Vista Center, The

Based on observation, interview, and review of the facility policy and procedure the facility failed to maintain the ice machine in a clean and sanitary manner. This had to potential to affect all residents except one resident (#36) who had a physician order for no fluids. The facility census was 49. Findings include: Observation during the tour of the kitchen on 01/06/25 from 9:17 A.M. to 9:30 A.M. with Dietary Manager (DM) #806 revealed the ice machine located outside of kitchen, on the outside of each side of the ice machine was a moderate amount of a white substance running down each side. Interview on 01/06/24 between 9:17 A.M. and 9:30 A.M., with DM #806 verified the white substance and stated when they place the water softener it will help eliminate that substance. DM #806 stated she believed the ice machine was cleaned monthly. Review of the facility policy titled Food Safety: Ice, undated revealed ice machines and containers will be cleaned and sanitized on a regular basis.

Based on review of staffing schedules and time sheets and interview, the facility failed to submit accurate data related to direct care staff to the Centers for Medicare and Medicaid Services (CMS) from July 2024 through September 2024. This had the potential to affect all 48 residents. Findings include: On 12/30/24 at 6:40 A.M., Certified Nursing Assistant (CNA) #840 reported the Residential Care Facility (RCF) hall had no separate staff between the hours of 11:00 P.M. to 7:00 A.M. On 12/30/24 at 6:45 A.M., Registered Nurse (RN) #819 stated there was no separate staff for the RCF form 11:00 P.M. to 7:00 A.M. Nursing facility staff cover the RCF during those hours with two nurses splitting the hall. Nursing assistants attended to personal needs of the residents of the RCF. Review of schedules for the RCF from July 2024 through September 2024 revealed there were no RCF staff scheduled from 11:00 P.M. to 7:00 A.M. There were 34 other shifts in which the RCF schedule did not reflect separate staff on the RCF. On 12/31/24 at 9:30 A.M., staffing and scheduling was discussed with Human…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, review of census sheets, policy review and interview, the facility failed to implement isolation protocol for a resident with clostridium difficile and failed to position catheters in a manner to decrease the possibility of urinary tract infections. This had the potential to affect all 48 residents. Finding include: 1. On 12/30/24 at 10:19 A.M., Resident #37 gave permission for a surveyor to enter his room. After entering the room, Resident #37 reported to the surveyor he had tested positive for clostridium difficile. No signs were posted regarding Resident #37 being on isolation. On 12/30/24 at 10:25 A.M., Activity Assistant #842 carried mail into Resident #37's room without donning personal protective equipment (PPE). Upon exiting Resident #37's room, Activity Assistant #842 stated she was aware Resident #37 had c diff and verified there was no signs for isolation posted. Activity Assistant #842 stated she did not need to wear PPE for residents with c diff when she 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.

Based on observations, interview, and record review the facility failed to ensure a clean, sanitary and functional environment. This affected 14 residents (#2, #3, #10, #13, #18, #19, #29, #31, #38, #47, #48, #49, #50, and #144) of 49 residents residing in the facility. The facility census was 49. Findings include: Observation on 12/30/24 at 11:25 A.M. of Residents #29 and #31's bathroom floor revealed a yellow/brown ring around the commode. Observation on 01/06/25 at 11:03 A.M. of Residents #2 and #19's room revealed multiple gouged areas in the bathroom wall, next to the shower, and trash was on the floor. Observation on 01/06/25 at 11:58 A.M. of Residents #47 and #144's room revealed the shower floor had a large, dried dirt stain and dried dirt stains on the bathroom floor and throughout room. Interview at the time of the observation, with Resident #47, revealed the floors were dirty and hadn't been mopped. Interview on 01/06/25 at 2:25 P.M. with Resident #50 revealed the right side bed rail (on their bed) was stuck and doesn't come up. Resident #50 stated it has been that way…

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 medical records were complete and contained documentation regarding medication administration, catheter care, a fall, a dietary upgrade, activities of daily living, restorative care, and the refusal of a dental extraction. This affected six (Resident #9, #13, #97, #26, #1, and #10) of 23 records reviewed for documentation. The facility census was 49. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 03/29/19 with diagnoses including amyotrophic lateral sclerosis, cerebral palsy, muscle weakness, dysphagia, pressure ulcer of sacrum, and schizophrenia. Review of the Care Plan, initiated on 04/25/22, revealed the resident received antipsychotic medication for schizophrenia with interventions including to administer medications as ordered. Review of Physician Order, dated 03/28/24 revealed the order for Aristada 882 milligrams (mg)/3.2 milliliters (ml) to be injected intramuscularly (IM) monthly on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review and interview, the facility failed to treat residents in a dignified manner by searching a resident's room without his knowledge and by providing incontinence care to a resident in a common area resulting in a video recording of the resident. This affected two (Residents #13 and #28) of three residents reviewed for dignity. Findings include: 1. During an interview with Resident #13 on 01/06/25 at 12:04 P.M., he stated he did not feel he was treated with dignity or respect because staff had gone into his room without his knowledge or permission and searched his belongings. Review of Resident #13's medical record revealed diagnoses including alcohol abuse and major depressive disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #13 was able to understand others, able to make himself understood, and was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15 (the maximum score one could get on the assessment). On 01/07/25…

