Carecore At Lima

Based on resident interview, staff interview, and test tray, the facility failed to serve palatable meals. This affected two residents (#57 and #60) of two residents reviewed for meals. The facility was 80. Findings include: Review of a test tray on 09/25/24 at 11:55 A.M. with Registered Nurse #178 revealed a plate with roast pork loin, mashed potatoes, and broccoli. Gravy covered the mashed potatoes and pork loin. The broccoli was served in a separate bowl on the plate. The plate presentation was pleasing. The temperature of the food was warm. The pork was seasoned well and tender. The mashed potatoes were bland with very little flavor. Additionally, the gravy had minimal flavor. Further, the broccoli was cooked to an appropriate texture but was bland and unseasoned. RN #178 confirmed the mashed potatoes, gravy, and broccoli tasted bland and lacked seasoning. Interview on 09/25/24 at 12:23 P.M. with Resident #60 revealed she thought the mashed potatoes and gravy tasted bland. Interview on 09/25/24 at 12:26 P.M. with Resident #57 revealed she felt the mashed potatoes were 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.

Based on record review, observations staff and resident interviews and policy review the facility failed to ensure a residents dressing changes were completed per physician orders. This affected one (#20) out of three residents reviewed for skin breakdown. The facility census was 70. Findings include: Record review of Resident #20 revealed an admission date of 12/20/23. Diagnoses included complete traumatic amputation of left great toe, spina bifida, inflammatory polyneuropathy, paraplegia, osteomyelitis, non-pressure chronic ulcer, adult failure to thrive, gastro-esophageal reflux disease, pressure ulcer of unspecified site, major depressive disorder, opioid dependence, anorexia and stimulant abuse. Review of the Minimum Data Set (MDS) assessment completed on 01/01/24 revealed Resident #20 with a Brief Interview for Mental Status (BIMS) with a score of 15 out of 15 indicating the resident was cognitively intact. Functional imitation in range of motion revealed no impairment both upper extremities, and impairment to both lower extremities. Further review of Resident #20's medical…

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

Based on record review, review of a medication error report, staff interview and policy review, the facility failed to ensure medications were transcribed and administered per the physician's order. This affected one (#20) out of three residents reviewed for medication administration. The facility census was 70. Findings include: Record review of Resident #20 revealed an admission date of 12/20/23. Diagnoses included complete traumatic amputation of left great toe, spina bifida, inflammatory polyneuropathy, paraplegia, osteomyelitis, non-pressure chronic ulcer, adult failure to thrive, gastro-esophageal reflux disease, pressure ulcer of unspecified site, major depressive disorder, opioid dependence, anorexia and stimulant abuse. Review of the Minimum Data Set (MDS) assessment completed on 01/01/24 revealed Resident #20 with a Brief Interview for Mental Status (BIMS) with a score of 15 out of 15 indicating the resident was cognitively intact. Functional imitation in range of motion revealed no impairment both upper extremities, and impairment to both lower extremities. Review of…

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

Based on observation, record review, staff interview and policy review, the facility failed to ensure residents received medication per the physician's orders resulting in three medication errors out of 25 opportunities or a 12 percent (%) medication error rate. This affected one (#32) out of two residents observed for medication administration. The facility census was 70. Findings include: Record review of Resident #32 revealed an admission date of 02/29/24. Diagnoses included cerebral infarction due to embolism of right middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, coronary artery disease, major depressive disorder, personal history of transient ischemic attack (TIA), cerebral infarction, anxiety disorder, history of other venous thrombosis and embolism, history of traumatic brain injury, chronic pain syndrome, seizures, dementia and mood disturbance Observation on 03/22/24 at 8:54 A.M. of medication administration pass with Licensed Practical Nurse (LPN) #210 revealed Resident #32 was administered the following…

