Milcrest Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and policy review, the facility failed to ensure a resident had a care plan for elopement and the use of a Wanderguard. This affected one (#25) out of one residents reviewed for elopement. The facility census was 44. Findings include: Review of Resident #25's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, high blood pressure, diabetes and depression. Review of an elopement risk assessment dated [DATE] identified the resident to be at risk for elopement. An interventions on the assessment included the use of a Wanderguard. Review of the care plan dated 02/06/25 did not identify the resident to be at risk for elopement or identify the us of the Wanderguard. Observation of Resident #25 on 04/07/25 at 02:17 P.M. revealed she was wearing a Wanderguard on her leg. Review of policy titled Wanderguard Devices, dated 06/19/17, revealed a potential for elopement plan of care will be implemented including Wanderguard 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, staff interviews, and policy review, the facility failed to ensure care conferences were completed quarterly and included participation of the interdisciplinary team and the resident/responsible party. This affected two (#1 and #13) residents reviewed for care conferences. The facility census was 44. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 06/12/23. Diagnoses included vascular dementia, anxiety disorder, major depressive disorder, and chronic kidney disease stage three. Review of Significant Change Data Set Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had cognitive impairment. This resident was assessed to be independent with eating, require substantial assistance with toileting and transfers, and partial assistance with bathing and dressing. Review of the care conferences for the last 12 months revealed Resident #1 received a care conference on 03/10/24, 06/14/24, and 09/24/24 with no…

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

Based on record review, staff interview, and review of the facility policy, the facility failed to maintain hospice documentation for one (#11) of one resident reviewed for Hospice. The facility identified three residents receiving hospice care (#11, #14 and #37). The facility census was 44. Findings include: Review of the medical record for Resident #11 revealed an admission date of 11/08/24. Diagnoses included adult failure to thrive, malnutrition, muscle weakness Parkinson's disease, atrial fibrillation, and chronic kidney disease. Review of Hospice election and admission paperwork dated 02/10/25 revealed Resident #11 was admitted to hospice care. Review of the hospice communication binder for Resident #11 contained no documentation from hospice visits. Interview on 04/10/25 at 9:36 A.M. with Unit Manager (UM) #511 confirmed the hospice communication binder for Resident #11 had no documentation from visits. UM #511 revealed they had blank communication forms in the binder. The electronic medical record and paper medical record were reviewed and found no documented communication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide pressure reducing interventions as recommended to aide in the healing of a pressure ulcer for one (#08) out of four residents reviewed for pressure ulcers. The facility census was 44. Findings include: Review the medical record revealed Resident #08 admitted to the facility on [DATE]. Diagnoses included pressure ulcer of sacral regional stage three, pressure ulcer of left hip stage three, adult failure to thrive, malignant neoplasm of right female breast, polyneuropathy, anxiety disorder, iron deficiency anemia, type two diabetes mellitus, and fibromyalgia. Review of Resident #08's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #08 required supervision with rolling left and right, sitting to lying, lying to sitting, sitting to standing, and transfers. Resident #08 had one stage three pressure ulcer that was present upon admission to the facility. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff and resident interviews, and policy review, the facility failed to ensure nail care was provided for one (#30) of three residents reviewed for activities of daily living. The facility census was 44. Findings include: Review of the medical record for Resident #30 revealed an admission date of 01/28/25. Diagnoses included vascular dementia,, stage three kidney disease, anxiety, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 was cognitively intact and required assistance from staff for activities of daily living (ADLs). Review of the care plan dated 02/02/25 revealed Resident #30 needs assistance from staff for ADL needs with interventions to assist with bathing as needed. The care plan did not specify assistance with nail care. Review progress notes dated 02/01/25 to 04/10/25 revealed no notes related to toe nail care or podiatry services. Review of skin and shower sheets from 02/01/25 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 review of the medical record and staff interviews, the facility failed to implement interventions in a timely manner after a significant weight loss. This affected one (#29) of four residents reviewed for nutrition. The facility census was 44. Findings include: Review of the medical record for Resident #29 revealed an admission date of 02/20/24. Diagnoses included with fracture of superior rim of right pubis, major depressive disorder, anxiety disorder, and Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had severe cognitive impairment. The resident was assessed to be independent with eating. Review of the care plan dated 04/04/25 revealed Resident #29 was at risk for altered nutrition related to medical diagnoses including Alzheimer's disease. Interventions included administer medications as ordered, encouraged intake as needed, obtain and monitor laboratory work as needed, obtain weight as ordered, provide and serve diet as ordered, and provide…

