Louisville Gardens Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of the facility nurse signature list and review of facility policy, the facility failed to ensure nurses followed appropriate professional standards when documenting medication administration. This affected one resident (Resident #20) of three residents who were observed for medication administration. The facility census was 53. Findings include:Review of the medical record for Resident #20 revealed an admission date of 08/11/25 with diagnoses including hereditary and idiopathic neuropathy, retention of urine, type two diabetes mellitus, acute kidney failure, atrial fibrillation, unspecified protein-calorie malnutrition, gastroesophageal reflux disease (GERD), cognitive communication deficit, irritable bowel syndrome (IBS), depression, epilepsy, and gastroparesis. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 had intact cognition with no rejection of care or other behaviors. Further review of the MDS revealed Resident #20…

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, review of pharmacy invoices, interview and facility policy review, the facility failed to ensure Resident #16's skin treatments were implemented as ordered and Resident #1's dialysis medications were available for resident use. This finding affected one resident (Resident #16) of three residents reviewed for pressure ulcers and general skin conditions and one resident (Resident #1) of one resident reviewed for dialysis services. The facility census was 53. Findings include:1. Review of the medical record revealed Resident #16 was admitted on [DATE] with diagnoses including dementia, cognitive communication deficit, and muscle weakness. Review of the wound grid dated 06/18/25 revealed Resident #16 had a left buttock Stage II pressure ulcer (partial-thickness loss of skin, affecting only the epidermis and dermis layers, which appears as a shallow open wound or a serum-filled blister) which measured zero cm (centimeters) length, zero cm width and zero cm depth which improved…

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 THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, witness statement reviews, interview and facility policy review, the facility failed to ensure Resident #45 was provided with adequate supervision to prevent a burn. This finding affected one resident (Resident #45) of six residents reviewed for accidents and hazards. The facility census was 53. Findings include:Review of Resident #21's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, adult failure to thrive, and schizoaffective disorder. Review of Resident #45's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, schizoaffective disorder, and anxiety. Review of Resident #45's malnutrition care plan revealed an intervention dated 09/16/24 to provide the physician prescribed diet and notify nursing of any changes in appetite, feeding…

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

Based on review of the medical record, interview and review of the facility policy, the facility failed to ensure appropriate assessments were consistently completed before and after dialysis. This affected one resident (Resident #1) of one resident reviewed for dialysis. The facility census was 53. Findings include:Review of the medical record for Resident #1 revealed an admission date of 05/19/25 with diagnoses including end stage renal disease, unspecified protein-calorie malnutrition, paroxysmal atrial fibrillation, major depressive disorder, essential (primary) hypertension, ventricular tachycardia, type II diabetes mellitus, diabetic neuropathy, acquired absence of the right leg below the knee, acquired absence of the left leg below the knee, and dependence on renal dialysis. Review of the physician orders revealed an order dated 05/20/25 that Resident #1 was to receive dialysis every Monday, Wednesday, and Friday and for facility staff to check for a bruit (a swishing sound heard over a blood vessel) and thrill (a palpable vibrating sensation over a blood vessel) to 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 record review, observation, and interview, the facility failed to accurately document and put a treatment in place in a timely manner for Resident #34 that was admitted with a pressure ulcer. This affected one (Resident #34) out of three residents reviewed for pressure ulcers. Facility census was 38. Findings include: Review of the medical record revealed Resident #34 was admitted on [DATE] with diagnoses that included surgical aftercare and a pressure ulcer to the right buttock. Review of the admission skin assessment dated [DATE] revealed Resident #34 had a pressure ulcer to the left gluteal fold that measured one centimeter (cm) long, one cm wide, and 0.1 cm deep. Review of the treatment administration record revealed no evidence of a treatment being done to Resident #34's right or left gluteal/buttock from 01/13/25 until 01/17/25. A weekly skin assessment dated [DATE] revealed Resident #34 had a Stage II (partial-thickness skin loss involving the epidermis and dermis) pressure ulcer to right gluteal…

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 the use of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 32 residents residing in the facility. Findings Include: Review of the Payroll Based Journal (PBJ) report for Fiscal Year (FY) Quarter 4 2023 (07/01/23 through 09/30/23) revealed the facility triggered for no RN hours. Continued review of the reporting data, as submitted by the facility revealed the facility had no RN hours on 07/06/23, 07/07/23, 07/11/23, 07/12/23, 07/16/23, 07/20/23, 07/21/23, 07/25/23, 07/26/23, 08/30/23 or 08/31/23. Interview on 02/26/24 at 11:23 A.M. with the Administrator revealed she was responsible for submitting PBJ data to Centers for Medicare and Medicaid (CMS). The Administrator verified the information as noted on the PBJ report for Fiscal Year (FY) Quarter 4 2023 as noted above. This deficiency is an example of noncompliance investigated under Complaint Number OH00151258.