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, review of the Local Health Department Inspection, review of the dishwasher temperature logs, review of the dishwasher manufacture recommendations, and staff interviews, the facility failed to ensure the dishwasher was at a temperature to properly sanitize dishes. This had the potential to affect all 70 residents who received food from the kitchen. The facility identified two residents who do not receive food from the kitchen. The facility census was 74. Findings include: Observation on 03/06/24 at 7:51 A.M. of the dishwasher in the kitchen revealed dishwasher model was AF 30 S. Specifications on label on dishwasher revealed wash 45 seconds, rinse 30 seconds and dwell 15 seconds. Recommended wash temperatures is 120 degrees Fahrenheit (F) minimum and 50 parts per million (PPM) of chlorine rinse. Rinse temperature is 120 degrees F minimum. Two compartment sink observed in the dish area and one compartment sink observed in the prep area. Observation on 03/06/24 at 8:13 A.M. revealed the dishwasher in the kitchen was in use and had a wash temperature of 66 degrees…

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 policy, the facility failed to ensure the medical record contained accurate documentation regarding resident monitoring. This affected one (#14) of three residents reviewed for monitoring. The facility census was 67. Findings include: Review of the medical record for Resident #14 revealed an admission date of 01/03/23 with diagnoses of encephalopathy, chronic pancreatitis, and need for assistance with personal care. Further review revealed Resident #14 was admitted to the hospital on [DATE] and remained out of the facility at the time of the survey conducted 12/18/23. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had impaired cognition and did not exhibit physical, verbal, or other behaviors. Further review revealed Resident #14 was not on an anticoagulant. Continued review revealed Resident #14 received scheduled and as-needed pain medication. Review of the physician orders for Resident #14 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review, local police detective interview, staff interviews, family interview, review of local newspaper article, and review of the Self-Reported Incident reporting website, the facility failed to timely report to the state agnecy allegations of mistreatment/neglect of a resident. This affected one (#1) of six residents reviewed for potential mistreatment/neglect. The current census is 69. Findings include: Review of Resident #1's medical record revealed and admission date of [DATE] and discharged on [DATE]. Diagnoses for Resident #1 included: metabolic encephalopathy, diabetes type two, kidney disease, pulmonary edema, and acute respiratory failure. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and was a one-person assist for Activities of Daily (ADL). Per the assessment the resident had not been diagnosed with any neurological disorders. Per the assessment the resident had been diagnosed 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 on medical record review, policy review, local police detective interview, staff interviews, family interview, review of local newspaper article, and review of the Self-Reported Incident reporting website, the facility failed to investigate allegations of mistreatment/neglect of a resident. This affected one (#1) of six residents reviewed for potential mistreatment/neglect. The current census is 69. Findings include: Review of Resident #1's medical record revealed and admission date of [DATE] and discharged on [DATE]. Diagnoses for Resident #1 included: metabolic encephalopathy, diabetes type two, kidney disease, pulmonary edema, and acute respiratory failure. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and was a one-person assist for Activities of Daily (ADL). Per the assessment the resident had not been diagnosed with any neurological disorders. Per the assessment the resident had been diagnosed with depression but no other…

