Prestige Gardens Rehabilitation And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and review of facility policy, the facility failed to provide dignity during dining when staff was standing over a resident while assisting with feeding. This affected one resident (Resident #16) out of six residents (#7, #12, #14, #15, #16, #36) reviewed for dignity. The census was 56 residents. Findings include: Review of Resident #16's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included hypertension, osteoarthritis, major depressive disorder, and generalized anxiety disorder. Review of Resident #16's quarterly Minimal Data Set (MDS) assessment dated [DATE] revealed she had a Brief Interview for Mental Status score of 11, indicative of mildly impaired cognition. MDS assessment further revealed Resident #16 was independent for eating. Review of Resident #16's self care deficit care plan dated 06/22/22 revealed she was at risk for self care deficit related to an increased need for assistance with her activities of daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interviews, staff interviews, and review of facility policy, the facility failed to protect a resident (Resident #14) after an allegation of verbal abuse by a staff member and continued to let the staff member work at the facility. This affected one resident, Resident #14, out of three residents (#15, and #16) reviewed for abuse. The facility census was 56. Findings include: Review of the medical record for Resident #14 revealed an admission date of 01/16/23. Diagnoses included carcinoma in situ of esophagus, severe protein calorie malnutrition, hypertension, depression, hyperlipidemia, chronic kidney disease stage III, vascular dementia, alcohol abuse, muscle weakness, cognitive communication deficit, metabolic encephalopathy, and acquired AKA (above the knee amputation). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13 and required one person assist with…

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

Based on record review, interviews and facility policy and procedures review, the facility failed to ensure the physician and or prescribing practitioner documented a rationale in the resident's medical record for the use of a psychotropic drug for 180 days. This had the potential to affect one (Resident #4) out of five residents reviewed for unnecessary medications. The census was 56. Findings include: Review of the medical record for Resident #4 revealed an admission date of 11/04/22 with mild cognitive deficits. Diagnoses included traumatic hemorrhage of the cerebrum, hemiplegia and hemiplegia, acute chronic respiratory and obstructive pulmonary disease. A care plan relative to her physical and psychological needs revealed individualized interventions with measurable goals. Review of the Consultant Pharmacist Recommendation to Physician dated 7/16/24 and 2/11/25. The pharmacist requested a recommended reorder for specific number of days for the as needed (PRN) order of Lorazepam (antianxiety) 1 milligram (mg) for Resident #4 or to discontinue the medication per federal guideline.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the medical record for Resident #14 revealed an admission date of 01/16/23. Diagnoses included carcinoma in situ of esophagus, severe protein calorie malnutrition, hypertension, depression, hyperlipidemia, chronic kidney disease stage III, vascular dementia, alcohol abuse, muscle weakness, cognitive communication deficit, metabolic encephalopathy, and acquired AKA (above the knee amputation). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13 and required one person assist with activities of daily living and had no history of behaviors. Review of facility self reported incidents (SRI)s revealed no submission related to verbal abuse allegation involving Resident #14. Telephone interview on 05/06/25 at 9:43 A.M. with Certified Nursing Assistant (CNA) #51 revealed she witnessed very concerning behavior from CNA #22 a little less than one month ago. CNA #51 stated that she overheard CNA #22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the medical record for Resident #14 revealed an admission date of 01/16/23. Diagnoses included carcinoma in situ of esophagus, severe protein calorie malnutrition, hypertension, depression, hyperlipidemia, chronic kidney disease stage III, vascular dementia, alcohol abuse, muscle weakness, cognitive communication deficit, metabolic encephalopathy, and acquired AKA (above the knee amputation). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13 and required one person assist with activities of daily living and had no history of behaviors. Interview with Regional Operations Director #154 on 05/06/25 at 09:29 A.M. revealed no reports of abuse in the last month. Review of the facility's Self Reported Incidents (SRI)s revealed there was no report completed regarding Resident #14 in regards to verbal abuse. Telephone interview on 05/06/25 at 09:43 A.M. with Certified Nursing Assistant (CNA) #51…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the medical record for Resident #14 revealed an admission date of 01/16/23. Diagnoses included carcinoma in situ of esophagus, severe protein calorie malnutrition, hypertension, depression, hyperlipidemia, chronic kidney disease stage III, vascular dementia, alcohol abuse, muscle weakness, cognitive communication deficit, metabolic encephalopathy, and acquired AKA (above the knee amputation). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13 and required one person assist with activities of daily living and had no history of behaviors. Telephone interview on 05/06/25 at 09:43 A.M. with Certified Nursing Assistant (CNA) #51 revealed she witnessed very concerning behavior from CNA #22 a little less than one month ago. CNA #51 stated that she overheard CNA #22 get into a verbal disagreement with Resident #14 and Resident #27 in the TV room/hallway and it escalated when that aide got into…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure the appropriate and pertinent information was communicated to the receiving health care institution during a resident transfer. This had the potential to affect one (#57) of five residents reviewed for transfer and discharge. The facility census was 56. Finding Include: Review of the medical record for Resident #57 revealed an admission date of 01/30/24. Diagnoses included arthritis due to other bacteria of the right knee, chronic pain, acute kidney failure, unspecified low back pain, hypo-osmolality and hyponatremia, multiple myeloma, hypertension, pneumonia, ileus, unspecified muscle weakness. Review of physician orders dated 02/04/25 revealed routine laboratory values were ordered to assess Resident #57's hemoglobin (an iron-containing protein found in red blood cells that is responsible for transporting oxygen throughout the body) levels. Review of additional orders on 02/07/25 revealed Resident #57 was to be…