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 interview, the facility failed to provide a resident timely access to information in the medical record. This affected one (Resident #10) of four residents interviewed during a resident council meeting. Findings include: Review of Resident #10's medical record revealed diagnoses including chronic osteomyelitis, metabolic encephalopathy, paraplegia, pressure ulcer to the sacrum, depression, and diabetes mellitus type II. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #10 was cognitively intact. On 01/07/25 between 2:06 P.M. and 2:20 P.M., Resident #10 reported he had requested to see his medical record in regard to x-ray results and wound assessments but was told he could not. On 01/09/25 at 3:40 P.M., the Administrator stated she was unaware of any resident requests to view their medical records. On 01/09/25 at 3:50 P.M., Resident #10 stated he could not recall who he had spoken to regarding wanting to review his medical record.…

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 ensure advance directives were accurate. This affected one (Resident #1) of 24 residents reviewed for advance directives. The facility census was 49. Findings include: Review of Resident #1's medical record revealed an admission date of 12/16/03 with diagnoses that included intentional self-harm by firearm discharge, traumatic brain injury and vascular dementia. Further review of the medical record including the electronic medical record code status indication, physician's orders and care plan indicated an advance directive of do not resuscitate comfort care arrest (DNRCC-A) (full medical care is implemented until the resident experiences cardiac or respiratory arrest and then comfort measures are initiated). Review of the actual advance directive form for Resident #1, signed by the resident's guardian and physician, indicated the actual advance directive of DNRCC (do not resuscitate comfort care) (comfort measures, no life saving measures) On 01/08/24 at 2:45 P.M. interview with the Director of Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to notify the resident representative of a change in health status. This affected one (Resident #35) of two residents reviewed for notification of change. The facility census was 49. Findings include: Medical record review revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including muscle weakness, cerebral infarction, major depressive disorder, acquired absence of left leg below the knee, and cognitive communication deficit. Review of the 5-Day Minimum Data Set (MDS) 3.0 assessment, dated 12/01/24, revealed a Brief Interview for Mental Status (BIM) score of 15, which indicated intact cognition. The MDS further revealed Resident #35 required staff assistance with activities of daily living (ADLs). Review of the admission record revealed Resident #35's son was listed as the resident's emergency contact and power of attorney. Interview on 12/30/24 at 9:20 A.M. with Ombudsman #950 revealed he had an open case…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of disciplinary action and investigative reports, policy review and interview, the facility failed to prevent neglect of a resident's physical needs. This affected one (Resident #28) of two residents reviewed for abuse. Findings include: Review of Resident #28's medical record revealed diagnoses including Alzheimer's disease, dementia, generalized anxiety disorder, restlessness and agitation. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had short and long term memory loss and had moderately impaired cognitive skills for daily decision making, and was always incontinent of bowel and bladder. A care plan initiated 03/27/24 revealed Resident #28 had alteration in thought process related to end stage Alzheimer's disease. Goals included for Resident #28's needs to be met on a consistent basis, to be clean, dry and odor free and for Resident #28 to be appropriately dressed. Interventions included providing simple daily routines and assisting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of disciplinary action/investigative reports, policy review and interview, the facility failed to timely report allegations of possible neglect of a resident's physical needs and failed to report allegations of neglect to the state survey agency. This affected one (Resident #28) of two residents reviewed for abuse. Findings include: Review of Resident #28's medical record revealed diagnoses including Alzheimer's disease, dementia, generalized anxiety disorder, restlessness and agitation. A quarterly MDS dated [DATE] revealed Resident #28 had short and long term memory loss and had moderately impaired cognitive skills for daily decision making, and was always incontinent of bowel and bladder. A care plan initiated 03/27/24 revealed Resident #28 had alteration in thought process related to end stage Alzheimer's disease. Goals included for Resident #28's needs to be met on a consistent basis, to be clean, dry and odor free and for Resident #28 to be appropriately dressed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of disciplinary action and investigative reports, policy review and interview, the facility failed to ensure a thorough investigation of allegations of possible neglect was completed. This affected one (Resident #28) of two residents reviewed for abuse. Findings include: Review of Resident #28's medical record revealed diagnoses including Alzheimer's disease, dementia, generalized anxiety disorder, restlessness and agitation. A quarterly MDS dated [DATE] revealed Resident #28 had short and long term memory loss and had moderately impaired cognitive skills for daily decision making, and was always incontinent of bowel and bladder. A care plan initiated 03/27/24 revealed Resident #28 had alteration in thought process related to end stage Alzheimer's disease. Goals included for Resident #28's needs to be met on a consistent basis, to be clean, dry and odor free and for Resident #28 to be appropriately dressed. Interventions included providing simple daily routines 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 medical record review and staff interview, the facility failed to ensure a resident Pre-admission Screening and Resident Review (PASRR) document accurately indicated all diagnoses. This affected one (Resident #37) of two residents reviewed for PASRR documents. The facility census was 49. Findings Include: Medical record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, quadriplegia, depressive disorder, obsessive-compulsive disorder, and alcohol abuse. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/04/24, revealed the resident had intact cognition with diagnoses including depression and manic depression. Review of Resident #37's PASRR document, dated 09/25/24, revealed under Section E, the diagnosis of bipolar disorder and major depression. Review of the resident's diagnoses list revealed obsessive-compulsive disorder, which was not indicated on Section E. Further review of Section E revealed Resident #37's diagnosis of…