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, policy review and staff interview, the facility failed to ensure the medical records contained the name of the nurse who provided care and all assessments contained accurate information. This affected two (#1 and #4) residents of four resident medical records reviewed for accuracy. The current census is 69. Findings include: 1. Review of Resident #1's medical record revealed and admission date of 05/31/23 and discharged on 11/27/23. Diagnoses for Resident #1 included: metabolic encephalopathy, diabetes type two, kidney disease, pulmonary edema, and acute respiratory failure. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and was a one-person assist for Activities of Daily (ADL). Per the assessment the resident had not been diagnosed with any neurological disorders. Per the assessment the resident had been diagnosed with depression but no other psychiatric disorders. Review of Resident #1's care plans 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 observation, resident and staff interviews, review of Resident Council meeting minutes, and policy review, the facility failed to ensure food was served at a safe and appetizing temperature. This had the potential to affect all 72 residents who received meals from the facility. The facility identified Resident #90 as receiving no food from the kitchen. The facility census was 73. Findings include: Interview on 08/09/23 at 5:46 A.M. with Resident #54 stated her meals are not hot when delivered to her room and she did not think it tasted very good. Interview on 08/09/23 at 6:31 A.M. with Registered Nurse (RN) #45 confirmed she was aware of resident complaints related to the food not taking good. Interview on 08/09/23 at 8:02 A.M. with Resident #14 stated her meals are not hot and the drinks are not always cold when delivered to her room. Resident #14 stated the meals usually did not taste good. Interview on 08/09/23 at 7:41 A.M. with Resident #48 stated his meals are always cold when delivered to his room and the drinks are not cold but cool to taste. Resident #48 also 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 record review and staff interview, the facility failed to ensure Dietary Manager #232 had proper Safe Serve credentials. This had the potential to affect 73 residents who received meals from the kitchen. The facility census was 75. Findings include: Review of Dietary Managers #232 Serve Safe certificate revealed an expiration date of [DATE]. Interview on [DATE] at 09:44 A.M. Dietary Manager #232 verified her Serve Safe certificate was expired as of [DATE].

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 residents' Minimum Data Set (MDS) assessments were accurate. This affected six (#7, #32, #41, #53, #63, and #71) of 26 residents reviewed for MDS assessment accuracy. The facility census was 75. Findings include: 1. Review of the medical record revealed Resident #41 was admitted on [DATE]. Diagnosis included schizophrenia, infection and inflammatory reaction due to indwelling urethral catheter, resistance to multiple antibiotics, unspecified asthma, sepsis due to escherichia coli, major depressive disorder recurrent, anxiety, paraplegia, muscle weakness, weakness, need for assistance with personal care, neuromuscular dysfunction of bladder, hypothyroidism, essential (primary) hypertension, sleep apnea, dependence on supplemental oxygen, autoimmune thyroiditis, and acute kidney failure. Review of the Minimum Data Set (MDS) assessment, dated 03/01/22, revealed the resident received an anticoagulant seven…

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 the care plan accurately reflected the care of five residents (#45, #53, #44, #41, and #73) out of five residents reviewed for accuracy of the care plan. The facility census was 75. Findings include: 1. Review of the medical record of Resident #45 revealed an admission date of 02/26/18 with a diagnosis of neuromuscular dysfunction of bladder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed the presence of the indwelling urinary catheter. Review of the care plan revised on 05/02/22 revealed no mention of the indwelling urinary catheter with no interventions. Interview on 05/04/22 at 2:04 P.M. Regional Director of Clinical Operations #250 verified the care plan did not included the indwelling urinary catheter for Resident #45. 2. Review of the medical record for Resident #53 revealed an admission date of 03/07/22 with a diagnosis of urinary tract infection (UTI). Resident #53…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure the appropriate/required members of the interdisciplinary team (IDT) were invited to participate in the care planning process. This affected five residents (#7, #31, #44, #53, and #73) of five residents reviewed for care planning. The facility census was 75. Findings include: 1. Review of the medical record revealed Resident #73 was admitted on [DATE]. Diagnosis include quadriplegia, retention of urine, anorexia, urinary tract infection, muscle weakness, pressure ulcer of right buttock stage IV, pressure ulcer of other site stage IV, pressure ulcer of left heel unstageable, pressure ulcer of left hip stage IV, uninhibited neuropathic bladder, moderate protein-calorie malnutrition, schizoaffective disorder, non-pressure chronic ulcer of right calf with unspecified severity, anemia, pressure ulcer of sacral region stage IV, non-pressure chronic ulcer of skin of other sites with unspecified…