Based on observation and staff interview, the facility failed to ensure posted nursing staff information was updated in a timely manner. This had the potential to affect all 32 residents residing in the facility. Findings include: Observation of the posted nursing staff information on 02/26/24 at 7:34 A.M. revealed the posted nursing staff information was dated 02/05/24. Interview on 02/26/24 at 8:02 A.M. with Receptionist #200 confirmed the posted staffing information had not been updated since 02/05/24. This deficiency is an example of noncompliance investigated under Complaint Number OH00151258.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy review, the facility submitted plan of correction to the state agency, facility assessment review, and interviews, the facility failed to establish an effective governing body, legally responsible to establish and implement policies regarding the management and operation of the facility, including but not limited to compliance with all financial obligations for the delivery of care. This had the potential to affect all 32 residents in the facility. Findings include: Review of the facility survey history revealed on 11/15/23 a complaint survey was completed which resulted in concerns related to financial solvency. A plan of correction was submitted to the state agency to correct the deficient practice of not paying invoices on time in which the facility/company would pay any outstanding balance to vendors through payment plans if the past due invoice could not be paid in full. Following the 11/15/23 survey, the facility provided evidence of payments being made to various…

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 staffing information submitted to the Centers for Medicare and Medicaid (CMS) was complete and accurate. This had the potential to affect all 32 residents in the facility. Findings Include: Review of the Payroll Based Journal (PBJ) report for Fiscal Year (FY) Quarter 3 2023 (04/01/23 through 06/30/2023) revealed the facility triggered for a one star staff rating and excessively low weekend staffing. Review of the PBJ report for Fiscal Year (FY) Quarter 4 2023 (07/01/23 through 09/30/23) revealed the facility continued to trigger for a one star rating. Review of the PBJ report for Fiscal Year (FY) Quarter 1 2024 (10/01/23 through 12/30/23) revealed the the facility continued to trigger for a one star rating. This report was the most recent report available for review at the time of the investigation. Interview on 02/26/24 at 11:23 A.M. with the Administrator revealed she was responsible for submitting PBJ data to CMS. The Administrator verified the facility had triggered with a one star staff rating and excessively…

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

Based on record review and staff interview, the facility failed to ensure continuous evaluations were in place to verify financial obligations were met as planned to prevent a potential disruption in resident care and services through the Quality Assurance Performance Improvement (QAPI) program committee. This had the potential to affect all facility residents. The facility census was 32. Findings include: Review of the provided QAPI documentation for December 2023 and January 2024, revealed an identified problem of vendors not being paid promptly. The root cause revealed invoices were not being entered electronically when received. Review of invoices and calls with the Administrator and Business Office Manager were to be completed weekly. Review of the facility survey history revealed on 11/15/23 a complaint survey was completed which resulted in concerns related to financial solvency. A plan of correction was submitted to the state agency to correct the deficient practice of not paying invoices on time in which the facility/company would pay any outstanding balance to vendors…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents received showers as planned and based on their preference. This affected two residents (#12 and #13) of five residents reviewed for showers. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 01/18/22 with diagnoses including diabetes mellitus, asthma, respiratory failure and prostate cancer. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. The assessment revealed the resident required substantial or maximum assistance for oral hygiene, toileting, showering or bathing and personal hygiene and was dependent on staff for eating. The assessment also noted it was very important to the resident to choose between a tub bath, shower, bed bath or a sponge bath. Review of the shower schedule revealed the resident preferred to receive a shower on Tuesday and Saturdays. Review of the State Tested Nurses Aide (STNA) task…