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

Based on medical record review and interview, the facility failed to ensure residents and/or their representatives were provided with a written summary of the baseline care plan. This affected three (Residents #28, #29, and #97) of ten residents reviewed for baseline care plans. Findings include: 1. Review of Resident #28's medical record revealed an admission date of 03/15/24. Diagnoses included Alzheimer's disease, dementia, seizures, moderate protein calorie malnutrition, hypertension, generalized anxiety disorder, generalized anxiety disorder, epilepsy, hyperlipidemia, difficulty swallowing, restlessness and agitation. No evidence was located indicating a summary of the baseline care plan was provided to the resident and/or resident representative. On 01/13/25 at 3:40 P.M., the Director of Nursing (DON) provided a form signed by Social Service Designee (SSD) #812 which indicated discharge planning was discussed. The DON verified there was no information indicating Resident #28 and/or her representative provided with a summary of the baseline care plan. 2. Review of 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 resident interview, medical record review and staff interview, the facility failed to ensure medication orders for the use of laxatives were transcribed and administered as ordered for Resident #29 and vital signs obtained as ordered for Resident #9. This affected two (Resident #29 and #9) of 20 residents reviewed. The facility census was 49. Findings include: 1. Review of Resident #29's medical record revealed an admission date of 12/10/24 with diagnoses that included spinal stenosis, chronic pulmonary edema and constipation. Review of the Minimum Data Set (MDS) 3.0 admission assessment with a reference date of 12/17/24 indicated the resident had an independent and intact cognition level. Further review of the medical record including physician progress notes revealed on 12/24/24 Resident #29 was evaluated by the physician. Resident #29 had a concern of constipation. The physician ordered the use Milk of Magnesia (laxative) 30 milliliters (ml) daily until a bowel movement, then change to daily as needed. Review of the medication administration record (MAR) revealed on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, policy review, and interview, the facility failed to provide appropriate services after being observed on the floor. This affected one (Resident #26) of three residents reviewed for accidents. Findings include: Review of Resident #26's medical record revealed diagnoses including schizophrenia, muscle wasting and atrophy, parkinsonism, generalized muscle weakness, difficulty walking, need for assistance with personal care, blindness in one eye, and seizures. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #26 was usually able to make herself understood and was severely cognitively impaired. Resident #26 had inattention and disorganized thinking which fluctuated. Resident #26 had two or more falls since the prior assessment. A nursing note dated 12/31/24 at 2:42 P.M. indicated Licensed Practical Nurse (LPN) #844 was walking onto the unit when an aide notified her Resident #26 had fallen. When LPN #844 got to Resident #26's room she 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 record review and interview the facility failed to ensure consistent communication with dialysis and ensure medications were given per physician order on dialysis days. This affected one resident (#17) of one resident reviewed for dialysis. The facility census was 49. Findings include: Review of the medical record for Resident #17 revealed an admission date of 11/15/24. Diagnoses included noninfective gastroenteritis and colitis, moderate protein-calorie malnutrition, type 2 diabetes mellitus with diabetic nephropathy, diarrhea, end stage renal disease, hypomagnesemia, and dependence on renal dialysis Review of the admission minimum data set (MDS) assessment dated [DATE] revealed Resident #27 had intact cognition, required setup or clean up help for eating, received a therapeutic diet, and was on dialysis. Review of the physician orders for January 2025 revealed active orders for: Dialysis on Monday, Wednesday and Friday with chair time at 6:00 A.M., Calcium Acetate (phosphate binder) Oral Tablet 667…

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 pharmacy recommendations were addressed by the physician. This affected two (Resident #38 and Resident #10) of five residents reviewed for unnecessary medications. The facility census was 49. Findings include: 1. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including cerebral ischemia, muscle weakness, diabetes mellitus, chronic obstructive pulmonary disease, and peripheral vascular disease. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment, dated 12/10/24, revealed a Brief Interview for Mental Status (BIMS) assessment could not be completed. The resident was dependent on staff for physical assistance with activities of daily living (ADL)s. Review of the Monthly Regimen Review (MRR), dated 06/25/24, revealed the pharmacist recommended the intervention to rinse the resident's mouth with water after the use of her corticosteroid inhaler Advair to prevent thrush from…