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

Based on medical record review and staff interview the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) form prior to discharge. This affected one resident (#129) out of three residents reviewed for NOMNC notification. The facility census was 75. Findings include: Review of the closed medical record of Resident #129 revealed an admission date of 11/15/21 and a discharge, per his request, on 12/15/22. The record was silent for any NOMNC form being issued to him. Resident #129 left the facility prior to his last day of coverage. Interview on 05/04/22 at 10:02 A.M. with Minimum Data Set Nurse #201 revealed the facility had no documentation of Resident #129 having been issued a NOMNC before discharge. She added Resident #129 had left voluntarily but still should have received a NOMNC as the facility knew at least a week in advance of his departure and he would have days remaining.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review, staff interview, and policy review, the facility failed to notify the resident/resident representative in writing of the reason for transfer/discharge to the hospital. Additionally, the facility failed to notify the ombudsman of the resident's transfer/discharge to the hospital. This affected one (#76) of one resident reviewed for hospitalization. The census was 75. Findings include: Review of the medical record for Resident #76 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, opioid dependence, dependence on renal dialysis,, psychoactive substance use, pneumonia, schizophrenia, affective mood disorder, atrial fibrillation, major depression, severe protein calorie malnutrition. Review of the progress notes revealed Resident #76 was sent to the hospital on [DATE] at 3:00 P.M. for evaluation and treated related to blood and a large mass, dark in color, with no odor in the resident's bedpan. Continued review of 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 resident record review, staff interview, and policy review; the facility failed to notify the resident/resident representative of the facility's bed hold policy when a resident was transferred to the hospital. This affected one (#76)) of one resident record reviewed for hospitalization. The census was 75. Findings include: Review of the medical record for Resident #76 revealed the resident was admitted to the facility on [DATE]. Diagnoses include chronic obstructive pulmonary disease, opioid dependence, dependence on renal dialysis, psychoactive substance use, pneumonia, schizophrenia, affective mood disorder, atrial fibrillation, major depression, severe protein calorie malnutrition. Review of the progress notes revealed Resident #76 was sent to the hospital on [DATE] at 3:00 P.M. for evaluation and treated related to blood and a large mass, dark in color, with no odor in the resident's bedpan. Continued review of a progress note dated 02/27/22 at 3:11 P.M., revealed the resident was admitted to 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, resident and staff interviews, and review of facility policy, the facility failed to provide timely follow-up appointments and implement a treatment plan to include wound vac as ordered by the physician. This affected one resident (#58) of one resident reviewed for out of facility appointments and one resident(#73) of one resident reviewed for functional wound treatment equipment. The census was 75. Findings include: 1. Review of the medical record revealed Resident #58 was admitted on [DATE]. Diagnoses included unspecified fracture of fourth thoracic vertebra subsequent encounter for fracture with routine healing, infection following a procedure deep incisional site, methicillin resistant staphylococcus aureus infections as the cause of disease classified elsewhere, acute respiratory failure with hypoxia, and centrilobular emphysema. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively intact. Review of orthopedic specialist notes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review and staff interview, the facility failed to timely notify the physician of abnormal laboratory results. This affected one (#7) of three residents reviewed for urinary tract infection. The census was 75. Findings include: Review of the medical record for Resident #7 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, schizophrenia, and chronic obstructive pulmonary disease (COPD). Review of a 5-day Minimum Data Set assessment dated [DATE], revealed Resident #7 had severe impaired cognition. The resident was dependent of one person for toileting and occasionally incontinent of urine. Review of the medical record for Resident #7 revealed the resident was admitted to the hospital for COPD exacerbation and hypoxia from 03/09/22 to 03/17/22. Review of a laboratory test, specimen collection date 03/09/22, revealed the resident had an abnormal urinalysis. The results were reported to the facility on [DATE] and included the sensitivity…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, review of a facility policy, and review of guidance from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure unvaccinated residents were quarantined following readmission. This affected two (#73 and #277) of two residents reviewed after readmission to the facility. The census was 75. Findings include: 1. Review of the medical record revealed Resident #73 was admitted on [DATE]. Diagnosis include quadriplegia, retention of urine, anorexia, urinary tract infection, muscle weakness, pressure ulcer of right buttock stage IV, pressure ulcer of other site stage IV, pressure ulcer of left heel unstageable, pressure ulcer of left hip stage IV, non-pressure chronic ulcer of right calf with unspecified severity, anemia, pressure ulcer of sacral region stage IV, non-pressure chronic ulcer of skin of other sites with unspecified severity, pressure ulcer of right lower back stage IV, pressure ulcer of left lower back stage IV, 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 resident record review, staff interview, review of infection surveillance documentation, and review of facility policy, the facility failed to implement antibiotic stewardship protocol to ensure appropriate antibiotic use. This affected one resident (#7) of three residents reviewed for urinary tract infection. The census was 75. Findings include: Review of the medical record for Resident #7 revealed the resident was admitted to the facility on [DATE]. Diagnoses include chronic kidney disease, schizophrenia, and chronic obstructive pulmonary disease (COPD). Review of a 5-day minimum data set assessment dated [DATE], revealed Resident #7 had severe impaired cognition. The resident was dependent of one person for toileting and occasionally incontinent of urine. Review of a laboratory test, specimen collection date 03/09/22, revealed the resident had an abnormal urinalysis (UA). The results were reported to the facility on [DATE] and included the sensitivity results. Review of the laboratory test results…

