Altercare Of Louisville Ctr For Rehab & Nsg Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure Resident #81 was administered medication according to physician orders. The affected one resident (#81) of five residents reviewed for medication administration. The facility census was 77.Findings include: Review of the medical record revealed Resident #81 was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus. Resident #81 discharged from the facility on 04/09/25.Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #81 had intact cognition, had lower extremity impairment on one side, required substantial assistance with turning in bed, urinary continence was not rated, and he was frequently incontinent of bowels. Resident #81 was at risk of developing pressure injuries however he was not admitted with any unhealed pressure injuries. Review of the physician orders revealed Resident #81 had an order for Mounjaro (diabetic medication)15 milligrams subcutaneous one a week on Monday…

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 review of facility policy, the facility did not ensure gradual dose reduction recommendations pertaining to anti-anxiety medications for Resident #58 were addressed by the physician. This affected one resident (Resident #58) of five residents reviewed for unnecessary medications. The facility census was 77.Findings include:Review of the medical record for resident #58 revealed an admission date of 04/28/23. Diagnoses included senile degeneration of the brain, difficulty walking, muscle weakness, dementia, depression and anxiety. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #58 was severely cognitively impaired, required supervision for eating, substantial assistance for oral hygiene, dressing and personal hygiene and was totally dependent for toileting and showering. Review of the physician orders for September 2024 revealed an order for Ativan (for anxiety) one milligram every two hours (mg) as needed (prn) for anxiety.…

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 review of facility policy, the facility failed to ensure staff performed hand hygiene during medication administration for Resident #21. This affected one resident (Resident #21) of five residents (Resident #7, #21, #22, #30, and #71) observed for medication administration. The facility census was 77.Findings include:Observation of medication administration on 07/23/25 at 9:45 A.M. revealed Registered Nurse (RN) #205 pushed the medication cart from the nurses station down to the room of Resident #21. RN #205 went into Resident #21's room, obtained his blood pressure, walked back out to the medication cart, prepared his medication, took the medication to Resident #21 and administered the medication all without performing any hand hygiene. After she administered the medications to Resident #21, RN #205 walked back out to the medication cart and started to push the medication cart up the hall way to continue the medication administration. An interview on 07/23/25 at 9:50 A.M. with RN #205 verified she had not washed hands before going into Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, and staff interview, the facility failed to ensure Resident #29's pain medication was reordered timely. This affected one resident (#29) out of three (Resident #18, Resident #29, and Resident #54) reviewed for medication administration. The facility census was 64. Findings include: Review of the medical record for Resident #29 revealed an admission date of 01/24/25. Diagnoses included malignant neoplasm of head, face and neck, malignant neoplasm of tongue, dysphagia, oropharyngeal phase, and gastrostomy status. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #29 was mildly impaired with a Brief Interview for Mental Status (BIMS) of 12. Review of Resident #29's February 2025 physicians orders revealed an order for Gabapentin 12 milliliters (ml) to equal 600 milligrams (mg) to be administered orally twice daily. Review of Resident #29's Medication Administration Record revealed the resident did not receive his Gabapentin 600 mg 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, self-reported incident review (SRI), interview, and facility policy review the facility failed to ensure Resident #21 was free from staff-to-resident physical abuse. This finding affected one resident (#21) of five residents reviewed for Abuse, Neglect and Misappropriation of Resident Property. The facility census was 70. Findings include: Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including vascular dementia, muscle weakness and need for assistance with personal care. Review of Resident #21's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of physical abuse SRI Tracking #244568 dated 02/26/24 revealed Resident #21 became behavioral when State Tested Nursing Assistant (STNA) #833 and STNA #904 attempted to provide care 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, interview, and facility policy review the facility failed to ensure Resident #46 was provided timely incontinence care. This finding affected one resident (#46) of three residents reviewed for incontinence care. The facility census was 70. Findings include: Review of Resident #46's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with early onset, altered mental status, and adult failure to thrive. Review of Resident #46's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment and was always incontinent of bowel and bladder Review of Resident #46's physician orders revealed an order dated 05/14/21 for miconazole powder (antifungal powder) twice daily and an order dated 05/19/21 for zinc oxide 20% (cream used to treat or prevent skin irritation) twice daily to affected areas. Review of Resident #46's physician's orders revealed an order dated 05/01/24…