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, interview and policy review , the facility failed to obtain a laboratory sample/test in a timely manner or as ordered. This affected one (Resident #37) of two residents reviewed for isolation and one (Resident #9) of five residents reviewed for unnecessary medications. Findings include: Review of Resident #37's medical record revealed diagnoses of enterocolitis due to clostridium difficile (diagnosis list indicated a date of 08/27/24), need for assistance with personal care, bipolar disorder, quadriplegia, and obsessive-compulsive disorder. A nursing note dated 12/19/24 at 1:49 P.M. indicated Resident #37 complained of severe diarrhea which had an odor to it. The physician was contacted and an order was received to obtain a stool specimen to rule out clostridium difficile (a very contagious bowel infection). A nursing note dated 12/19/24 at 3:51 P.M. indicated a stool specimen was collected. A nursing note dated 12/21/24 at 7:58 A.M. indicated a stool sample was to be collected and sent via (the contracted lab) in a sterile plain specimen cup on the…

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

Based on medical record review, review of the infection control log, interview, and policy review the facility failed to ensure the appropriate use of antibiotics. This affected two (Resident #9 and Resident #10) of five residents reviewed for unnecessary medications. Finding include: 1. Review of the medical record for Resident #9 revealed an admission date of 03/29/19 with diagnoses including amyotrophic lateral sclerosis, cerebral palsy, muscle weakness, dysphagia, pressure ulcer of sacrum, and schizophrenia. Review of Resident #9's urinalysis (UA), dated 01/04/25, revealed the urine color was turbid with trace protein, 4+ leukocytes, white blood cells greater than 50 (high power field) HPF, and bacteria too numerous to count. The UA indicated a culture and sensitivity (C&S) was pending as the UA met criteria. Further review of the medical record revealed no evidence of the UA culture and sensitivity result/report. Review of the Infection Control Log, dated January 2025, revealed the resident was ordered Cefdinir 300 milligrams (mg) for a UTI, with a start date of 01/05/25. There…

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 policy review, the facility failed to provide documented evidence of refusals of pneumococcal and influenza immunizations. This affected two (Resident #9 and Resident #38) of five residents reviewed for immunizations. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 03/29/19 with diagnoses including amyotrophic lateral sclerosis, cerebral palsy, muscle weakness, dysphagia, pressure ulcer of sacrum, and schizophrenia. Review of Resident #9's immunization report revealed the resident refused a Pneumovax immunization, however, there was no refusal/declination form signed by the resident/responsible party. 2. Review of the medical record for Resident #38 revealed an admission date of 06/12/24 with diagnoses including cerebral ischemia, muscle weakness, diabetes mellitus, chronic obstructive pulmonary disease, and peripheral vascular disease. Review of Resident #38's immunization report revealed the resident refused a pneumococcal immunization, however, there was no refusal/declination form signed…

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 closed medical record review, policy review, and interview, the facility failed to timely address resident health concerns resulting in the resident leaving the facility against medical advice (AMA). This affected one resident (Resident #7) of three residents reviewed for medications. Findings include: Review of the closed medical record for Resident #7 revealed an admission date of 07/21/23. Diagnoses included acute and chronic respiratory failure with hypoxia, muscle wasting and atrophy, chronic congestive heart failure, anxiety disorder, post-traumatic stress disorder, and major depressive disorder. The resident left the facility, against medical advice (AMA), on 07/22/23 at 2:20 A.M. Review of the admission assessment, dated 07/21/23, revealed the resident was cognitively intact. Review of a physician order, dated 07/21/23, revealed the order for buspirone (an anti-anxiety medication) HCL, one five milligram (mg) tablet by mouth four times per day for major depressive disorder. Review of a nurse progress note, authored by Licensed Practical Nurse (LPN) #21, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews with staff and residents, record review, policy review, and review of the the the payroll-based journal (PBJ) staffing report, the facility failed to have sufficient staffing to meet the needs of the residents. This affected Residents #12, #36, and #38 and had the potential to affect all residents. The census was 48. Findings include: 1. Review of the PBJ staffing report from fiscal year (FY) quarter one (10/01/23 through 12/31/23) revealed the facility had a one star staffing rating and excessively low weekend staffing. Observation upon entrance to the facility on [DATE] at 1:51 P.M. revealed no staff members in the hallways or at the nurses' station on the [NAME] wing (skilled unit) and the call light on for room [ROOM NUMBER]. Further observation revealed two housekeepers wheeling their carts down the first hall of the [NAME] wing, but no nursing staff were observed in the [NAME] wing. No nursing staff was observed in the front hall of the [NAME] wing until 2:01 P.M. when…

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 registered nurse coverage at least eight hours per day, seven days per week. This had the potential to affect all 48 residents residing in the facility. Findings include: Review of the staffing schedules from 03/03/24 to 03/09/24 with Human Resources (HR) #158 revealed no evidence of registered nurse (RN) coverage on 03/09/24 for at least eight hours as required. Interview on 03/28/24 at 11:58 A.M. with HR #158 confirmed the facility did not have RN coverage of at least eight hours on 03/09/24. At the time of the interview, the Administrator was also present and verified there was no RN coverage in the building for at least eight consecutive hours. This deficiency represents non-compliance investigated unde Complaint Number OH00151901, OH00151617, and OH00151630.