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 review of a facility policy, the facility failed to ensure expired medications were disposed of according to manufacturer guidelines. The facility also failed to ensure medications and biologicals were properly secured. This affected one of two medication storage rooms and one intravenous medication storage cart and had the potential to affect all 76 residents residing in the facility. The facility census was 76. Findings include: Observation of the facility medication storage room on the 500 hallway on 07/02/19 at 7:45 A.M. with the Assistant Director of Nursing (ADON) #26 revealed two unopened full bottles (60 tablets) of Advanced Stress Formula Plus Zinc (supplement) with an expiration date of 10/2017, eight sixteen ounce bottles of Dioctyl Liquid (stool softener/laxative) with an expiration date of 03/2018, one four ounce bottle of Guaiasorb M (cough syrup) with an expiration date of 04/2018, one four ounce bottle of Guaiasorb M with an expiration date of 05/2019 and two bottles of Aspirin 325 milligrams (100 tablets) with an expiration…

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

Based on review of sign-in sheets for Quality Assurance (QA) Meetings and staff interview, the facility failed to ensure the Medical Director (MD) was present for the quarterly meetings. This had the potential to affect all 76 residents who resided in the facility. The census was 76. Findings include: Review of the QA quarterly meeting sign-in sheets dated 10/18/18, 12/11/18, 01/10/19, and 04/24/19 revealed there was not signature for the MD. Interview with the Administrator on 07/02/19 at 10:37 A.M. verified the MD didn't sign in for the QA meetings. The Administrator stated if he couldn't attend the QA meetings on the exact day the facility scheduled the meeting, we would have a meeting with him at a later date and go over, in detail what the meeting was about. The facility confirmed this had the potential to affect all 76 residents residing in the facility.

Based on record review staff interview and review of policy and procedures, the facility failed to have an adequate infection control surveillance program in place for tracking and trending infections to prevent possible outbreaks. This had the potential to affect all 76 residents residing in the building. Facility census was 76. Findings include: Review of the facility's infection control surveillance program revealed the facility was using a floor map will yellow high lighted areas. The highlight areas also lacked any identification of the organism to ensure tracking and trending was completed. Further review lacked any documentation/tracking of the residents name, pathogen/infection, requiring isolation or not, date of onset, signs or symptoms, treatment, nosocomial or not and outcome of the residents infection type. On 07/01/19 at 2:57 P.M. interview with Director of Nursing (DON) verified the facility did not have an effective infection control surveillance program in place to monitor, track and trend infections as required. The DON was also unable to ensure which type of…