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 complete and provide a bed hold notice and reason for transfer to residents and resident representative and failed to notify the long-term care ombudsman of a resident transfer as required. This affected three (#57, #56, and #12) of five residents reviewed for transfer and discharge. The facility census was 56. Finding include: 1. Review of the medical record for Resident #57 revealed an admission date of 01/30/24. Diagnoses included arthritis due to other bacteria of the right knee, chronic pain, acute kidney failure, unspecified low back pain, hypo-osmolality and hyponatremia, multiple myeloma, hypertension, pneumonia, ileus, and unspecified muscle weakness. Review progress notes dated 02/04/25 revealed Resident #57's hemoglobin (an iron-containing protein found in red blood cells that is responsible for transporting oxygen throughout the body) was 7.6 grams per deciliter (g/dL) on 01/30/25 and laboratory values were…

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, facility failed to ensure Pre-admission Screening and Resident Review (PASARR) documents were accurately completed for two (#23 and #27) of five residents reviewed for PASARR. The facility census was 56. Findings include 1. Review of the medical record for Resident #23 revealed an admission date of 03/21/23. Diagnoses included schizoaffective disorder (added 03/21/23), insomnia, diabetes, cognitive communication deficit, and encephalopathy. Review of Resident #23's PASARR dated 03/17/23 revealed the only diagnosis marked was mood disorder. Interview on 05/05/25 at 5:15 P.M. with Admissions #18 and Social Service Designee (SSD) #126 confirmed PASARR should be reviewed for accuracy at admission and updated for any changes in diagnosis during the admission. Both staff members confirmed Resident #23 PASARR document was not accurate. 2. Review of the medical record for Resident #27 revealed an admission date of 09/21/18. Diagnoses included cerebral palsy, depression, cognitive communication deficit, schizophrenia (added 11/22/23), 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 2. Review of the medical record for Resident #23 revealed an admission date of 03/21/23. Diagnoses included schizophrenia, diabetes, cognitive communication deficit, encephalopathy and insomnia. Review of Resident #23's plan of care dated 03/22/23 revealed the nutritional care plan had no intervention changes or updates in over two years in which time resident had significant weight loss of over 20 pounds, or 12.22 percent (%) weight loss, in six months. The interventions in the current care plan included monitoring for weight loss and to make diet recommendations as needed. Review Resident #23's progress notes revealed no notes regarding nutrition from 03/27/24 to 03/05/25. Review of a note dated 03/05/25 revealed the resident had excessive weight loss and a second weight was requested to confirm weight loss. Review of a note dated 03/12/25 revealed weight loss was acceptable and the resident went from an overweight body max index (BMI) to a healthy BMI. The note continued to begin weekly weights and monitor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, and medical record review, the facility failed to ensure staff followed physician orders for use of and documented use of specialized devices to aid in turning and repositioning as a pressure ulcer prevention intervention. This had the potential to affect one (#30) of three residents reviewed for pressure ulcers. The facility census was 56. Finding Include: Review of the medical record for Resident #30 revealed an admission date of 02/22/25. Diagnoses included hypo-osmolality and hyponatremia, malignant neoplasm of bilateral ovaries, hypothyroidism, Crohn's disease, morbid obesity, difficulty walking, need for assistance with personal care, major depressive disorder, pressure ulcer of the right buttocks, chronic kidney disease, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 was cognitively intact, required extensive assistance of two staff members for bed mobility, and total dependence 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, staff interview, and policy review, the facility failed to ensure residents were provided with adequate peri-care. This affected one (#161) of one residents reviewed for peri-care. The census was 56. Findings included: Medical record review for Resident #161 revealed an admission date of 04/24/25. Medical diagnoses included pneumonia, hypertension, and diabetes. