was observed wheeling down the hallway with an unlit cigarette hanging out of his mouth. Resident #35 was also observed smoking independently on 08/23/22 at 10:29 A.M. and 12:17 P.M. Review of Resident #35'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 interview, observation, and record review the facility failed to ensure the designated smoking area was maintained in a safe manner affecting all 23 residents (Residents #1, #2, #3, #8, #10, #11, #12, #14, #16, #20, #21, #23, #27, #31, #35, #37, #44, #45, #48, #51, #54, #156, #207) that smoked at the facility. The facility also failed to ensure Resident #31 was properly supervised and smoking materials were maintained by nursing as identified in her care plan and/or smoking assessment affecting one resident (Resident #31) out of three residents (Residents #31, #35, and #37) reviewed for smoking. The facility census was 58. Findings include: 1. Observation on 08/22/22 at 11:44 A.M. revealed a plastic garbage container without a cover was in the outside designated smoking area that was approximately three- fourths full of plastic and Styrofoam cups and paper debris. The garbage container also contained approximately 15 cigarette butts laying on top of the cups and paper debris, and cigarette ashes 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.

Based on record review and staff interview the facility failed to ensure resident funds were conveyed timely upon discharge from the facility. This affected one resident (#221) of two residents reviewed for conveyance of funds. The facility census was 58. Findings include: Review of the medical record for Resident #221 revealed an admission date of 02/25/22 and discharge date of 03/31/22. Review of the business records for Resident #221 revealed a check for $320.00 dispersed to the treasurer of the state dated 07/27/22 to close Resident #221's account. Interview on 08/25/22 at 11:09 A.M. with Administrator verified Resident #221's funds were conveyed outside of the required 30 day timeframe.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure reasonable care was taken for the protection of resident property from loss or theft. This affected two residents (Resident#14, and #34) out of three residents (Resident #14, #32, and #34) reviewed for misappropriation of personal property. The facility census was 58. Findings include: 1. Review of medical record for Resident #34 revealed an admission date of 09/09/21. Resident #34 was admitted to the hospital on [DATE]. Diagnoses included multiple sclerosis, hypertension, morbid obesity, bipolar disorder, mood disorder, and major depression. The medical record did not include a personal inventory of her belongings. Review of the care plan dated 10/28/21 revealed Resident #34 had an activities of daily living self-care deficit related to multiple sclerosis, neurogenic bladder, lymphedema, and obesity. The care plan indicated Resident #34 was totally dependent of staff with bed mobility, and transfers. There was nothing per her care plan regarding…

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 and record review the facility failed to ensure a Patient Assessment and Resident Review (PASRR) was completed as required for two residents (Resident #34 and Resident #37) out of two residents (Resident #34 and #37) reviewed for PASRR. The facility census was 58. Findings include: 1. Review of medical record for Resident #34 revealed an admission date of 09/09/21. The record revealed Resident #34 was admitted to the hospital on [DATE] and discharged to another facility on 08/22/22. Diagnoses included multiple sclerosis, bipolar disorder, mood disorder, and major depression. There was no PASRR, or hospital exemption noted in her medical record. Review of the care plan dated 10/28/21 revealed Resident #34 had behavioral symptoms related to psychiatric diagnoses. Resident #34 had verbal aggression as she yelled at staff when immediate gratification could not be met, argumentative when redirected per caregivers, demanding, accusatory and manipulative behaviors as she threatened to contact 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 and record review, the facility failed to ensure the physician acted upon the recommendations by the pharmacist for Resident #42. This affected one of five residents reviewed for unnecessary medications. Findings include: Review of the medical record revealed Resident #42 revealed the resident was admitted to the facility on [DATE] with diagnoses including pneumonia, vascular dementia with behavioral disturbance, hyperlipidemia, hypertension, hypothyroidism, psychosis, COVID 19, cerebral infarction. Review of the current physician orders revealed Resident #42 was ordered ibuprofen (a non-opioid analgesic) 500 milligrams as needed for pain and oxycodone (an opioid analgesic) for pain. There were no parameters as to when to administer the non-opioid or opioid analgesic. Review of the pain evaluation dated 06/15/22 indicated Resident #42 had general pain, occasionally, made it hard to sleep at night, limited her day to day activities, movement increased her pain, pain meds only help. Description…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review the facility failed to ensure a bottle of Dakin's (diluted bleach solution) was secured in Resident #30 and Resident #48's room located on the secured unit. This affected two (Residents #30 and #48) out of seven Residents (#8, #15, #28, #29, #30, #48, and #256) reviewed for unsecured medications and/ or treatment supplies in their rooms. This had the potential to affect 18 residents (Resident #11, #12, #13, #16, #20, #24, #25, #27, #30, #32, #40, #48, #49, #50, #51, #52, #54, #156, #256) on the secured unit that were independent with ambulation and/or locomotion or unsecured medication was located in their room. Findings include: 1. Review of the medical record for Resident #48 revealed an admission date of 03/15/22 and diagnoses included chronic obstructive pulmonary disease, diabetes, quadriplegia, alcohol abuse, and borderline personality disorder. Review of the care plan dated 04/03/22 revealed Resident #48 required the secured behavioral unit as he 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.