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

Based on interview and record review, the facility failed to timely notify a physician or nurse practitioner regarding a change in condition for Resident #34. This affected one resident (#34) of three residents reviewed for change in condition. The facility census was 33. Findings include: Review of the medical record for Resident #34 revealed an admission date of 10/09/23 with diagnoses including hypertension, unspecified dementia, retention of urine, and Wernicke's encephalopathy. Review of the physician orders for Resident #34 revealed an order dated 12/21/23 that stated may insert Foley catheter related to obstructive uropathy for one week. Review of the progress notes for Resident #34 revealed a progress note dated 12/28/23 at 1:10 A.M. that stated when the nurse checked on the resident it was noted the resident had pulled out his Foley catheter with the balloon intact. A moderate amount of cherry red blood was noted on the floor in a trail leading to the bathroom. Resident #34 denied any complaints of pain. Resident #34 was cleaned up by staff and was resting in bed with 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, review of facility billing/financial information, review of the Facility Assessment, review of the Employee Handbook, facility policy review and interview the facility neglected to operate in a manner to ensure all bills were being paid in a timely manner to prevent potential interruption in services and sufficient funds were available to meet payroll demands. This had the potential to affect all 30 residents residing in the facility. Findings Include: 1. On 11/05/23 at 12:20 P.M. an interview related to the facility finances and billing/payment process with the Administrator revealed the facility forwarded all invoices received to the Accounts Payable (AP) department for Epic Healthcare Solutions (the facility corporation). The facility does not pay any of the vendors directly for services rendered at the facility, the payments were being made by an AP department which was based in Florida. On 11/06/23 at 9:20 A.M. interview with Chief Financial Officer #375 (a member of the Florida AP…

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, facility policy review, the facility submitted plan of correction to the state agency, facility assessment review, and interviews, the facility failed to establish an effective governing body, legally responsible to establish and implement policies regarding the management and operation of the facility, including but not limited to compliance with all financial obligations for the delivery of care. This had the potential to affect all 30 residents in the facility. Findings include: Review of the facility survey history revealed on 11/15/23 a complaint survey was completed which resulted in concerns related to financial solvency. A plan of correction was submitted to the state agency to correct the deficient practice of not paying invoices on time in which the facility/company would pay any outstanding balance to vendors through payment plans if the past due invoice could not be paid in full. Following the 11/15/23 survey, the facility provided evidence of payments being made to various…

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

Based on record review and staff interview, the facility failed to ensure continuous evaluations were in place to verify financial obligations were met as planned to prevent a potential disruption in resident care and services through the Quality Assurance Performance Improvement (QAPI) program committee. This had the potential to affect all facility residents. The facility census was 30. Findings include: Review of the provided QAPI documentation for December 2023 and January 2024, revealed an identified problem of vendors not being paid promptly. The root cause revealed invoices were not being entered electronically when received. Review of invoices and calls with the Administrator and Business Office Manager were to be completed weekly. Review of the facility survey history revealed on 11/15/23 a complaint survey was completed which resulted in concerns related to financial solvency. A plan of correction was submitted to the state agency to correct the deficient practice of not paying invoices on time in which the facility/company would pay an outstanding balance to vendors…

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 menu review, the facility failed to ensure food was palatable. This affected 35 residents receiving food from the kitchen as Resident #23 was ordered nothing-by-mouth. The facility census was 36 residents. Findings include: Review of a menu for the week of 02/13/23 revealed the lunch meal for Tuesday 02/14/23 was roast pork loin, homestyle baked beans, California blend vegetables, pineapple upside-down cake and 2% milk. Observation on 02/14/23 at 11:50 A.M. with [NAME] #126 revealed foods to be served for the lunch meal on the steamtable were temped using the facility's self-calibrating thermometer. Temperatures were as follows: pork roast, 195 degrees Fahrenheit (F); California blend vegetables, 204 degrees F; baked beans, 200 degrees F; mashed potatoes, 197 degrees F and gravy, 191 degrees F. Desserts were portioned in bowls off of the steamtable. Trayline began at 12:30 P.M. The 200 unit trays were completed at 12:33 P.M.; the 100 unit trays were done at 12:42 P.M. and the dining room residents were finished being served at 12:55 P.M. The meal…