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #161 was cognitively intact and was assessed as continent for bowel and bladder. Observation of peri-care on 05/08/25 at 5:39 A.M. revealed Resident #161 was on the bedpan. Certified Nurse Aide (CNA) #500 revealed he placed on gloves and had cleansing wipes for the care. While the resident was still on the bed pan, CNA #500 wiped down each side of the resident's inner thigh area and did not touch either side of the resident's labia. He removed the bed pan and rolled the resident to the left side and provided care to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to provide complete information requested. This affected one (#159) of one residents reviewed for medical record documentation. The census was 56. Findings included: Medical record review for Resident #159 revealed an admission date of 01/15/25. Medical diagnoses included heart failure, renal insufficiency, diabetes, depression, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #159 was cognitively intact. The resident's functional status was assessed as setup or clean up assistance for eating, dependent for toileting and transfers, and substantial/maximal assistance for bed mobility. Resident #159 was frequently incontinent of bowel and bladder. During an interview and observation on 05/05/25 at 12:16 P.M. revealed Receptionist #116, who also was the appointment scheduler, pulled out the appointment book and showed the surveyor a date on a paper with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, resident interview, review of the facility handbook, and review of the facility policy, the facility failed to ensure resident personal and medical information was kept confidential. This affected four (Residents #18, #23, #36 and #37) of five records reviewed for privacy and confidentiality. The facility census was 59. Findings include: Review of the medical record for Resident #10 revealed an admission date of 08/29/23 with diagnoses including [NAME]-Danlos Syndrome, anxiety disorder, protein-calorie malnutrition, dysuria, and depression. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 12/08/23 revealed the resident was cognitively intact and required limited assistance with activities of daily living (ADLs.) Review of email records revealed the Administrator sent an email on 02/19/24 regarding Resident #10 with an attached Medicaid Pending Log to Resident #10, Ombudsman #107, Corporate [NAME] Representative #501, Hearing Officer…

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, hospice staff and family interviews, the facility failed to administer a residents medications per physician orders. This affected one (#79) of three residents reviewed for medication administration who received hospice services. The facility census was 59. Findings include: Review of medical record for Resident #79 revealed admission [DATE] and discharged on 09/01/23. Diagnoses include pathological fracture hip, cerebral atherosclerosis, umbilical hernia, altered mental status, chronic kidney disease stage three, hypokalemia, gout, insomnia, arthritis, and anxiety. Review of admission Minimum Data Set (MDS) for Resident #79 dated 08/05/23 revealed a brief interview of mental status (BIMS) score of 11 which indicated moderate cognitive impairment. Resident #79 required extensive assistance for activities of daily living with exception of supervision for eating. Review of care plan for Resident #79 revealed admit to hospice due to cerebral atherosclerosis. Interventions…