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 review of the medical record, pharmacy recommendations, interviews, and policy review, the facility failed to timely implement pharmacy recommendations for one (#29) of five residents reviewed for medications. The facility census was 44. Findings include: Review of the medical record for Resident #29 revealed an admission date of 02/20/24. Diagnoses included with fracture of superior rim of right pubis, major depressive disorder, anxiety disorder, and alzheimer's disease. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had cognitive impairment. Review of the monthly medication review (MMR) dated May 2024 revealed Resident #29 was recommended laboratory (lab) tests of magnesium, complete metabolic panel (CMP), thyroid stimulation hormone (TSH), and complete blood count (CBC). Review of the physician orders revealed no order was placed for the magnesium, CMP, TSH, or CBC for Resident #29 per the recommendation of the MMR. Review of the physician order dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure a resident received dental care after breaking a tooth. This affected one (#05) resident out of two residents reviewed for dental care. The facility census was 44. Findings include: Review of the medical record revealed Resident #05 admitted to the facility on [DATE]. Diagnoses included muscle weakness, protein calorie malnutrition, iron deficiency anemia, constipation, anxiety disorder, and dysphagia. Review of Resident #05's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired. Resident #05 was independent with eating and required set up assistance with oral hygiene. Resident #05 had obvious or likely cavities or broken natural teeth. Review of Resident #05's census information dated 04/10/25 revealed Resident #05 was on Medicaid. Review of Resident #05's oral cavity assessment dated [DATE] revealed Resident #05 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record reviews, observations, staff interviews, and policy review, the facility failed to ensure infection control measures were followed during medication administration. This affected one (#197) of four residents reviewed for medication administration. The facility census was 44. Findings include: Review of the medical record for Resident #197 revealed an admission date of 04/02/25. Diagnoses included bacteremia, end stage renal disease (ESRD), and atrial fibrillation. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #197 had intact cognition. Review of the care plan dated 04/08/25 revealed Resident #197 was at risk for infection related to indwelling medical device, open wound and central vein catheter (CVC). Interventions included to wear gown and gloves when providing high-contact resident care activities. Review of the physician order date 04/05/25 revealed Resident #197 was ordered enhanced barrier precautions (EBP) related to indwelling devices…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, review of the facility's Self-Reported Incidents (SRI), and policy review, the facility failed to timely report allegations of neglect to the State Survey Agency and Local Law Enforcement. This affected one (Resident #15) of three residents reviewed for abuse and neglect. The facility census was 47 residents. Findings include: Review of the closed medical record for Resident #15 revealed an admission date of [DATE]. Diagnoses included atrial fibrillation, mesothelioma (an aggressive and rare form of cancer that usually occurs in the thin layer of tissue that lines the lungs or the abdomen), and respiratory failure with hypoxia. Resident #15 died on [DATE] at 12:50 A.M. at the emergency room. Review of the physician orders for Resident #15 revealed an order dated [DATE] for the resident to be a full code. Review of Resident #15's medical record revealed there was no documentation of a blood pressure reading or the inability to obtain blood pressure. There was no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to timely notify residents and responsible parties of a change in condition. This affected two (#10 and #80) of three residents reviewed for wounds. The facility census was 47. Findings include: 1. Review of Resident #10's medical record revealed the resident was admitted to the facility with 06/02/23 with diagnoses that include chronics respiratory failure, pneumothorax, need for assistance with personal care, and chronic venous hypertension with ulcer of the left lower extremity. Review of the weekly wound tracking logs for July and August 2023 for Resident #10 revealed on 07/07/23 Resident #10 had a stage two pressure ulcer (partial-thickness skin loss with exposed dermis) to the left buttocks that resolved on 07/14/23. Further review revealed Resident #10 had a stage two pressure ulcer on the coccyx beginning 07/24/23 and continued until 08/11/23 when the wound healed. On 08/18/23, Resident #10 was again documented 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 and staff interview, the facility failed to ensure resident care conferences were held with residents and resident representatives to allow for input into the resident's plan of care. This affected two (#60 and #90) of six residents reviewed for care planning conferences. The facility census was 47. Findings include: 1. Review of Resident # 60's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include occlusion and stenosis of carotid artery, dysphagia, aphasia, chronic kidney disease, type two diabetes, and history of falling. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #60 was assessed with intact cognition. Further review of Resident #60's medical record revealed the facility had two care planning conferences since admission on [DATE] that were held on 06/30/22 and on 07/03/23. There was no documentation of the facility holding care planning conferences during quarterly review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure resident medications were stored in a safe and secure manner. This affected one (#60) of one residents observed for medication storage. The facility census was 47. Findings include: Review of Resident # 60's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include occlusion and stenosis of carotid artery, dysphagia, aphasia, chronic kidney disease, type two diabetes, and history of falling. Review of the most recent Minimum Data Set assessment dated [DATE] revealed Resident #60 was cognitively intact. Review of Resident #60's medication orders revealed Resident #60 was ordered the pain medication aspirin 81 milligrams (mg), the blood pressure medication metoprolol 12.5 mg, the stool softener Miralax 17 grams, the antidepressant Zoloft 50 mg, and the supplement vitamin D3 50 micrograms (mcg) scheduled daily between 6:00 A.M. and 9:00 A.M.; the supplement cranberry…