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, Medscape online medication review, policy review, and staff interview the facility failed to ensure appropriate diagnosis for use of antipsychotic medications for Residents #11 and #32. The facility also failed to ensure appropriate assessments were completed for use of antipsychotic medications for Resident #32. The facility also failed to ensure behavior monitoring was completed for Residents #9, #11, #31 and #32 who were receiving psychotropic medications. In addition, the facility failed to ensure non-pharmacological interventions were attempted for Resident #11 prior to the administration of anti-anxiety medications. This affected four residents (#9, #11, #31 and #32) of five residents reviewed for medication use. The facility census was 36. Findings include: 1. Review of Resident #32's medical record revealed an admission date of 11/09/22 with diagnoses including dementia, bipolar disorder, and anxiety. Review of the current physician's orders revealed on 01/24/23 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 interview and record review the facility failed to ensure resident funds were disbursed in a timely manner for Resident #35 after death as required. Additionally, the facility failed to provide spend-down letters for Resident #13 each month she was over the resource limit. This affected two residents (#13 and #35) of five residents reviewed for resident funds. The facility census was 36 residents. Findings include: 1. Review of Resident #13's medical record revealed an admission date of [DATE] with diagnoses including type two diabetes, dementia, hypertension, anemia, and unspecified abdominal pain. Review of nurses' notes from [DATE] to [DATE] revealed no notes' concerning the need to spend-down resident funds. Review of Resident #13's quarterly funds statement for [DATE] to [DATE] revealed a balance of $2714.63 on [DATE], $2770.20 on [DATE] and $2762.62 on [DATE]. Review of supporting funds documentation revealed spend-down letters were issued on [DATE] and [DATE]. Interview on [DATE] at 12:44 P.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy review, and interview the facility failed to complete a discharge summary as required. This affected one resident (#34) of one resident reviewed for discharge from the facility. The facility census was 36 residents. Findings include: Review of Resident #34's medical record revealed and admission date of 07/29/22 and diagnoses including chronic obstructive pulmonary disease, type two diabetes, alcoholic cirrhosis of liver with ascites, opioid abuse, hypertension, and unspecified intracranial injury without loss of consciousness. Review of completed physician's orders for Resident #34 revealed an order dated 12/07/22 for may discharge to [facility name] on 12/08/22. May send all medications with resident. Review of a discharge-return not anticipated minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #34 discharged to another nursing home on [DATE]. Resident #34 was cognitively intact and required supervision for most activities of daily living. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, policy review and staff interview, the facility failed to ensure Resident #9 was assisted with Activities of Daily Living (ADL) including hygiene, dressing, and showers. The facility also failed to assist Resident #86 with denture care. This affected two residents (#9 and #86) of two residents reviewed for ADL assistance. The facility census was 36. Findings include: 1. Review of Resident #9's medical record revealed an admission date of 07/15/14 with diagnoses including quadriplegia, chronic obstructive pulmonary disease, and diabetes mellitus. Review of Resident #9's Minimum Data Set (MDS) 3.0 annual assessment with a reference date of 01/12/23 revealed the resident had an independent cognition level and required total staff assistance with ADL including dressing, personal hygiene, and toileting. Review of Resident #9's plan of care revealed a care plan for ADL assistance that indicated Resident #9 required total staff assistance with ADL due 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 observation, record review, and interview the facility failed to timely turn and reposition Resident #11 and failed to timely complete a Braden Scale for predicting pressure sore risk assessment. The facility also failed to ensure pressure ulcer wound assessments were timely and thoroughly completed for Resident #12. This affected two residents (#11 and #12) of two residents reviewed for pressure ulcers. The facility census was 36. Findings include: 1. Medical record review revealed Resident #11 was admitted on [DATE] with diagnoses including diabetes mellitus, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, morbid obesity, chronic kidney disease, cerebral infarction, hemiplegia and hemiparesis affecting right side, spinal stenosis, and depression. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 was severely cognitively impaired and required extensive assistance of two staff for bed mobility. Review of the care plan dated 03/06/20…

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 fall interventions were in place for Resident #11. This affected one resident (#11) of one resident reviewed for accidents. The facility census was 36. Findings include: Medical record review revealed Resident #11 was admitted on [DATE] with diagnoses including diabetes mellitus, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, morbid obesity, chronic kidney disease, cerebral infarction, hemiplegia and hemiparesis affecting right side, spinal stenosis, and depression. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 was severely cognitively impaired and required extensive assistance of two staff for bed mobility and was totally dependent on the staff for transfers. The resident had a history of falls. Review of the care plan dated 03/06/20 revealed Resident #11 was at risk for falls related to decreased physical condition, incontinence,…