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, observation, review of manufacturer's directions, and review of facility policy, the facility failed to prime an insulin pen prior to administration per manufacturer recommendation. This affected one (Resident #27) of four residents observed during medication administration. The facility census was 59. Findings include: Review of the medical record for Resident #27 revealed an admission date of 10/06/23 with diagnoses included acute kidney failure, anemia, type two diabetes, hypertension, cellulitis, and unspecified open wound of scrotum and testes. Review of December physician orders for Resident #27 revealed humano kwikpen 100 units/milliliter (ml) per slicing scale 150-200 give 2 units, 201-250 give 4 units, 251-300 give 6 units, 301-350 give 8 units, and 351-400 give 10 units. Any blood sugar above 400 and below 60 notify the physician. Twice daily. Insulin Glargine (lantus) subcutaneous solution pen-injector 100 unit/ml, inject 32 units subcutaneously one time a day for diabetes type two. Review of the Care Plan dated 10/27/23 for Resident #27…

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

Based on observations, interviews and record review, the facility failed to ensure meals were served using the correct serving size, and failed to ensure mechanical soft and pureed meals were prepared according to a recipe. This had the potential to affect all 69 residents who received meals from the kitchen. The facility identified two residents (Resident #16 and #276) who received nothing by mouth and did not receive food from the kitchen. The facility census was 71. Findings include Observation and interview on 06/01/22 at 11:01 A.M. with [NAME] #6 revealed the facility had four pureed meal orders and five mechanical soft meal orders. [NAME] #6 placed four four ounce (oz) scoops of green beans into the blender, with an unmeasured amount of water which appeared to be roughly a tablespoon, and blended them to a pureed consistency. [NAME] #6 then placed three breaded chicken tenders in the blender and blended them to a mechanical soft consistency. [NAME] #6 then scooped out an unmeasured amount of the blended chicken for the mechanical soft diets and placed the mechanical soft…

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

Based on observations, interviews and record review, the facility failed to prepare food in a sanitary manner. This had the potential to affect all 69 residents who received meals from the kitchen. The facility identified two residents (Resident #16 and #276) who received nothing by mouth and did not receive food from the kitchen. The facility census was 71. Findings include 1. Observation on 06/01/22 at 11:01 A.M. of [NAME] #6 preparing the pureed meal items revealed [NAME] #6 placed four four ounce (oz) scoops of green beans in the blender then blended them to a pureed texture. [NAME] #6 then rinsed the blender with water only. [NAME] #6 did not use soap or sanitizer when cleaning the blender and the blender was not dried. [NAME] #6 then placed three breaded chicken tenders in the blender and blended them to a pureed consistency. [NAME] #6 then rinsed the blender with water only. [NAME] #6 did not use soap or sanitizer when cleaning the blender and the blender was not dried. [NAME] #6 then placed one and a half four oz scoops of plain ziti pasta noodles in the blender with an…

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

Based on review of the facility assessment and staff interview, the facility failed to ensure the facility assessment addressed the use of contract nursing staff to provide services. This had the potential to affect all 71 residents. The census was 71. Findings include: Review of the facility assessment, reviewed and revised on 03/17/22, revealed the facility assessment did not address the facilities use of contract (agency) nursing staff to provide services. Review of the daily assignment sheets provided by the facility during the survey week from 05/31/22 to 06/02/22 revealed the facility used agency nursing staff on 13 shifts. Interview with the Administrator on 06/01/22 at 11:30 A.M. verified the facility utilized agency nurses to provide services and confirmed the assessment does not include information regarding the facilities use of agency nursing staff even after it was reviewed and revised on 03/17/22.