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

Based on record review, staff interview and review of policy and procedures, the facility failed to have a adequate antibiotic stewardship program in place to ensure antibiotics were prescribed for infections. This had the potential to affect all 76 residents residing in the facility. Facility census was 76. Findings include: Review of antibiotic stewardship information provided by the facility for (March/April/May 2019) documented residents names with antibiotic used, diagnosis, with some durations documented. The documentation was on a note book paper. Further review lacked dates the antibiotic were initiated, any culture results or documentation the antibiotics were reviewed to ensure it was prescribed properly to treat infections with outcome details. On 07/01/19 at 2:57 P.M. interview with Director of Nursing (DON) verified her antibiotic stewardship program was not effective and she was unable to produce enough information about the antibiotics prescribed to ensure they were being use properly to treat verified infections. The DON further revealed some residents come from 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 2. Review of medical record for Resident #37 revealed an admission date of 04/04/18 with diagnosis including abnormal posture, muscle weakness, osteomyelitis of the vertebrae, sacral and sacrococcygeal region, heart failure, multiple sclerosis, colostomy status, neuromuscular dysfunction of the bladder, anemia and hyperlipidemia. Review of Quarterly MDS assessment dated [DATE] documented Resident #37 was cognitively intact with deficits assessed. Review of nursing notes dated 06/09/19 documented Resident #37 was discharge to the hospital on [DATE] due to a change of condition. Review of nurse notes dated 06/21/19 documented resident #37 was readmitted from the hospital. Review of entire medial record for Resident #37 lacked any documentation of written documentation being provided to the resident in an understandable language for the reason she was being discharged to the hospital. Further review also lacked any documentation of the office of the state long term care ombudsman being notified of the hospital…

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 2. Review of medical record for Resident #37 revealed an admission date of 04/04/18 with diagnosis including abnormal posture, muscle weakness, osteomyelitis of the vertebrae, sacral and sacrococcygeal region, heart failure, multiple sclerosis, colostomy status, neuromuscular dysfunction of the bladder, anemia and hyperlipidemia. Review of Quarterly MDS assessment dated [DATE] documented Resident #37 was cognitively intact with deficits assessed. Review of nursing notes dated 06/09/19 documented Resident #37 was discharge to the hospital on [DATE] due to a change of condition. Review of nurse notes dated 06/21/19 documented resident #37 was readmitted from the hospital. Review of entire medial record for resident #37 lacked any documentation of her receiving a bed hold policy notification in regards to her bed hold days remaining upon transfer to the hospital. 3. Medical record review for Resident #49 revealed he was admitted on [DATE]. Medical diagnoses included heart failure, peripheral vascular disease,…

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 review of facility policy, the facility failed to ensure call lights were installed in bathrooms accessible to residents in the 300 hallway. This had the potential to affect 16 (#222, #58, #54, #48, #25, #59, #6, #68, #172, #52, #61, #45, #33, #64, #2 and #18) who resided on the 300 hall and that could access the bathroom located on the 300 hallway. The facility census was 76. Findings include: Observation on 06/30/19 at 9:10 A.M. of the bathrooms near the 300 hall nurses station found the bathroom door unlocked, opened and had no call light installed in the bathroom. Two independently mobile residents were observed outside the open door of the bathroom. Interview on 06/30/19 at 9:15 A.M. with Housekeeping Staff (HS) #15 revealed the unmarked bathroom was considered the women's bathroom but anyone could use it. HS #15 reported the bathroom was kept unlocked. Observation on 06/30/19 at 10:09 A.M. of the women's bathroom near the 300 hall nurses station found the bathroom door unlocked and no call light installed in the bathroom. An…