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, staff interview, and review of the facility policy the facility failed to ensure smoking assessments were completed with a quarterly according to the facility's smoking policy. This affected three residents (#10, #25, and #29) of three residents reviewed for smoking. The facility identified six residents (#10, #25, #26, #29, #36, and #37) who smoked at the facility. The facility census was 65. Findings include: 1. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including sepsis, acute kidney failure, chronic obstructive pulmonary disease, and personal history of nicotine dependence. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 was cognitively intact. Further review of Resident #10's medical record revealed that smoking assessments were not done quarterly. Smoking assessments were completed on 12/13/22 and then another smoking assessment was completed on 11/16/23 after 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 closed record review and interview, the facility failed to timely notify Resident #63's family representative and physician of the resident's complaints of pain in the left arm. This finding affected one resident (#63) of three residents reviewed for notification. Findings include: Review of Resident #63's closed medical record revealed the resident was admitted on [DATE] with diagnoses including bipolar disorder, pain in the left shoulder, and obsessive-compulsive disorder. Review of Resident #63's Activities of Daily Living (ADL) care plan dated 04/26/22 revealed the resident required a Hoyer (mechanical) lift transfer with the assistance of two staff members. Review of Resident #63's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #63's State Tested Nursing Assistant (STNA) Witness Statement form authored by STNA #804 dated 10/06/23 at 9:30 P.M. indicated the STNA went into the resident's room on 10/06/23 at 7:15…

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 Resident #40's lidocaine pain patch was administered as ordered. This finding affected one resident (#40) of six residents reviewed for medication administration. Findings include: Review of Resident #40's medical record revealed the resident was readmitted to the facility on [DATE] with diagnoses including malignant neoplasm of the colon, partial intestinal obstruction, and neutropenia. Review of Resident #40's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated she exhibited intact cognition. Review of Resident #40's physician orders revealed an order dated 09/07/23 to administer the lidocaine adhesive pain patch 5% (percent) to the lower back once per day from 6:00 P.M. to 10:30 P.M. Review of Resident #40's medication administration records (MAR) from 11/01/23 to 11/04/23 revealed Registered Nurse (RN) Assistant Director of Nursing (ADON) #807 documented on the MAR that she administered the lidocaine pain patch as…

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 central catheter access lines were removed in a timely manner, as ordered by the physician. This affected one (Resident #70) of three residents reviewed for central catheter access lines. The facility census was 72. Findings include: Review of Resident #70's closed medical record revealed an admission date of 08/29/23 with diagnoses that included urinary tract infection (UTI), diabetes mellitus and congestive heart failure. Review of hospital discharge records and facility admission records revealed the use of Invanz (antibiotic) one gram daily by Peripherally Inserted Central Catheter (PICC) until 09/04/23 for UTI treatment. Review of the Medication Administration Record (MAR) revealed special instructions for the Invanz which indicated PICC line to be removed after Invanz treatment completed. Additional review of the physician's orders revealed orders to discontinue and remove Resident #70's PICC line on 09/08/23, 09/11/23 and 09/12/23. Review of the nurses' notes indicated the PICC line was removed…

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 laboratory testing was completed as ordered by the physician to monitor for medication side effects. This affected one (Resident #70) of three residents reviewed for laboratory testing. The facility census was 72. Findings include: Review of Resident #70's closed medical record revealed an admission date of 08/29/23 with diagnoses that included urinary tract infection (UTI), diabetes mellitus and congestive heart failure. Review of the physician orders revealed an order to monitor the resident for worsening heart failure every shift dated 08/29/23; torsemide (diuretic) 10 milligrams (mg) daily and weigh every Monday, Wednesday and Friday dated 09/11/23. Review of Resident #70's physician and Advanced Practitioner Nurse (APN) progress notes revealed on 09/12/23 the resident was evaluated due to increasing edema and diuretic use. A Basic Metabolic Profile (BMP) was ordered on 09/12/23 to be obtained on 09/14/23. An APN progress note on 09/18/23 indicated the BMP was not obtained as ordered for 09/14/23.…