Based on observation, staff interview, and review of glucometer manufacture instructions, the facility failed to ensure the glucometer (machine used to test blood sugar level) was properly disinfected between residents. This affected four residents (Resident #45, #276, #277, and #281) out of 17 residents who resided on the 100 hall. The facility census was 71. Findings include: Observation of medication administration on 06/01/22 at 7:50 A.M. with Licensed Practical Nurse (LPN) #29 revealed LPN #29 set out four alcohol pads and lancets to test blood sugars for multiple residents. LPN #29 was observed to obtain a blood sugar for Resident #277 with the glucometer. LPN #29 returned to the medication cart and cleaned the glucometer (which was a 100 hall community machine) with an alcohol pad. The nurse then obtained a blood sugar for Resident #276, using the same machine. LPN #29 was getting ready to test Resident #45 and Resident #281 and was stopped by the state surveyor. LPN #29 was asked if she cleaned the glucometer with anything other than an alcohol pad. LPN #29 identified 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 observation and staff interview, the facility failed to ensure the stand up scale was properly maintained. This had the potential to affect all 24 residents (Resident #3, #4, #8, #9, #10, #16, #17, #18, #19, #21, #28, #29, #30, #32, #36, #40, #41, #46, #47, #53, #58, #60, #61, and #77) who could utilize the stand up scale and resided on the 300/400 hallway. The facility census was 71. Findings include: Observation of Resident #36 being weighed on the stand up scale on 06/02/22 at 9:33 A.M. with State Tested Nurse Aide (STNA) #216 revealed Resident #36 was able to stand on the scale, however the scale was observed to tilt forward and was wobbling. STNA #216 confirmed the scale was broken and turned the scale over to discover there was a missing leg under the base of the scale. The scale was observed to have three loose legs and one leg was missing. Interview with Maintenance Director #64 was completed on 06/02/22 at 1:17 P.M. The interview confirmed he was notified the scale was not working properly on Monday 05/31/22 and placed it in the shower room on the 300/400 hallway.…

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 maintain an accurate code status in the paper medical record and electronic medical record. This affected one (Resident #5) out of two residents reviewed for advanced directives. The facility census was 71. Findings include Review of the medical record for Resident #5 revealed an admission date of 11/15/21. Diagnoses included encephalopathy, chronic obstructive pulmonary disease, failure to thrive, vascular dementia, kidney disease, and adjustment disorder. Review of the Do Not Rescucitate (DNR) paperwork dated 11/18/21 signed by the physician revealed Resident #5 had elected DNR comfort care code status. Review of the Physician Order dated 11/28/21 revealed Resident #5 had a code status order for DNR comfort care arrest. Interview on 05/31/22 at 12:20 P.M. with [NAME] President of Clinical Services #75 revealed Resident #5 ' s advanced directives and code status in the electronic medical record do not match the DNR form signed by the physician. Review of policy titled Advanced Directives, dated 12/2016, revealed…

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

Based on medical record review and staff interview, the facility failed to complete an updated Preadmission Screening and Resident Review for a resident with a newly evident or possible serious mental disorder. This affected one (Resident #49) out of one resident reviewed for Preadmission Screening and Resident Review. The facility census was 71. Findings include: Medical record review for Resident #49 revealed an admission date of 09/17/16. Diagnoses included type two diabetes mellitus, hypokalemia, major depressive disorder, cerebral infarction, and essential hypertension. Resident #49 had a diagnosis of Schizoaffective disorder, depressive type added on 11/18/21. Review of the Preadmission Screening and Resident Review (PASRR) Result Notice dated 06/01/22 revealed a referral was made for a level II evaluation. Review of the medical record for Resident #49 revealed no evidence of a new PASRR having been completed prior to 06/01/22 since Resident #49's new diagnosis of Schizoaffective disorder, depressive type on 11/18/21. Interview on 06/01/22 at 3:09 P.M. Social Services Director…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, policy review, and review of a job description, the facility failed to implement an effective and timely discharge planning process. This affected one (Resident #43) of two residents reviewed for discharge. The facility census was 71. Findings include: Review of the medical record for Resident #43 revealed an admission date of 03/13/22. Diagnoses included asthma, diabetes type two, COVID-19, guillain-barre syndrome, and respiratory failure with hypoxia. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #43 was cognitively intact and required extensive assist of two staff for bed mobility and transfers. Review of the care plan dated 04/01/22 revealed Resident #43 was anticipated as a short term stay at the facility with discharge anticipated back home to the community with services and HME (home medical equipment) needed with interventions to document all discharge planning, and document all interactions with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to provide adequate assistance with eating. This affected one (Resident #36) out of four residents reviewed for nutrition. The facility census was 71. Findings include: Review of Resident #36's medical record revealed admission to the facility occurred on 07/23/20. Resident #36 had medical diagnoses including dementia, high blood pressure, and coronary artery disease. Review of Resident #36's most recent quarterly assessment dated [DATE] revealed Resident #36 had severe cognitive impairment. Review of Resident #36's speech therapy discharge instructions dated 04/13/22 revealed Resident #36 required concrete one step directions. Observation of Resident #36's lunch meal on 05/31/22 at 12:26 P.M. revealed Resident #36 was in bed with her lunch tray. Resident #36 was not provided any assistance including opening her milk carton. The observation revealed Resident #36 ate no food and drank half of a nutritional shake before her tray…