Based on observation of trayline, review of a test tray, interview, record review and policy review the facility failed to ensure meals were served at palatable temperatures. This had the potential to affect all 49 residents residing in the facility. Findings include: Observation of lunch trayline on 08/27/19 starting at 12:03 P.M. revealed a meal consisting of bruchetta chicken (breaded chicken breast with tomatoes and cheese), buttered bowtie pasta, Italian green beans, a bread stick and an ice cream cup. Temperatures were taken at the start of trayline by [NAME] #106 with the facility's self-calibrating digital thermometer and were as follows: pureed noodles 166 degrees Fahrenheit (F), pureed green beans 178 degrees F, mashed potatoes 197 degrees F, pureed chicken bruchetta 158 degrees F, ground chicken bruchetta 149 degrees F, noodles 143 degrees F, green beans 209 degrees F, chicken 182 degrees F and milk 33 degrees F. Trayline started on 08/27/19 at 12:10 P.M. and a test tray was requested for the back (secured) unit. The back unit meals were started at 12:21 P.M., the test…

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

Based on observation, interview and policy review, the facility failed to ensure clean and sanitary nourishment areas. This affected all 49 residents receiving food from the kitchen. The facility census was 49. Findings include: Observation of the back unit nourishment refrigerator with Dietary Manager (DM) #100 on 08/26/19 at 9:20 A.M. revealed three sandwiches not labeled or dated, three takeout containers not labeled or dated and a half gallon of chocolate milk dated 08/19/19. The back unit refrigerator's shelves were noted to have spilled juice on them. Observation of the front unit nourishment refrigerator with DM #100 on 08/26/19 at 9:25 A.M. revealed two sandwiches and one chef's salad not labeled or dated and three containers of whitefish spread not dated. Interview with DM #100 at the time of the above observations verified resident food items were to be labeled, dated and stored in a clean and sanitary environment. Review of an undated sign posted on both the back and front unit refrigerators revealed third shift nurses were responsible for filling out temperature logs…