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, facility policy review, and interview, the facility failed to ensure Resident #11 received proper incontinence care to decrease the resident's risk of developing a urinary tract infection. The facility also failed to provide timely catheter care to Resident #86. This affected two (Resident #11 and #86) of two residents reviewed for incontinence/urinary tract infection. The facility identified 22 residents who were occasionally or frequently incontinent of bladder and four residents who had urinary catheters. The facility census was 36. Findings include: 1. Medical record review revealed Resident #11 was admitted on [DATE] with diagnoses including diabetes mellitus, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, morbid obesity, chronic kidney disease, cerebral infarction, hemiplegia and hemiparesis affecting right side, spinal stenosis, and depression. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 11/01/22, revealed Resident #11 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 observation, interview and menu spreadsheet review, the facility failed to follow the menu's production spreadsheet as written. This affected one resident (Resident #17) of five residents receiving a pureed diet. The facility census was 36 residents. Findings include: Review of a menu for the week of 02/13/23 revealed the lunch meal for Tuesday 02/14/23 was roast pork loin, homestyle baked beans, California blend vegetables, pineapple upside-down cake and 2% milk. Reviewed of a production sheet for the lunch meal on Tuesday 02/14/23 revealed residents on a pureed diet were to receive a #8 scoop of pureed carrots, a #10 scoop of pureed pork loin, a #8 scoop of pureed baked beans and a #12 scoop of pureed pineapple upside-down cake. Observation on 02/14/23 at 11:50 A.M. with [NAME] #126 revealed foods to be served for the lunch meal on the steamtable included pureed baked beans, pureed carrots, mashed potatoes and pureed scrambled eggs which was a substitute for pureed pork loin. Desserts were portioned in bowls off of the steamtable. Trayline began at 12:30 P.M. The 200 unit…

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 meal intake amounts and meal assistance service was completely and accurately documented in the medical records for Resident #9. This affected one resident (Resident #9) of three residents reviewed for nutrition. The facility census was 36. Findings include: Review of Resident #9's medical record revealed an admission date of 07/15/14 with diagnoses that included quadriplegia, chronic obstructive pulmonary disease and diabetes mellitus. Review of Resident #9's Minimum Data Set (MDS) 3.0 annual assessment with a reference date of 01/12/23 revealed the resident had an independent cognition level and required total staff assistance with activity of daily living (ADL) for eating. Review of Resident #9's plan of care reveled a care plan for ADL assistance that indicated Resident #9 required total staff assistance with ADLs due to weakness and quadriplegia. Further review of Resident #9's plan of care revealed a nutritional risk care plan which indicated staff were to assist with meals by feeding the…

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

Based on record review, interview, and policy review, the facility failed to provide a pneumococcal immunization. This affected one(Resident #32) of five residents reviewed for immunizations. The facility census was 36. Findings include: Review of the medical record for Resident #32 revealed an admission date of 11/09/22 with diagnoses including dementia, anxiety, depression, and hypertension. Review of Resident #32's medical record revealed there was documentation of the resident representative consenting on 11/10/22, for the resident to receive the pneumococcal vaccine. Further review of the medical record revealed Resident #32 had not received a pneumococcal immunization. During interview on 02/16/23 at 1:22 P.M., the Director of Nursing (DON) confirmed Resident #32 had given consent to receive the pneumococcal vaccine, however, she had not received the pneumococcal vaccine. Review of the facility's policy, Pneumococcal Vaccine, dated August 2016, revealed prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and 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 interview and document review, the facility failed to ensure the medical director or his designee was present at the quarterly quality assessment and assurance meetings. This had the potential to affect all 41 residents residing in the facility. Findings include: Review of the quality assessment and assurance meeting attendance records since October 2020 revealed a physician was present at the 10/08/20 and 04/15/21 meetings only. Meetings were held on 10/08/20, 11/20/20, 01/15/21, 02/11/21, 03/11/21 and 04/15/21. Interview with the medical director on 04/22/21 at 9:00 A.M. reported he was present in the facility weekly to see his residents and had attended quality assessment and assurance meetings in the past. Interview with the administrator on 04/22/21 at 12:38 P.M. verified the medical director/designee did not attend quarterly quality assessment and assurance meetings but completed monthly medical director reports that were reviewed at each meeting. The facility had weekly opportunities to conduct a quality assessment and assurance meetings with the medical director.