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, observation, resident interview, staff interview, and policy review, the facility failed to obtain physician orders prior to completing wound treatments. This affected one (Resident #427) out of two residents reviewed for skin concerns. The facility census was 71. Findings include Review of the medical record for Resident #427 revealed an admission date of 05/27/22. Diagnoses included lumbar vertebra fracture, vascular disease, and absence of fingers. Review of Resident #427's care plan dated 05/27/22 revealed Resident #427 was at risk for skin breakdown with interventions including skin assessment as needed and provide supplements as ordered. Review of the progress note dated 06/01/22 revealed Resident #427 had wounds with dressings to bilateral arms. Review of Resident #427's physician orders dated 06/01/22 revealed an order for skin tear to left arm with instructions to pat dry and apply oil emulsion dressing and ABD pad wrap with bandage roll and change daily until healed. Review of Resident #427's physician order dated 06/01/22 revealed skin tear…

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 staff interviews and medical record review, the facility failed to ensure residents received timely treatment and assistive devices to maintain vision. The affected one (Resident #18) out of one resident reviewed for vision services. The facility census was 71. Findings include: Review of the medical record for Resident #18 revealed an admission date of 01/27/22. Diagnoses included end stage renal disease, diabetes type two, and chronic obstructive pulmonary disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had mild cognitive impairment. Review of the 360 eye visit schedule and resident list revealed Resident #18 was seen by the eye physician on 03/04/22. Review of the documents from 360 vision professionals revealed Resident #18 was assessed and provided a new eye prescription. Interview on 05/31/22 at 11:08 A.M. with Resident #18's wife revealed Resident #18 had seen the eye doctor at the facility about three months ago and had not heard of an update…

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, resident interview, observation, and policy review, the facility failed to complete weekly skin assessments, monitor wound progress, and timely implement interventions for pressure ulcers. This affected one (Resident #43) out of four residents reviewed for pressure ulcers. The facility census was 71. Findings include: Review of the medical record for Resident #43 revealed an admission date of 03/13/22. Diagnoses included diabetes type two, COVID-19, lymphedema, and guillain-barre syndrome. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was cognitively intact and required extensive assist of two staff for bed mobility and transfers. Review of the care plan dated 04/01/22 revealed Resident #43 was at risk for skin breakdown due to decreased mobility with interventions including encourage resident to turn and reposition as tolerated, observe skin for signs and symptoms of breakdown and document and notify the physician,…

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 interviews, the facility failed to ensure nutritional supplements were provided as ordered. This affected one (Resident #36) out of four residents reviewed for nutrition. The facility census was 71. Findings include: Review of Resident #36's medical record revealed admission to the facility occurred on 07/23/20. Resident #36 had medical diagnoses including dementia, high blood pressure, and coronary artery disease. Review of Resident #36's most recent quarterly assessment dated [DATE] revealed Resident #36 had severe cognitive impairment. The assessment revealed Resident #36 had unintended weight loss. Review of Resident #36's physician orders dated 09/15/20 revealed an order for house supplement (House Shake/Nutritional Shake) three times a day. Review of Resident #36's physician order dated 03/06/22 revealed an order for nutritional treat (ice cream nutritional supplement) two times a day. Review of Resident #36's Nutritional Notes dated 03/06/22 revealed…