Based on interview and medical record review, the facility failed to complete pressure ulcer wound care per physician orders. This affected one resident (Resident #12) out of three residents reviewed for wound care. The facility census was 48. Findings include: Review of the medical record for Resident #12 revealed an admission date of 01/11/24 with diagnoses including osteomyelitis (infection of bone), muscle wasting and atrophy, dysphagia, pressure ulcer of the sacral region, anxiety disorder, and tracheostomy status. Review of the admission Minimum Data Set (MDS) assessment completed on 01/18/24 revealed Resident #12 had moderately impaired cognition, was always incontinent of urine, was dependent on staff for toileting and bathing, and was admitted with two unhealed, unstageable pressure ulcers. Review of the care plan dated 03/12/24 revealed Resident #12 was at high risk for altered skin integrity related to altered sensations, fragile skin, impaired mobility, incontinence, a colostomy bag for elimination, and a condom catheter. The care plan further revealed Resident #12 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, interviews, record review, and facility policy review the facility failed to ensure timely and appropriate incontinence care was provided for Resident #36 and Resident #38. This affected two of three residents who were reviewed for incontinence care. The facility census was 48. Findings include: 1. Review of the Medical Record for Resident #36 revealed an admission date of 12/23/21. Diagnoses included atrial fibrillation, muscle wasting and atrophy, type two diabetes mellitus, moderate protein-calorie malnutrition, adult failure to thrive, and systolic (congestive) heart failure. Review of the quarterly Minimum Data Set (MDS) assessment completed on 03/08/24 revealed Resident #36 had intact cognition, was dependent for toileting, always incontinent of urine, was at risk for the development of pressure ulcers, and had no skin issues at the time of the assessment. Review of the latest assessment titled CHS Skin assessment weekly/return/ER/LOA, dated 03/21/24, revealed Resident #36 had intact skin. Review of the Care Plan dated 03/08/24 revealed Resident #36 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 medical record review and interview, the facility failed to maintain accurate medical records for Resident #1 and Resident #12. This affected two residents (#1 and #12) of six residents reviewed for documentation of medications and wound care treatments. The facility census was 48. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 01/12/24 with diagnoses including acute and chronic respiratory failure with hypoxia, need for assistance with personal care, chronic obstructive pulmonary disease, type two diabetes mellitus, pneumonia, and hypertension. Review of the admission Minimum Data Set (MDS) assessment completed on 01/18/24 revealed Resident #1 had intact cognition, was incontinent of urine, dependent for toileting, and had no unhealed pressure ulcers. Review of the assessment titled Skin Grid Pressure 3.0 - V2 dated 01/23/24 revealed a new pressure area of the left buttock described as a shallow circular area composed of friable granular tissue. Review of physician orders revealed an order dated 02/13/24 to cleanse the open…

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

Based on observations and interview the facility failed to ensure food was properly labeled and dated in the refrigerator to prevent risk of food borne illness. This affected all 44 residents who ate food from the kitchen, as the facility did not identify any residents who did not eat by mouth. The facility census was 44. Findings included: Observation of the facility kitchen on 02/28/24 from 8:22 A.M. through 8:50 A.M. revealed in the refrigerator there was a bag of gravy-like liquid sitting in a stainless steel pan with no label to indicate what it exactly was, when it was opened nor a use-by date. In addition, there were several other food items having no dates to indicate when the items were prepared or opened and/or when they should be discarded by the staff. These items included a large bag of shredded cabbage and carrots (coleslaw mix), a bag of deli ham slices, a large stainless steel container which had three peanut butter and jelly sandwiches, two plates with tomato, lettuce and onion wrapped in plastic wrap, two plates with just lettuce wrapped in plastic wrap, two small…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the medical record, review of the facility fall investigation, review of facility policy and interview with the resident and staff, the facility failed to provide adequate assistance with care to prevent a fall for Resident #34. This affected one resident (Resident #34) of three residents reviewed for falls. The facility census was 44. Findings include: Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including need for assistance with personal care, muscle wasting and atrophy, Alzheimer's disease, diabetes, and cerebral infarction. Review of the plan of care dated 01/30/20 revealed Resident #34 had alterations in self bed mobility. Interventions included a bed mobility program and two-person assistance with all bed mobility. The care plan had subsequent revisions on 10/06/21, 04/10/23 and 07/24/23 to add Resident #34 was at risk for impaired functional range of motion related to left side weakness, had a behavior problem 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, review of the facility's Self-Reported Incident (SRI) Tracking Number 239908, and interview, the facility failed to ensure Resident #4 was treated with dignity and respect. This affected one (Resident #4) of three residents reviewed for dignity. The facility census was 49. Findings include: Review of the medical record for Resident #4 revealed an admission date of 08/25/23 with diagnoses including hemiplegia and hemiparesis, cerebral vascular infarction, chronic obstructive pulmonary disease (COPD), muscle wasting, adult failure to thrive, and moderate protein-calorie malnutrition. Review of the admission Minimum Data Set (MDS) 3.0 assessment for Resident #4, dated 09/01/23, revealed the Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The assessment revealed there were no behaviors or rejection of care. The resident required extensive, one-person physical assistance for bed mobility, transfers, toileting, and personal hygiene. Review of the Self-Reported Incident (SRI) Tracking Number 239908, 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.