Based on interviews and review of resident council meeting minutes, the facility failed to keep the resident council informed of actions taken to address ongoing concerns about staffing. This had the potential to affect all current residents with the exception of four residents (Residents #13, #143, #194 and Resident #195) who resided on a unit with one nurse and one nursing assistant scheduled. The facility census was 41. Findings include: Review of resident council meeting minutes from November 2020 to April 2021 revealed concerns including: * On 11/02/20 a concern was voiced ice water was not passed and one resident (discharged ) complained her care needs were not met. The residents were interviewed individually due to COVID. * December 2020 minutes revealed 18 residents were interviewed on an individual basis. One resident (discharged ) complained she was not getting showers consistently. Resident #15 reported there needed to be more help and she had to wait a long time for her needs to be met. * March 2021 minutes revealed 15 residents were interviewed individually. Residents…

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 the surety bond was purchased for a sufficient amount to ensure the security of all resident funds deposited in the facility resident fund account. This finding had the potential to affect thirty residents (#2, #3, #4, #6, #7, #12, #8, #9, #10, #15, #16, #17, #18, #19, #20, #21, #23, #24, #25, #26, #27, #28, #30, #32, #34, #36, #37, #39, #192 and #197) with funds deposited into the facility resident fund account. The facility census was 41. Findings include: Review of the surety bond dated 07/09/20 indicated the surety bond was in the amount of $50,000.00 (fifty thousand dollars). Review of the Trial Balance form dated 04/19/21 indicated the total amount of resident funds deposited with the facility in a resident fund account was in the amount of #53,195.35 for thirty residents (Residents #2, #3, #4, #6, #7, #12, #8, #9, #10, #15, #16, #17, #18, #19, #20, #21, #23, #24, #25, #26, #27, #28, #30, #32, #34, #36, #37, #39, #192 and #197). Interview on 04/19/21 at 10:05 A.M. with Administrative Assistant #803 confirmed…

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, interview and document review the facility failed to provide sufficient nurse staffing levels to meet residents needs. This had the potential to affect all 41 residents currently residing in the facility. Findings include: 1. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] from another long term care facility. Her diagnoses included chronic obstructive pulmonary disease, respiratory failure with hypoxia or hypercapnia, quadriplegia, asthma, diabetes with neuropathy, anxiety, obstructive sleep apnea, schizophrenia, osteoarthritis, arthropathic psoriasis, anemia, hypothyroidism, osteoporosis, mixed severe bipolar disorder with psychotic features, severe morbid obesity, chronic pain, post traumatic stress disorder and major depressive disorder. Review of the annual comprehensive assessment (MDS 3.0) dated 03/02/21 indicated Resident #34 was alert, oriented and independent in daily decision making ability. No behavioral symptoms…

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

Based on observation, review of the Centers for Disease Control hand hygiene guidelines and interview, the facility failed to ensure staff practiced appropriate hand hygiene. This affected one (Resident #28) of one resident observed for incontinence care and had the potential to affect 15 additional residents (Residents #3, #6, #7, #15, #16, #17, #20, #21, #23, #24, #26, #29, #30, #36 and #39) residing on the same unit. Findings include: On 04/22/21 from 9:21 A.M. to 9:30 A.M., State Tested Nursing Assistant (STNA) #814 was observed providing incontinence care to Resident #28. After incontinence care was provided, with gloves still on, STNA #814 pulled the sheet up then used the crank at the foot of the bed. STNA #814 then removed gloves and was observed running her hands through her hair and touching her face shield. Resident #28 asked for a drink of water which was provided then supplies were gathered, and STNA #814 left the room without washing her hands. On 04/22/21 at 9:33 A.M., STNA #814 verified the above observations. Review of Center for Disease Control hand hygiene…

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

Based on review of COVID testing records, review of COVID-19 testing guidance, review of COVID 19 screening, review of employment information and interview, the facility failed to ensure staff testing for COVID 19 was conducted with the required frequency. This had the potential to affect all but six (Residents #10, #93, #143, #193, #194 and #195) of the facility's 41 residents. The six residents either currently had COVID-19 or had it within the prior 90 days (Residents #10, #93, #143, #193, #194 and #195). Findings include: On 04/20/21 at 9:28 A.M., Licensed Practical Nurse (LPN) #801 was interviewed regarding the facility's infection control program. LPN #801 reported COVID testing was done in accordance with the most recent guidance. If staff had two doses of the vaccine they were tested weekly. If not, testing continued to be completed twice a week. Review of staff COVID testing records revealed State Tested Nursing Assistant (STNA) #818 was tested for COVID 19 on 03/31/21 and 04/19/21. Both tests were negative. Review of COVID 19 screening records revealed STNA #818 exhibited…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Residents #28 and #36's dignity was maintained during meals and Resident #10's dignity was maintained during the resident's pressure ulcer wound care. This finding affected two residents (Residents #28 and #36) of 16 residents observed eating lunch on the 200 unit and one resident (Resident #10) of one resident reviewed for wound care. The facility census was 41. Findings include: 1. Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including severe sepsis with septic shock, unspecified protein-calorie malnutrition and heart failure. Review of Resident #10's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited severe cognitive impairment. Observation on 04/20/21 from 11:52 A.M. to 12:06 P.M. with Licensed Practical Nurse (LPN) #801 of Resident #10's pressure ulcer wound care on the left buttock, right buttock,…