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

Based on observation, review of manufacture instructions, and staff interview, the facility failed to ensure insulin was administered according to manufactures instructions. This affected one (Resident #281) of four residents observed for medication administration. The facility census was 71. Findings include: Observation of medication administration on 06/01/22 at 7:50 A.M. with Licensed Practical Nurse (LPN) #29 revealed LPN #29 obtained Resident #281's blood sugar which was found to be at 380 milligrams/deciliter. LPN #29 then obtained Resident #281's insulin pen, added a new needle and adjusted the dosage to 10 units. LPN #29 was then observed to administer the 10 units of Novolog insulin to Resident #281. Upon returning to the medication cart, LPN #29 was asked about priming the insulin pen prior to administration and LPN #29 confirmed she did not prime the insulin pen prior to administration and was not aware of the need to do so. Review of the Novolog flex pen (insulin pen) manufactures instructions revealed in the steps for administration; step seven priming, turn the dose…

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

Based on medical record review, review of pharmacy medication reviews, and staff interview, the facility failed to ensure the physician was aware and responded to pharmacy medication reviews/recommendations in a timely manner. This affected one (Resident #28) out of five residents reviewed for unnecessary medications. The facility census was 71. Findings include: Review of Resident #28's medical record revealed admission to the facility occurred on 07/23/21 with medical diagnoses including diabetes, depression, high blood pressure, dementia, and Covid-19 infection (03/17/22). Review of Resident #28's Medication Regimen revealed he was receiving Aricept (a medication used to treat dementia in people who have Alzheimer's disease) five milligrams (mg) daily for the diagnosis of dementia. Review of Resident #28's Medication Administration Record for May 2022 and June 2022 confirmed Resident #28 was receiving Aricept five mg daily. Review of a pharmacy review/recommendation dated 04/23/22, revealed on 03/20/22 a new order for Resident #28 to receive Aricept five mg at bedtime 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 medical record review and staff interview, the facility failed to obtain laboratory testing as ordered. This affected one (Resident #28) out of five residents reviewed for unnecessary medications. The facility census was 71. Findings include: Review of Resident #28's medical record revealed admission to the facility occurred on 07/23/21 with medical diagnoses including diabetes, major depression, high blood pressure, and Covid-19 (03/17/22). Review of Resident #28's physician orders dated 11/14/21 revealed orders for blood laboratory testing of Complete Blood Count (CBC), Metabolic Panel (BMP), and Hemoglobin A1C (measures average blood glucose levels), to be completed every three months. Review of the Resident #28's medical record revealed no evidence of any blood laboratory testing having been conducted since November 2021. Interview with the Director of Nursing (DON) on 06/02/22 at 1:55 P.M., confirmed the facility did not obtain Resident #28's blood laboratory testing (CBC, BMP, Hemoglobin A1C), every three months, as ordered by the physician. The interview 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, resident interview, and staff interview, the facility failed to ensure resident call lights were in working order. This affected one (Resident #28) out of 24 reviewed for functioning call lights. The facility census was 71. Findings include Review of the medical record for Resident #28 revealed an admission date of 07/23/21. Diagnoses included type two diabetes, depression, hyperlipidemia, acute embolism, and hyperlipidemia. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #28 was cognitively intact. Observation and interview on 05/31/22 at 9:27 A.M. with Resident #28 revealed Resident #28 was pressing his call light and reported staff were not responding. Resident #28 was observed to push the call light again and the light on the wall as well as the light outside door did not activate. Resident #28 revealed his call light had not been working for about a week and stated he had mentioned it to staff. Interview on 05/31/22 at 9:28 A.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical and facility record review and staff interview, the facility failed to provide notification of resident's transfers to the hospital to the resident and/or representative and to the Office of the State Long-Term Care Ombudsman. This affected three (#24, #51 and #57) of three residents reviewed for hospitalization. The facility census was 57. Findings include: 1. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE]. Diagnoses included pressure ulcer sacral region, spina bifida unspecified, chronic osteomyelitis, paraplegia, morbid obesity, and neuromuscular dysfunction of the bladder. Review of the Minimum Data Set (MDS) assessment, dated 03/31/19, revealed the resident had no cognitive impairment. Further review of the record revealed Resident #24 was sent to the hospital on [DATE] for significant change in condition and returned to the facility on [DATE]. The medical record was silent of verification, that a notification of transfer, was provided in writing…