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

Based on observation, staff interview and review of a facility policies, the facility failed to ensure the facility was maintained in good repair. This affected seven (#4, #46, #20, #31, #17, #29 and #69) out of 76 residents room observed during the survey. The facility census was 76. Findings included: Observations during the initial pool on 06/30/19 from 8:00 A.M. through 12:00 P.M. revealed Resident #4's wall behind the head of the bed to have damaged drywall with deep gouges to the surface of the wall. Resident #4's bathroom was a shared bathroom with Resident #46, #20 and #31 and had damaged drywall indicated by torn strips of dry wall next to the soap dispenser on the wall near the sink. Observation of Resident #17's bathroom revealed it to be a shared bathroom with Resident #29 and #69 with damaged drywall indicated by torn strips of dry wall next to the soap dispenser on the wall near the sink. Resident #17, #29 and #69's bathroom wall to the left side of the toilet was observed to have a brown dried splattered substance to the lower wall. Interview on 07/01/19 at 7:50 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 medical record review, observation, staff interview, and policy review, the facility failed to ensure residents were afforded their right to dignity when covers were not in place over indwelling foley (urinary) catheter bags for Resident #37 and #49. This affected two (#37 and #49) of three residents reviewed for catheters. The facility identified there were four indwelling foley catheters. The census was 76. Findings included: 1. Medical record review for Resident #37 revealed an admission date of 04/04/18. Medical diagnoses included heart failure, deep vein thrombosis, multiple sclerosis, and neurogenic bladder. Review of annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. Functional status was total dependence for bed mobility, transfer, toilet use and eating was supervision. She was coded for an indwelling foley catheter. Observation was made of Resident #37 on 06/30/19 at 1:11 P.M. revealed she was sitting in the hallway in her wheelchair with her indwelling…

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 proper paperwork was completed for advance directive for Resident #37. This affected one (#37) out of 24 reviewed for advanced directives. The facility census was 76. Findings included: Medical record review for Resident #37 revealed an admission date of 04/04/18. Medical diagnoses included heart failure, deep vein thrombosis, multiple sclerosis, and neurogenic bladder. Review of annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Functional status was total dependence for bed mobility, transfer, toilet use and eating was supervision. Review of electronic medical record for Resident #37 revealed she was a Do Not Resuscitate Arrest (DNR-Arrest). Further review of hard chart for Resident #37 revealed it was silent for proper paperwork for a DNR-Arrest. Interview with Licensed Practical Nurse (LPN) #49 on 06/30/19 at 3:45 P.M. verified there was no paperwork in Resident…

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

Based on observation, medical record review and staff interview the facility failed to ensure there was a baseline care plan initiated for Resident #173 for indwelling foley (urinary) catheter care. This affected one (#173) of six reviewed for 48-hour baseline care plans. The census was 76. Findings included: Medical record review for Resident #173 revealed an admission date of 06/20/19. Diagnoses included malignant neoplasm of colon. Review of admission observation dated 06/20/19 revealed she was cognitively intact. Functional status was independent for bed mobility, transfers, eating and toilet use. Review of 48-hour baseline care plans revealed they were silent to a care plan for indwelling foley catheter care. Observation of Resident #173 on 06/30/19 at 11:22 A.M. revealed she had a indwelling foley catheter. Interview with Licensed Practical Nurse (LPN) #6 on 07/01/19 at 2:05 P.M. verified there wasn't a 48-hour care plan for Resident #173 and there should have been.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, the facility failed to ensure residents were properly position for meals. This affected two (#16 and #17) of two residents randomly observed for positioning while eating. The facility census was 68. Findings include: Observation on 08/20/19 at 11:32 A.M., revealed Resident #16 and Resident #17 were observed sitting in their beds, slouched down where the bed bends with the head of the bed elevated. The over the bed tray table was placed over top over each resident. Resident #16 and Resident #17 were observed trying to lift their heads up off the bed so they could see and reach their lunch meal. Review of the medical record for Resident #16 revealed an admission date of 04/30/18. Diagnoses include essential hypertension, muscle weakness, type 2 diabetes mellitus with hyperglycemia, schizophrenia, iron deficiency anemia and acute kidney failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #16 had moderate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview, medical record review and review of facility policy, the facility failed to ensure a resident's blood sugars was obtained to ensure insulin was administered as ordered prior to residents consuming breakfast. This affected one (#64) of six reviewed for medications. The facility identified six residents who received morning insulin prior to breakfast. The facility census was 76. Findings include: Review of Resident #64's medical record revealed an admission date of 03/30/19. Diagnoses included heart disease, hyperlipidemia, hypertension, chronic kidney disease, hypothyroidism, type II diabetes, anemia, cirrhosis of the liver, epilepsy, peripheral vascular disease, and dementia. Review of Resident #64's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine indicating Resident #64 was moderately cognitively impaired. Resident #64 required supervision for bed mobility, transfer, walking, locomotion, dressing, eating,…