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 #4's right half bedrail was in good repair. This affected one (Resident #4) of forty-one residents reviewed for environmental concerns. The facility census was 41. Findings include: Review of Resident #4's medical record revealed the resident was admitted [DATE] with Alzheimer's disease, essential hypertension and generalized anxiety disorder. Review of Resident #4's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited a memory problem and required extensive two person assist for bed mobility and transfers. Observation on 04/19/21 at 8:54 A.M. of Resident #4's resident room revealed the right metal bedrail was tilted inward toward the bed, was loose and wiggled when grabbed. The rail was not securely fastened to the bed and was not in good repair. The resident was observed in the bed at the time of the observation. Interview on 04/21/21 at 7:14 A.M. with the Director of Nursing (DON) confirmed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, review of medical records, shower records, and the facility shower policy and CMS 672 review the facility failed to ensure Resident #34, who was dependent on staff for all activities of daily living, received showers as scheduled. This affected one of two residents (#34 and #38) reviewed for activities of daily living. The facility census was 41. Findings include: Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] from another long term care facility. Her diagnoses included chronic obstructive pulmonary disease, respiratory failure with hypoxia or hypercapnia, quadriplegia, asthma, diabetes with neuropathy, anxiety, obstructive sleep apnea, schizophrenia, osteoarthritis, arthropathic psoriasis, anemia, hypothyroidism, osteoporosis, mixed severe bipolar disorder with psychotic features, severe morbid obesity, chronic pain, post traumatic stress disorder and major depressive disorder. Review of the annual comprehensive Minimum Data Set assessment (MDS 3.0)…

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, and interview the facility failed to provide individualized activity programs for two (Residents #7 and #23) of three residents reviewed for activities. The facility census was 41. Findings include: 1. Review of Resident #7's medical record revealed diagnoses including dementia and depression. A care plan initiated 12/14/18 indicated Resident #7 enjoyed most group activities with her favorites being music, walking, being social and some crafts. Goals included keeping Resident #7 socially involved with staff and peers daily and for her to remain actively engaged in group activities. Interventions included engaging Resident #7 in group activities and inviting and escorting Resident #7 to group activities. A significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #7 was sometimes able to make herself understood and was sometimes able to understand others. Resident #7 had short and long term memory problems. The assessment revealed it was very…

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 appropriate infection control practices were maintained during Resident #10's pressure ulcer wound care for multiple wounds. This affected one (Resident #10) of one resident reviewed for pressure ulcer wounds. The facility census was 41. Findings include: Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including severe sepsis with septic shock, unspecified protein-calorie malnutrition and heart failure. Review of Resident #10's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited severe cognitive impairment. Review of Resident #10's physician orders revealed an order dated 04/12/21 to apply an adhesive foam dressing to the resident's left buttocks every night shift, an order dated 04/13/21 to apply a foam dressing to the resident's left lateral proximal foot every night shift on Tuesday, Thursday and Saturday,…

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, and interview the facility failed to ensure safety assessments and interventions were implemented for two (Residents #9 and #16) of four residents reviewed for accidents. The facility census was 41. Findings include: 1. Review of Resident #9's medical record revealed an admission date of 01/05/19. Diagnoses included anxiety disorder, alcohol dependence, depression, and alcohol-induced persisting dementia. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #9 was moderately cognitively impaired with a Brief Interview of Mental status (BIMS) score of 9 but had not exhibited wandering during the reference time period. A nursing note dated 11/15/20 at 12:21 P.M. indicated Resident #9 was found walking down the road where the facility was located. Resident #9 indicated she was upset about not being able to smoke because of COVID-19 restrictions. Resident #9 was safely returned to the facility. Resident #9 was educated that she could not leave 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.