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, staff interview and review of facility policy, the facility failed to notify the resident and/or representative of the facility's bed hold policy. This affected one (#57) of three residents reviewed for hospitalization. The facility census was 57. Findings include: Closed medical record review for Resident #57 revealed an admission date of 02/23/19. Diagnoses included bacteremia, disorder of kidney and ureter, acute kidney failure, unspecified abdominal pain, disease of pancreas, alcoholic cirrhosis of liver without ascites, sepsis and acute pancreatitis without necrosis. Further review of the record revealed the resident was transferred to the hospital per squad after a significant change in condition on 02/28/19. The resident's wife was present at the time of the transfer. The medical record contained no documentation of the resident and/or representative having been provided with the bed hold policy at the time of transfer. Interview with Social Service Designee #510 on 05/22/19 at…

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

Based on record review, staff interview and policy review, the facility failed to ensure the baseline care plan addressed the use of an anticoagulant for Resident #305. This affected one (#305) of 16 residents reviewed for care plans. The facility census was 57. Findings include: Review of the medical record for Resident #305 revealed an admission date of 05/10/19 with diagnoses including heart failure, respiratory failure, coronary artery disease, and chronic embolism and thrombosis of deep veins of lower extremity. Review of the medical record revealed an order dated 05/10/19 for Warfarin sodium, a medication used as a blood thinner, tablet six milligrams by mouth one time a day. Review of the baseline care plan for Resident #305, dated 05/10/19, revealed Warfarin use was not addressed on the baseline care plan. Interview on 05/23/19 at 10:48 A.M. with Director of Nursing (DON) verified Resident #305's baseline care plan did not address Warfarin use. During interview on 05/23/19 at 10:48 A.M. with DON, the DON agreed Resident #305's baseline care plan should have addressed the use…

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, observation and staff interview, the facility failed to ensure one resident's behavior of picking at her skin and facial lesions was addressed on the resident's plan of care. This affected one (#38) of 16 care plans reviewed during the survey. Findings include: Review of Resident # 38's medical record revealed the resident was admitted to facility on 01/06/16. Diagnoses included dementia without behavioral disturbance, vitamin B12 deficiency and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment, dated 05/10/19, indicated the resident was severely cognitively impaired and required extensive assistance with activities of daily living including dressing and personal hygiene. Review of a weekly skin assessment, dated 05/22/19, indicated the resident had multiple scratches to her face. Review of the resident's care plan revealed it did not indicate the resident picked or scratched her face. Observation on 05/20/19 at 10:21 A.M. of Resident # 38 revealed she had lesions on her face. Interview on 05/22/19 at 1:45 P.M. with State Tested Nursing…

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

Based on policy review, record review, observation and staff interview, the facility failed to ensure one resident's facial lesions were documented in the medical record, treated and monitored for improvement and failed to have hospice progress notes available for review for another resident. This affected one (#38) of two resident's reviewed for non-pressure skin issues and one (#8) of two residents reviewed for hospice services. Findings include: 1. Review of Resident #38's medical record revealed the resident was admitted to facility on 01/06/16. Diagnoses included dementia without behavioral disturbance, vitamin B12 deficiency and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment, dated 05/10/19, indicated the resident was severely cognitively impaired and required extensive assistance with activities of daily living including dressing and personal hygiene. Review of the resident's care plan revealed it did not indicate the resident picked or scratched her face. Review of weekly skin assessments, dated 05/13/19 and 05/20/19, revealed it did not indicate 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 and staff interview, the facility failed to ensure psychotropic medications were not administered for extended periods of time without attempts for gradual dose reductions for one (#14) of five residents reviewed for unnecessary medications. The facility census was 57. Findings include: Medical record review for Resident #14 revealed an admission date of 10/08/15. Diagnoses included major depressive disorder and generalized anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 03/12/19, revealed the resident had moderate cognitive impairment and had no mood or behavior issues. Review of quarterly social service progress notes, from 01/02/18 to 04/03/19, reflected the resident was without mood or behavior issues. Review of physician progress notes from 04/16/19 to 05/29/18 revealed the resident was pleasant, alert and were silent to any mood or behavior problems. Review of current physician orders for Resident #14 revealed the resident had orders to receive an antianxiety medication named Buspar five milligrams (mg.) twice daily since…

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.