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 an advanced directive was signed by the physician on the hard chart. This affected one resident (#34) out of 18 residents reviewed for advanced directives. The facility census was 45. Findings include: Review of the medical record for Resident #34 revealed an admission date of 04/09/22. Diagnoses included cognitive communication deficit, type II diabetes, atrial fibrillation, congenital myopathy, cirrhosis of the liver and emphysema. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Resident #34 required extensive assistance of two people for transfers, bed mobility, dressing, toileting, and bathing. Review of the Care Plan dated 04/11/22 revealed Resident #34 had a Do Not Resuscitate Comfort Care Arrest (DNRCCA) in place. Interventions included the facility would review code status annual and as needed…

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, and resident and staff interviews, the facility failed to maintain a clean and sanitary environment. This affected two residents (#38 and #20) out of five residents reviewed for environment. The census was 45. Findings include: 1. Observation on 05/23/22 at 3:06 P.M. of Resident #38's room revealed the bed linens were visibly soiled. The fitted sheet covering the resident's mattress had areas of brown discoloration starting at the middle of the bed which continued to the foot of the bed. The spots appeared as fingerprints and smears. There were also brown particles, appearing as dirt, located on the fitted sheet. Observation on 05/24/22 at 1:28 P.M. of Resident #38's bed linens revealed the bed linens were unchanged from the previous observation on 05/23/22. The same brown discolorations spots were visible. Interview on 05/24/22 at 1:29 P.M. State Tested Nurse Aide (STNA) #304 reported bed linens were changed when linens were dirty or on resident's scheduled shower days. STNA #304 verified Resident #38's bed linens were dirty and needed to be changed. 2.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to update a care plan for one resident (#15) out of four residents reviewed for care planning. The facility census was 45. Findings include: Medical record review for Resident #15 revealed an admission date of 06/30/21 with diagnoses including but not limited to, dementia without behavioral disturbance, Parkinson's disease, obstructive and reflux uropathy, and repeated falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine, indicating Resident #15 was cognitively impaired. Resident #15 required extensive assistance of two people for Activities of Daily Living (ADLs). Review of the care plan dated 01/19/22 revealed Resident #15 was at risk for falls. Interventions included side rails to assist with bed mobility and positioning, perimeter mattress, non-skid footwear to be worn at all times, physical therapy to evaluate and treat, ensure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure fall interventions were utilized as identified in the plan of care. This affected one (#13) of four resident reviewed for falls. The census was 45. Findings include: Review of the medical record for Resident #13 revealed the resident was admitted to the facility on [DATE]. Diagnoses include hemiplegia, diabetes mellitus type two, chronic obstructive pulmonary disease, bipolar, anxiety, depression, chronic kidney disease, and end stage renal disease. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was rarely to never understood. The resident was totally dependent of two people for bed mobility and transfers. Review of the fall risk assessment dated [DATE] revealed Resident #13 was at moderate risk for falls. Review of the plan of care, date initiated 10/05/20, revealed Resident #13 was at risk for falls and potential injury, related to incontinence, lack of coordination, 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 medical record review, observation, and staff interview, the facility failed to ensure an indwelling urinary catheter was stabilized. This affected one resident (#4) out of of two residents reviewed for urinary catheter. The census was 45. Findings include: Review of the medical record for Resident #4 revealed an admission date of 08/10/21. Diagnoses included sepsis, methicillin resistant staphylococcus bacteremia (MRSA), obstructive reflux uropathy, chronic osteomyelitis to right ankle and foot, paroxysmal atrial fibrillation, hypertension, systolic congestive and diastolic congestive heart failure, coronary artery disease, obstructive uropathy, and chronic obstructive pulmonary disease (COPD). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident required extensive assistance of two plus persons for bed mobility and transfers. The resident required one-person extensive assistance for dressing, toilet use, and personal 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to assess a resident upon return from dialysis. This affected one resident (#38) out of one resident reviewed for dialysis. The census was 45. Findings include: Review of the medical record for Resident #38 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease stage four, noncompliance with medication regime, weakness, peripheral vascular disease, and diabetes mellitus type two Review of an the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Resident #38 received dialysis at the facility within the last 14 days. Review of the plan of care dated 04/20/22, revealed Resident #38 received dialysis at a contracted dialysis center located in the community on Tuesday, Thursday, and Saturday. Review of a document titled, Hemodialysis Communication Form, dated 05/10/22, 05/11/22, 05/13/22, 05/16/22, 05/18/22, and 05/20/22, revealed the facility utilized 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.