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 facility investigation, observation, interview, and policy review the facility failed to ensure a resident was safely transferred with a mechanical lift and resident smoking materials were stored in a secure area. This affected one (Resident #23) of three residents reviewed for falls and six (#22, #29, #37, #41, #43, and #52) of six residents reviewed for smoking. Findings include: 1. Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including laceration with foreign body of the scalp, muscle weakness, other reduced mobility, intervertebral disc degeneration of the lumbar region, chronic pain, stiffness and pain of left knee, difficulty walking, lack of coordination, dizziness, osteoarthritis of knee, needs assistance with personal care, abnormalities of gait and mobility, artificial right knee joint, and age related physical debility. Review of Resident #23's activity of daily living (ADL) plan of care dated 12/05/18 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 record review, review of facility reported incident (FRI) investigation, review of the controlled drug receipt form, interview, and policy review the facility failed to ensure a thorough investigation was completed and documented for misappropriation of narcotics. This affected one (Resident #52) of one resident reviewed for abuse. Findings include: Resident #53 was admitted to the facility on [DATE] with diagnoses including pain in throat, malignant neoplasm of tonsillar pillar, unspecified malignant neoplasm of lymph nodes of head, face, and neck, malignant neoplasm of pharynx, acute post procedural pain, neoplasm related pain, and oral mucositis due to radiation. Review of the FRI (225260) investigation dated 08/12/22 revealed Resident #53's liquid Morphine had been misappropriated. The liquid Morphine was measured with medication cups to clarify count. The measurement showed that medication was under by 12.5 milliliters (ml). All four staff members that had access to the Morphine in the last 48…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review the facility failed to ensure Pre-admission Screening and Resident Review (PASARR) documentation was updated when resident diagnoses changed. This affected three residents (#23, #24, and #32) of three residents reviewed for PASARR. Findings include: 1. Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including bipolar II. The following diagnoses were added after admission: hallucination on 02/28/20, bipolar on 02/28/20, major depressive disorder, recurrent severe without psychotic features, on 04/06/20, schizoaffective disorder bipolar type on 04/06/20, schizoaffective disorder, depressive type on 04/09/20, anxiety disorder on 08/26/20, bipolar on 05/06/21, major depressive disorder on 06/03/21, and obsessive-compulsive behavior on 05/26/22. Review of Resident #23's PASARR dated 11/25/15 revealed the resident had mood disorder and bipolar. There was no evidence of the determination. The PASARR was completed for…

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

Based on record review and interview, the facility failed to ensure smoking care plans were updated in a timely manner. This affected three (Residents #22, #41, and #43) of six residents reviewed for smoking. The census was 67. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 11/02/18 with diagnoses including schizoaffective disorder, major depressive disorder, acute and chronic respiratory failure with hypoxia, and nicotine dependence. Review of the physician's orders for December 2022 identified no orders pertaining to smoking. Review of the care plan revised 10/13/22 at 2:35 P.M. revealed Resident #22 was unable to smoke without supervision due to needing assistance from staff for mobility and lack of coordination. Interventions included all smoking materials would be locked up in a designated location when not in use, any burns or injuries would be reported immediately to the nurse for evaluation, physical assistance by staff would be offered to ensure resident safety, resident and resident's representatives would be responsible 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, observation, and interview the facility failed to ensure Resident #23 received assistance with placement of hearing aids and changing hearing aid batteries. This affected one (Resident #23) of one resident reviewed for hearing. Findings include: 1. Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including need for assistance with personal care, polyneuropathy, muscle weakness, reduced mobility, cognitive communication deficit, and age-related physical debility. Review of Resident #23's plan of care for hearing loss dated 12/05/18 revealed the resident had potential for alteration in communication related to wearing bilateral hearing aids. Staff intervention included to report any change/decline in communication ability. Review of an audiology note dated 05/04/22 revealed the facility would store Resident #23's hearing aids and help with insertion, removal, and batteries. Resident #23 had bilateral sensorineural hearing loss. The left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and policy review revealed the facility failed to ensure duplicate treatments were not applied to the same area. This affected one (Resident #34) of one resident reviewed for skin conditions. Finding include: Record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including moisture associated skin damage (MASD), spinal stenosis, diabetes with diabetic neuropathy, and excoriation disorder. Interview on 12/13/22 at 9:10 A.M., with Resident #34's daughter revealed the resident complained her buttocks hurt. The staff kept the area covered and applied ointment. The daughter indicated her mother had been in bed 24 hours a day since they almost lost her recently. Observation on 12/14/22 at 10:31 A.M., of Resident #34's buttocks with Registered Nurse (RN) #864 whom was also the wound nurse, and the Director of Nursing (DON) revealed the area was difficult to view due to the resident had cream on the coccyx area. The skin appeared scaly 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, observation, interviews, and policy review the facility failed to follow Resident #34's dietary orders for supplements, ensure the resident was encouraged to get up to eat, and substitutes were offered if less then 50 percent of meal was consumed. This affected one (Resident #34) of three residents reviewed for nutrition. Findings include: Record Review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including abnormal weight loss, failure to thrive, dehydration, spinal stenosis, muscle weakness, needs assistance with personal care, lack of coordination, cognitive communication deficit, diabetes, dehydration, age-related physical debility, and dysphagia (difficulty swallowing). Review of Resident #34's plan of care for activities of daily living (ADL), dietary, and non-compliance revealed to offer resident verbal cues if needed for chewing and swallowing, or to finish eating. Help with feeding if needed. Offer and encourage substitute if intakes were less than…