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 review of beneficiary notices, the facility failed to ensure Residents #38 and #53 were provided skilled nursing facility advanced beneficiary notices upon being cut from skilled services and remaining in the facility and failed to provide 48 hours notice of the end of skilled services to Resident #53 to initiate an appeal if desired. This affected two of three beneficiary notices reviewed (#3). The facility census was 49 residents. Findings include: Review of the beneficiary notices revealed Resident #38 was provided a notice of Medicare non-coverage that skilled services would end on 07/25/19 and signed receipt of the notice on 07/23/19. Resident #53 was provided a notice of Medicare non-coverage that skilled services would end on 08/09/19. The daughter signed receipt of the notice on 08/09/19. There was no evidence the notice was provided 48 hours prior to the end of skilled coverage. Review of the beneficiary notices revealed two residents (#38 and #53) who remained in the facility were not provided skilled nursing facility advanced beneficiary notice 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, interview and record review, the facility failed to ensure residents receive appropriate and assessed restorative services. This affected three residents (#9, #27 and #43) of four residents (#9, #27, #31 and #43) reviewed for range of motion out of 45 residents #2, #4, #5, #6, #7, #8, #9, #10, #12, #14, #15, #16, #17, #18, #19, #20, #21, #23, #25, #26, #27, #28, #29, #31, #32, #33, #34, #35, #36, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #49, #50, #51, #52, #53 and #204) identified as receiving one or more restorative services. The facility census was 49 residents. Findings include: 1. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including moyamoya disease, altered mental status, restlessness an agitation, hemiplegia and hemiparesis affecting left non dominant side, convulsions, brief psychotic disorder, encephalopathy, cortical blindness, left watershed and right stroke. Review of the restorative mobility assessment 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 observation, interview and policy review, the facility failed to ensure the humidifier had enough water to bubble and failed to ensure oxygen equipment was kept clean. The affected six residents (#6, #35, #38, #41, #43 and #55) of eight residents (#6, #18, #35, #38, #41, #43, #49, and #55) whose oxygen concentrators were not maintained. The facility census was 49. Findings include: On 08/26/19 at 9:30 A.M. Resident #43 was observed in room using oxygen via nasal canula at 2 liters per minute. The oxygen concentrator was observed to be moderately soiled with loose and dried debris. The bottle of water was dated 08/02/19 and was empty. On 08/26/19 at 4:28 P.M. Licensed Practical Nurse (LPN) #104 verified the condition of the oxygen concentrator, the date on the bottle and that the bottle was empty. Interview with LPN #104 on 08/26/19 at 4:28 P.M. indicated every shift the nurse was to check the oxygen for each resident. She said the equipment should be changed weekly including the humidifier. She confirmed the bottle was dated 08/02/19 and should have been changed a couple 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 record review and interview, the facility failed to ensure residents were provided with written notice of transfer. This affected one resident (Resident #41) of one resident reviewed for hospitalization. The facility census was 49 residents. Findings include: Review of Resident #41's medical record revealed an admission date of 05/14/12 and diagnoses including failure to thrive, multiple sclerosis, diabetes, cocaine abuse, dysphagia and hypertension. Review of a discharge minimum data set (MDS) assessment dated [DATE] revealed Resident #41 was cognitively intact and required extensive assistance for transfers and dressing. Review of a nurses' note dated 07/18/19 revealed Resident #41 was lethargic, drowsy, drooling and cold and clammy to touch. Registered Nurse (RN) #103 took his blood sugar which measured 46 millimoles/liter (mmol/L) and administered orange juice, oral glucose (sugar) and a glucagon injection (injectable sugar solution used to raise blood sugar levels). RN #103 took Resident #41'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 record review and interview, the facility failed to submit a resident discharge assessment for a resident who was discharged to the hospital and did not return to the facility. This affected one resident (Resident #1) of one residents reviewed for resident discharge assessments. The facility census was 49. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses including dementia, chronic obstructive pulmonary disease, senile degeneration of brain, hypertension and depression. Review of the medical record for Resident #1 revealed nurses' notes indicating the resident was discharged to the hospital on [DATE]. The medical record did not reveal a completed or transmitted resident MDS (minimum data set) discharge assessment. An interview with the Assistant Director of Nursing (ADON)/MDS Nurse on 08/29/18 at 3:00 P.M., confirmed that Resident #1 was transferred to the hospital on [DATE] and then transferred to another facility. The ADON/MDS Nurse indicated the family did not…

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 interview, the facility failed to coordinate care regarding resident pre-admission screen and resident review (PASRR). This affected one resident (Resident #19) of three residents reviewed who had a level two mental illness or intellectual disability. The facility census was 49. Findings include: Resident #19 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, muscle weakness, generalized anxiety disorder, dementia with behavioral disturbance and paranoid schizophrenia. Review of the pre-admission screen and resident review (PASRR) determination dated [DATE] revealed Resident #19 had a history of serious mental illness and was approved for nursing facility services for a specified period of 90 days to allow sufficient time to prepare for a safe and orderly transition from the nursing facility to the community. Resident #19 was to return to the community when the determination expired on [DATE]. Review of Resident #19's electronic and paper medical records…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure care plans were revised as needed. This affected one (Resident #51) of 23 residents reviewed for care plans. The facility census was 49 residents. Findings include: Review of Resident #51's medical record revealed an admission date of 02/27/19 with diagnoses including hypertension (high blood pressure), type two diabetes, anemia and osteoarthritis, Review of a quarterly comprehensive assessment dated [DATE] revealed Resident #51 was cognitively intact, required supervision for eating and extensive assistance of one staff for toileting, hygiene and dressing. Review of a smoking assessment dated [DATE] revealed Resident #51 required assistance to get to the outside patio and his cigarettes and lighter were to be kept in a secured area. Review of an undated care plan for smoking revealed Resident #51's cigarettes were to be kept at the nurses's station and the resident could smoke unsupervised. An additional intervention listed revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Resident #48 received treatment and care in accordance with the comprehensive person-centered care plan. This affected one, Resident #48, of three residents (#21, #35 and #48) reviewed for non-pressure skin impairment. The facility census was 49 residents. Findings include: Review of the medical record revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including altered mental status, symbolic dysfunctions, dementia without behavioral disturbance and weakness. Review of the physician's order dated 07/26/19 indicated she was to wear Tubigrips or Geri sleeves (protective sleeves) to all extremities. Review of the comprehensive assessment (MDS 3.0) dated 08/06/19 indicated she was severely cognitively impaired, displayed no behavioral symptoms, had skin tears and non surgical dressings. Review of the potential for skin tears related to thin skin plan of care developed on 07/26/19 indicated to keep her nails…

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.