Based on record review, review of the facility's Self-Reported Incident (SRI) Tracking Number 239908, and interview, the facility failed to maintain complete and accurate medical records. This affected one (Resident #4) of three residents reviewed for dignity. The facility census was 49. Findings include: Review of the medical record for Resident #4 revealed an admission date of 08/25/23 with diagnoses including hemiplegia and hemiparesis, cerebral vascular infarction, chronic obstructive pulmonary disease (COPD), muscle wasting, adult failure to thrive, and moderate protein-calorie malnutrition. Review of the admission Minimum Data Set (MDS) 3.0 assessment for Resident #4, dated 09/01/23, revealed the Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The assessment revealed there were no behaviors or rejection of care. The resident required extensive, one-person physical assistance for bed mobility, transfers, toileting, and personal hygiene. Review of the Self-Reported Incident (SRI) Tracking Number 239908, revealed on…

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

Based on interview, observation, review of Resident Council meeting minutes, and policy review the facility failed to ensure they served palatable meals at appropriate temperatures. This affected five (Residents #6, #19, #22, #145, and #292) of five residents reviewed for dietary services and had the potential to affect 36 of 38 residents who received meals from the kitchen. Residents #8 and #35 did not receive meals from the kitchen. The facility census was 38. Findings include: 1. Interview on 07/05/22 at 10:24 A.M. with Resident #145 revealed she received burnt scrambled eggs for breakfast that morning. 2. Interview on 07/05/22 at 10:30 A.M. with Resident #19 revealed she did not care for the food stating the meat was tough and the food was usually cold. 3. Interview on 07/05/22 at 12:10 P.M. with Resident #22 revealed she was not happy with the choices stating they served mainly processed foods. She said the food was either burnt or undercooked and there were no fresh fruits or veggies. 4. Interview on 07/05/22 at 2:30 P.M. with Resident #6 revealed the food is not good. 5.…

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 the Minimum Data Set (MDS) Assessment was coded correctly for Residents #31 and #34. This affected two of 18 residents reviewed for assessments. The facility census was 38. Findings include: 1. Resident #34 was admitted on [DATE] with diagnoses of pneumonia, muscle weakness, acute kidney failure and moderate intellectual disabilities. Review of the Pre-admission Screen and Resident Review (PASRR) revealed a level two evaluation from the State Department of Developmental Disabilities dated 06/06/22 revealed Resident #34 had a referral for a level two developmental disability. Review of Section A of the MDS assessment dated [DATE] revealed the facility answered yes to the Section, No ID/DD (Intellectual Disability/Developmental Disability). Review of the dental evaluation dated 06/03/22 was marked yes for 1 or more decayed or broken teeth and no for edentulous. Review of Section L of the MDS assessment dated [DATE] revealed the facility answered…

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 develop a plan of care to address Resident #35's indwelling urinary catheter. This affected one out of three residents reviewed for indwelling urinary catheter care. The facility census was 38. Findings include: Resident #35 was admitted from the hospital on [DATE] with diagnoses including anoxic brain injury following a cardiac arrest, pneumonia, urinary tract infection (UTI), sepsis, heart failure, respiratory failure, and diabetes mellitus. Review of a History of Present Illness from the hospital dated 05/19/22 indicated Resident #35 had an urinary tract infection. The hospital assessment dated [DATE] indicated Resident #35 was admitted to intensive care unit for septic shock, pneumonia and UTI. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #35 had an indwelling urinary catheter with active diagnoses including UTI and septicemia. The MDS assessment indicated a plan of care should be initiated to address care of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow the spreadsheet for portion sizes. This affected one (Resident #19) and had the potential to affect 33 out of 38 residents who received meals from the kitchen. Residents #8 and #35 did not receive meals from the kitchen and Residents #16, #24 and #147 received pureed diets. The facility census was 38. Findings include: Resident #19 was admitted to the facility on [DATE] with diagnoses including calculus of bile duct without cholangitis or obstruction, muscle weakness, and acute respiratory failure. Physician's orders revealed Resident #19 was on a regular diet with thin liquids. Observation on 07/06/22 at 12:25 P.M. in the dining room revealed Resident #19 received her tray with two small redskin potatoes as part of the meal. Interview on 07/06/22 at 12:25 P.M. with Resident #19 revealed she was supposed to have a baked potato, not redskin potatoes. Resident #19 voiced her dissatisfaction with the portion size. Interview on 07/06/22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review the facility failed to ensure staff documented Resident #24's fall in Resident #24's clinical record and complete an incident report form. This affected one out of three residents reviewed for falls. The facility census was 38. Findings include: Resident #24 was admitted on [DATE] with diagnoses including difficulty walking, need for assistance with personal care, muscle wasting, unspecified lack of coordination, malnutrition, heart/kidney failure and blood count disease. Resident #24 had impaired decision making and was severely cognitively impaired. A review of Resident #24's nursing progress note (late entry) dated 04/11/22 indicated during nurse to nurse report the night shift nurse reported Resident #24 had a witnessed fall. Resident #24 slid out of her wheelchair and had no complaints of pain. The Nurse Practitioner (NP) would be notified during rounds. A review of State Tested Nursing Assistant (STNA) #61's witness statement (undated) indicated after…