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 timely. This affected three (#9, #23, and #32) of four residents reviewed. The census was 67. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 03/25/22 with diagnoses including acute respiratory failure, chronic obstructive pulmonary disease, acute kidney failure, and hallucinations. Review of the physician's orders for Resident #9 identified an order for Trazodone 50 milligrams (mg) once a day as needed (PRN) initiated 06/28/22 with no scheduled end date. Review of the pharmacy monthly medication review dated 08/08/22 revealed the PRN use of Trazodone should be limited to 14 days. The recommendation was not addressed by the prescribing practitioner until 09/06/22, 29 days later. Review of the physician's orders for Resident #9 identified the order for Trazodone 50 milligrams (mg) once a day PRN was discontinued on 09/06/22. On 12/14/22 at 5:03 P.M., interview…

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 Resident #9's order for as needed Trazodone was re-assessed within the required 14-day time frame, Resident #23 had a gradual dose reduction attempted or evidence of a clinical indication why it was not attempted, and Resident #56 had a clinical indication for the continued use of Seroquel. This affected three of five residents reviewed for unnecessary medication. The census was 67. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 03/25/22 with diagnoses including acute respiratory failure, chronic obstructive pulmonary disease, acute kidney failure, and hallucinations. Review of the physician's orders for Resident #9 identified an order for Trazodone 50 milligrams (mg) once a day as needed (PRN) initiated 06/28/22 with no scheduled end date. The order was discontinued on 09/06/22. Review of the progress notes for June 2022 through September 2022 revealed no evidence that the continued use of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and policy review the facility failed to ensure residents received timely dental services. This affected two residents (#12 and #34) of four residents reviewed for dental. Findings include: Record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dysphagia, muscle weakness, and respiratory failure. Review of Resident #12's dental consent dated 10/03/18 revealed the resident consented to see the dentist. Review of Residents #12's dental care plan dated 10/08/19 revealed the resident was at risk for oral complication related to full upper and lower dentures. If resident stopped using dentures assess why resident did not wear and contact dentist if needed. Review of Resident #12's dental note dated 03/17/22 revealed the dental note was not legible. The dentist office sent a clarification email dated 12/15/22 to clarify the note said the resident's lower dentures were adjusted, adhesive would be only means…

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

Based on observation, interview and policy review, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This affected 76 of 77 residents who received meals from the dietary department. Resident #5 was NPO (nothing by mouth) and did not receive meals prepared by dietary staff. The facility census was 77. Findings: A tour of the kitchen was conducted on 01/02/2020 from 8:10 A.M. through 8:20 A.M. and revealed the stove had grease drippings on the side, there were portioned pears and an opened bag of cut-up fruit that were not labeled and dated in the walk-in refrigerator. The walk-in freezer had ice build-up, and there was ice on opened boxes of pizza and sheet cakes. This was verified by [NAME] #4 at the time of observation. A revisit to the kitchen on 01/02/2020 at 2:35 P.M. with Regional Dietary Manager #65 revealed the microwave was dirty. Review of the undated kitchen sanitation policy revealed that the food and nutrition department will be maintained in a clean and sanitary manner.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to maintain a clean and sanitary environment. This had the potential to affect all 77 residents residing in the facility. Findings include: Observations of the facility on 01/02/2020 from 10:15 A.M. through 12:30 P.M. and 01/03/2020 from 6:19 A.M. through 1:45 P.M. the following was observed: • Observation of the ceiling in Resident #280's room revealed what appeared to be a water stain. This observation was verified by State Tested Nursing Assistant (STNA) #52 on 01/02/2020 at 11:32 A.M. • Observations in Resident #283's room revealed food crumbs, a Styrofoam cup and bed controls on the floor. This observation was verified by STNA #64 on 01/02/2020 at 11:28 A.M. • Observation of Resident #313's room revealed a lunch tray and a dinner tray with tray tickets dated 01/01/2020 were in the room. This observation was verified by Licensed Practical Nurse (LPN) #38 on 01/02/2020 at 12:30 P.M. • Observation on 01/03/2020 at 6:19 A.M. revealed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure an accurate assessment of resident's signs/symptoms of possible infection was documented. This affected two residents (Resident #50 and Resident #79) of three residents reviewed for infection. The facility census was 77. Findings include: 1. Resident #79 was admitted to the facility on [DATE]. Her admitting diagnoses included ischemic cardiomyopathy, atrial fibrillation, pressure ulcer of left heel, stage II (partial thickness skin loss), anxiety disorder and major depressive disorder. Review of this resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was alert and oriented with no cognitive impairment. Functionally, the resident required extensive assistance of two people for most activities of daily living, including toilet use and personal hygiene. Observation by a surveyor on 01/02/2020 at 10:47 A.M. of Resident #79 revealed the resident's left eye was red, watery and crusted with dry discharge 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.