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 policy and procedures, the facility failed to ensure a resident received a splint device and passive range of motion (PROM) services as recommended by therapy to ensure the current level of function was maintained. This affected one (#12) out of two resident reviewed for positioning and mobility. The facility identified 12 resident currently residing in the facility with contractures. Facility census was 76. Findings included: Review of medical record for Resident #12 revealed an admission date of 02/25/19 with diagnosis including contracture of unspecified joint, dysphagia, heart failure, chronic kidney disease, difficulty walking, dementia with behavioral disturbances, hypertension and schizophrenia. Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #12 was assessed as moderately cognitively impaired. Further review documented he had no function limitation to his bilateral upper extremities affecting…

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 there were physician orders the use of indwelling foley (urinary) catheters and failed to ensure catheter care was completed for Resident #49 and #173. Additionally, the facility also failed to have interventions in place for Resident #49's indwelling foley catheter care. This affected two (#49 and #173) of four reviewed for indwelling foley catheters. The census was 76. Findings include: 1. Medical record review for Resident #49 revealed he was admitted on [DATE]. Diagnoses include heart failure, peripheral vascular disease, Non-Alzheimer's and neurogenic bladder. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was cognitively impaired. His functional status was extensive assistance for bed mobility, transfers, supervision for eating and total dependence for toilet use. He was coded for a indwelling foley catheter. Review of physician orders from 01/01/19 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interview, and review of a facility policy, the facility failed to ensure nutritional recommendations were implemented as recommended by the registered dietitian. This affected one (#41) out of three residents reviewed for nutrition. The facility census was 76. Findings include: Review of Resident #41's medical record revealed an admission date of 04/27/17. Diagnoses included urethritis, extrapyramidal movement disorder, embolism and thrombosis of unspecified vein, osteoarthritis, incompatibility reaction due to transfusion of blood products, abdominal hernia, nicotine dependence, asthma, anxiety disorder, major depressive disorder, type two diabetes mellitus, obstructive sleep apnea, overactive bladder, post-traumatic stress disorder, gastroesophageal reflux disorder, symbolic dysfunctions, epileptic seizures, schizophrenia, hypertension, dysphagia, pancreatitis, and flaccid hemiplegia of the left side. Review of the annual Minimum Data Set (MDS) assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, medical record review and review of facility policy, the facility failed to ensure resident's were provided diets as ordered. This affected one (#25) out of two residents reviewed for nutrition. The facility identified eight residents who received pureed diets. The facility census was 76. Findings included: Review of Resident #25's medical record revealed an admission date of 04/30/18. Diagnoses included anemia, difficulty walking, muscle weakness, hypertension, type II diabetes, schizophrenia, acute kidney failure, osteomyelitis of vertebra, and colostomy status. Review of Resident #25's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 indicating Resident #25 was moderately cognitively impaired. Resident #25 required extensive assistance with bed mobility, locomotion, dressing, toilet use, and personal hygiene. Resident #25 was totally dependent for transfer and required supervision for eating.…

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.