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 develop individualized, comprehensive care plans. This affected four residents (#3, #17, #18 and #38) of 23 residents whose care plans were reviewed. Findings include: 1. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, Alzheimer's disease, psychotic disorder, and weakness. Review of Resident #3's physician order, dated 06/10/19, revealed an order for Seroquel 100 milligrams (mg) by mouth, at bedtime for verbal aggression, combativeness, physical hitting related to dementia. Review of the Resident #3's care plan, dated 01/22/19, did not reveal a comprehensive care plan for the use of the antipsychotic medication, Seroquel. During interview on 08/21/19 at 1:00 P.M. Licensed Practical Nurse (LPN) #57 confirmed Resident #3's care plan was not comprehensive and was silent to the use of an antipsychotic medication. 2. Medical record review revealed Resident #17 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 observation, record review and interview the facility failed to ensure pressure ulcers were accurately and timely assessed and treatments provided as ordered for Residents #1, #17, #31, #103. This affected four residents (#1, #17, #31 and #103) of seven residents identified to have pressure ulcers. Findings include: 1. Medical record review revealed Resident #103 was admitted [DATE] with diagnoses including Crohn's disease, muscle wasting, muscle weakness, severe protein-calorie malnutrition, anemia and an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer to the coccyx. Review of the admission Skin and Wound Evaluation revealed an unstageable pressure ulcer in an unidentified location present on admission. The pressure ulcer was documented as 2.5 cm in length by 0.9 cm width with 90% slough and light serous drainage. The surrounding tissue was dry/flaky, red…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure medications and medical supplies were labeled, secured, disposed of when discontinued and expired. This affected one of the two units in the facility and had the potential to affect the 25 residents residing on this unit. The facility census was 54. Findings include: 1. Observation [DATE] at 06:15 P.M. of the [NAME] medication room revealed it contained: Nineteen (19) Para Pak Culture and Sensitivity collection containers with an expiration date of 04/2019. An opened undated Tuberculin vial was in the refrigerator without a pharmacy dispensing label or a date it was opened There were two bottles of Dakins solution opened and undated and one bottle of hydrogen peroxide was opened and undated. There were three bags of Vancomycin 1750 mg dispensed on [DATE] not disposed when discontinued [DATE]. Review of the facility's 09/18 Medication Storage policy revealed under procedure the provider company dispenses medications in containers that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to timely implement isolation precautions for Resident #102 who had a Methicillin Resistant Staphylococcus Aureus infection and failed to ensure a shared blood glucose meter was properly cleaned/sanitized between use to prevent the spread of infection. This affected one resident (#102) of one resident identified by the facility as having a communicable infection and 14 residents (Resident #4, #12, #14, #15, #16, #18, #20, #22, #25, #26, #34, #36, #40 and #44) receiving blood glucose testing using the shared glucometer on the East hall. Findings include: 1. Medical record review revealed Resident #102 was admitted [DATE] with diagnoses including morbid obesity, diabetes, and cutaneous abscess of the left lower limb with Methicillin-resistant Staphylococcus aureus (MRSA). Review of the 08/14/19 admission Minimum Data Set (MDS) 3.0 assessment revealed Resident #102 was independent for daily decision making. Record review revealed the resident 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, record and interview the facility failed to maintain Resident #103's privacy during wound care. This affected one resident (#103) of four residents reviewed for pressure ulcers. Findings include: Medical record review revealed Resident #103 was admitted to the facility on [DATE] with diagnoses including Crohn's disease, muscle wasting, muscle weakness, severe protein-calorie malnutrition and an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer to the coccyx. Review of the 08/15/19 admission Minimum Data Set Assessment (MDS) 3.0 assessment revealed the resident was independent for daily decision making. On 08/21/19 Licensed Practical Nurse (LPN) #58 was observed performing a dressing change to the resident's coccyx area. LPN #58 offered the resident the choice to lay on his side or to stand for the dressing change. Resident #103 indicated it 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 record review and interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were accurately completed to reflect each resident's medical diagnoses and/or pressure ulcers. This affected three residents (#31, #53 and #102) of 22 residents whose MDS 3.0 assessments were reviewed. Findings include: 1. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including Methicillin-resistant Staphylococcus aureus (MRSA) infection which was identified as multi-drug resistant organism (MDRO). Review of the physician's order dated 07/16/19 identified contact isolation for MRSA. Review of the MDS 3.0 assessment, dated 07/23/19 lacked indication the resident had a MDRO. Interview with Resident #53 on 08/19/19 at 2:29 P.M. confirmed she had MRSA in her shoulder and was receiving intravenous antibiotics. Interview with MDS Coordinator #57 on 08/21/19 at 3:42 P.M. verified the MDS 3.0 was not accurate for Resident #53 and the MDRO should have been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure restorative service plans were reviewed and revised. This affected three residents (#9, #18 and #45) of 29 residents identified to receive restorative programs. Findings include: 1. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including hypertension, malaise, weakness, difficulty walking, muscle wasting and atrophy, falls, and syncope and collapse. Review of the comprehensive assessment (MDS 3.0) dated 06/04/19 indicated she was receiving training and skill practice in transfers, ambulation, dressing and/or grooming. Review of the plan of care indicated she was to receive ambulation, transfer and dressing/grooming programs and the programs were to be reassessed quarterly. Review of the [NAME] (a medical information system used by nursing staff as a way to communicate important information on their residents) report for restorative services reflected the resident was only…