Based on observation, staff and resident interview and policy review the facility failed to ensure food was served at appropriate temperatures. This had the potential to affect all 37 residents. The census was 37. Findings include: Interview with Resident #35 on 05/19/19 at 2:20 P.M. revealed his meal is never hot and he has been told there was not a microwave to heat up his meal. Observation of the breakfast meal on 05/20/19 at 8:07 A.M. with Dietary Manager (DM) #34 revealed the temperature of the fired eggs was 95 degrees and the sausage links were 106 degrees. DM #34 utilized a facility thermometer to check the temperatures. Interview with DM #34 on 05/20/19 at 8:10 A.M. verified the meal was cold. Review of policy entitled Food Preparation dated 06/20/17 revealed all dietary staff will ensure all foods are held at appropriate temperature for hot foods at greater than 135 degrees.

Based on facility policy review and staff interview the facility failed to monitor and test for Legionella in the facility. This had the potential to affect all 37 residents. Findings include: Review of the Legionella Policy and Procedure, revision dated 05/16/19 revealed the facility was expected to implement a water management program that included control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. Testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained Interview with the Administrator on 05/21/19 at 4:00 P.M. confirmed the facility had not been monitoring water temperatures, chemical levels, flushing the lines, or monitoring for pathogens.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, resident and staff interviews and review of the activity calendar the facility failed to ensure an ongoing activity program was provided for the residents, failed to ensure there were activities provided in the evenings and also failed to ensure participation for activities were documented. This affected four (#13, #15, #32, and #35) of four residents reviewed during the annual survey for activities. The census was 37. Findings include: 1. Medical record review for Resident #35 revealed an admission date of 11/02/17. Medical diagnoses included diabetes, hemiplegia to left side for upper and lower extremities and end stage renal disease. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact. His functional status was supervision for bed mobility, transfer, and toilet use and he was independent for eating. Review of care plan dated 01/22/19 revealed he had little to no involvement in activities and was at risk for psychosocial well…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to notify resident's representatives of transfer to the hospital. This affected one (#36) resident of two reviewed for hospitalizations. The facility also failed to notify the Long- Term Care Ombudsman of transfers to the hospital. This affected two (#6 and #36) of two residents reviewed for hospitalizations. The facility census was 37. Findings include: 1. Resident #6 was admitted to the facility 10/25/18 with a diagnoses of Alzheimer's disease, chronic obstructive pulmonary disease, hypertension, anxiety disorder, depression and shortness of breath. Resident #6 was admitted on [DATE] to a local hospice company after a brief stay in the hospital. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #6 had severe cognitive impairment. Her functional status was listed as supervise one person assist for all activities of daily living. Review of the progress note dated 05/11/19 revealed the resident was sitting her wheelchair in 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, resident and staff interview, and review of facility policy the facility failed to have quarterly care conferences for residents and failed to have the proper staff attend the care conferences. This affected three Residents (#7, #13, and #35) of 16 reviewed during the investigative phase of the survey. The facility census was 37. Findings include: 1. Resident #7 was admitted to the facility on [DATE] with diagnoses of acute osteomyelitis of right radius and ulna, type II diabetes mellitus, bipolar disorder, chronic pain syndrome, opioid dependence, chronic obstructive disease, skin graft infection and Stevens-Johnson Syndrome. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #7 was cognitively intact. His functional status was listed as independent for all transfers and ambulation. Interview with Resident #7 on 05/19/19 at 2:00 P.M. revealed the facility did not hold quarterly care conferences and he wished they would. He revealed the facility did not have a social…

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 resident and staff interview, the facility failed to follow recommendations for restorative therapy. This affected one (#35) of one resident for restorative therapy. The facility identified seven residents who currently receive restorative care. The census was 37 residents. Findings include: Medical record review for Resident #35 revealed an admission date of 11/02/17. Medical diagnoses included diabetes, hemiplegia to left side for upper and lower extremities and end stage renal disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. His functional status was supervision for bed mobility, transfer, and toilet use and he was independent for eating. Review of discharge recommendations from Physical therapy (PT) dated 09/12/18 revealed ROM/strengthening of the left leg. Review of discharge recommendations from Occupational Therapy (OT) dated 11/01/18 revealed restorative for Range of Motion (ROM) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interview, the facility failed to ensure physicians orders were followed to hold blood pressure medication for a resident prior to receiving dialysis. This affected one (#35) of one resident reviewed for dialysis. The facility identified two residents who attending dialysis off grounds. The census was 37. Findings include: Medical record review for Resident #35 revealed an admission date of 11/02/17. Medical diagnoses included diabetes, hemiplegia to left side for upper and lower extremities and end stage renal disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. His functional status was supervision for bed mobility, transfer, and toilet use and he was independent for eating. Review of the care plan dated 11/08/17 revealed the resident needed dialysis due to renal failure. The intervention was to hold blood pressure medication on dialysis days. Review of progress note dated 03/27/19 at 10:10 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.