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 develop and implement comprehensive restorative nursing programs for Resident #9 and Resident #18 to assist each resident to maintain their highest functional level. This affected two residents (#9 and #18) of three residents reviewed for restorative nursing services. Findings include: 1. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including hypertension, malaise, weakness, difficulty walking, muscle wasting and atrophy, falls, and syncope and collapse. Review of the comprehensive assessment (MDS 3.0) dated 06/04/19 indicated she was receiving training and skill practice in transfers, ambulation, dressing and/or grooming. Review of the plan of care indicated she was to receive ambulation, transfer and dressing/grooming programs and the programs were to be reassessed quarterly. Review of the [NAME] (a medical information system used by nursing staff as a way to communicate important information…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure adequate and timely care was provided to treat an infection for Resident #102 and failed to ensure bruising for Resident #13 was adequately assessed and monitored. This affected two residents (#13 and #102) of 23 sampled residents. Findings include: 1. Medical record review revealed Resident #102 was admitted to the facility on [DATE] with diagnoses including morbid obesity, diabetes, and cutaneous abscess of the left lower limb with Methicillin-resistant Staphylococcus aureus (MRSA). Record review revealed the resident was admitted with an open area on the left iliac crest infected with MRSA. The 08/08/19 Skin and Wound Evaluation revealed the area as a surgical wound on the left front thigh the resident had for about a week. The wound measured 6.1 centimeters (cm) in length by 1.4 cm width with 5.2 cm depth. The wound was assessed to have 80% granulation tissue, 20% slough and moderate serous drainage. Review of the physician'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 observation, record review and interview the facility failed to develop and implement a comprehensive and individualized range of motion program for Resident #45 to address limitations to range of motion. This affected one resident (#45) of three residents reviewed for range of motion. Findings include: Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including post procedural complications and disorders of respiratory system, gastrostomy, osteoarthritis, intracranial injury, history of traumatic brain injury, hemiplegia and abnormal involuntary movements. Review of the occupational therapy evaluation and plan of treatment dated 07/11/13 indicated the resident had functional limitations as a result of contractures. Splint/orthotic recommendations were to wear the left hand/wrist splint for night hours only to improve passive range of motion for adequate hygiene and prevent/manage pain caused by muscle tightening. The plan of treatment identified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure oxygen concentrators were maintained in a clean and sanitary manner for Resident #10 and Resident #17. This affected two residents (#10 and #17) of five residents with oxygen concentrators in the facility. Findings include: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. The current physician orders indicated she was to use oxygen at three liters via nasal cannula continuously. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 06/04/19 reflected oxygen use. Review of the care plan indicated the resident used oxygen continuously. On 08/19/19 at 11:40 A.M. and 08/20/19 at 1:56 P.M. Resident #10's oxygen concentrator was observed with a black filter which was thick with white dust. Interview with Licensed Practical Nurse (LPN) #53 on 08/21/19 at 8:30 A.M. verified…

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 and interview the facility failed to maintain a medication error rate of less than five percent. The medication error rate was calculated to be 9.09% and included three medication errors of 33 medication administration opportunities. This affected three residents (#45, #53 and #106) of six residents observed for medication administration. Findings include: 1. Observation of medication administration 08/21/19 at 8:28 A.M. with Licensed Practical Nurse (LPN) #55 revealed Resident #106 had Floraster ordered for morning along with other medications. Floraster 250 milligrams (mg) was dispensed from a stock bottle and placed in the medication cup. When LPN #55 completed dispensing the medications and was prepared to administer it was pointed out the order was for 500 mg by mouth two times a day for probiotic. Floraster 250 mg had been placed in the medication cup. Interview 08/21/19 at 08:54 A.M. with LPN #55 verified two tablets of 250 mg of Floraster should of been dispensed instead of one. 2. Observation of medication administration 08/21/19 at 10:08…

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.