Hanover Healthcare Center

Based on record review, observations, interviews, and facility policy review the facility failed to maintain infection control by not disposing of used tracheostomy supplies and by not performing hand hygiene during incontinence care. These deficient practices affected two residents (Resident #12 and #44) out of nine residents reviewed for infection control. The facility census was 113.Findings Include: 1. Review of Resident #44's medical record revealed admission date 02/27/26 with diagnoses including but not limited to acute respiratory failure, epilepsy, kidney failure requiring hemodialysis, tracheostomy, and gastrostomy. Review of Resident #44's physician orders revealed an order dated 03/04/26 for tracheostomy care every shift. Review of Resident #44's care plan dated 03/06/26 revealed tracheostomy using Shiley (type of tracheostomy) size six extra-large with humidified air via trach collar. Review of Resident #44's Treatment Administration Record (TAR dated) 03/04/26 to 03/12/26 revealed the order for trach care was completed as ordered. Observation on 03/12/26 at 2:20 P.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, interviews, and facility policy review the facility failed to ensure call lights within reach of residents. This deficient practice affected three residents (Residents #45, #112, and #116) out of three residents reviewed for call light use. The facility census was 113. Findings Include: 1. Review of Resident #112's medical record revealed admission date 11/22/24 with diagnoses including but not limited to dementia, depression and high blood pressure. Review of Resident #112's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #112 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of three out of possible 15 and required limited assistance from staff for completion of Activities of Daily Living (ADL) tasks. Review of Resident #112's care plan dated 12/04/24 revealed Resident #112's primary language was Spanish and Resident #112 had self-care deficit requiring staff assistance related to language barrier and impaired mobility. Observation…

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

Based on observation, interview, and record review the facility failed to ensure the environment was maintained in a sanitary and working manner. This affected two residents (#12 and #71) out of thirteen residents reviewed for environmental concerns. The facility census was 113. Findings include: 1. An observation on 03/09/26 at 10:44 A.M. revealed areas of grime and dirt on the side rails of Resident #71's bed. An observation on 03/11/26 at 7:32 A.M. revealed the same areas of grime and dirt on the side rails of Resident #71's bed. An observation on 03/11/26 at 11:53 A.M. revealed extensive dried food debris on the legs and post of the bedside table, the same areas of grime and dirt on the side rails, and the bed frame was visibly soiled with a large amount of splatter marks. An interview on 03/11/26 at 12:02 P.M. with Licensed Practical Nurse (LPN) #506 revealed any staff member could clean up messes on the floor, side rails, bedside table, and bed frame. LPN #506 verified the above findings at that time. An interview on 03/11/26 at 2:15 P.M. with the Director of Nursing (DON)…

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 interview, the facility failed to provide sufficient staff to provide restorative nursing programs on a consistent basis. This affected three (Residents #26, #82, and #96) of three residents reviewed for restorative services. The facility identified 41 residents with orders for one or more restorative programs (Residents #1, #2, #3, #4, #6, #7, #11, #15, #18, #24, #26, #32, #34, #37, #41, #42, #43, #48, #51, #56, #61, #67, #68, #69, #70, #73, #75, #79, #81, #82, #86, #87, #90, #91, #92, #93, #94, #95, #96, #98 and #100). Findings include: 1. On 06/18/25 at 11:55 A.M., Resident #26 was observed sitting in a recliner in her room with three daughters visiting. All four individuals were in agreement that Resident #26 did not walk well and they had a fear she would fall. Review of Resident #26's medical record revealed diagnoses including cerebrovascular disease, hypertension, dizziness and giddiness, type two diabetes mellitus, unsteadiness on her feet, lumbar region intervertebral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review, and interview, the facility failed to ensure the nurse practitioner or physician were notified of a resident's low blood pressure reading prior to administering a medication with anti-hypertensive properties. This affected one (Resident #103) of three residents reviewed for medication administration. Findings include: Review of Resident #103's medical record revealed diagnoses including hypertensive heart disease, paroxysmal atrial fibrillation (irregular heart rhythm), atherosclerotic heart disease, malignant neoplasm of the scrotum and prepuce (a movable sheath of skin that covers the head of the penis), and pleural effusion. On 05/29/25 orders were started for midodrine HCL (a medication that belongs to the class of medications called alpha-adrenergic agonists. It works by causing blood vessels to tighten, which increases blood pressure.) 5 milligrams (mg) three times a day with instructions to hold the medication for a systolic blood pressure (top number of the…

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

Based on medical record review, policy review and interview, the facility failed to report allegations of misappropriation of money to the State Survey Agency. This affected one (Resident #49) of three residents reviewed for missing property. Findings include: Review of Resident #49's medical record revealed diagnoses including congestive heart failure (CHF), atherosclerotic heart disease, type two diabetes, bipolar disorder, and anxiety disorder. A nursing note by Licensed Practical Nurse (LPN) #215 dated 06/15/25 at 12:55 A.M. indicated Resident #49 returned to the facility from a leave of absence (LOA) and informed the nurse when he got into his lock box he had $350.37 missing from his box. Resident #49 stated he had the box locked all day in his room and had the key on his bag out with him all day. Police were informed and took a report from Resident #49. A social service note dated 06/16/25 at 8:48 A.M. indicated Resident #49 had voiced concerns which were documented on appropriate forms. Resident #49 wanted out of the facility and indicated the prior two days were tough as…

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

Based on medical record review, policy review and interview, the facility failed to initiate a thorough investigation of allegations of a resident's stolen money. This affected one (Resident #49) of three residents reviewed for missing property. Findings include: Review of Resident #49's medical record revealed diagnoses including congestive heart failure (CHF), atherosclerotic heart disease, type two diabetes, bipolar disorder, and anxiety disorder. A nursing note by Licensed Practical Nurse (LPN) #215 dated 06/15/25 at 12:55 A.M. indicated Resident #49 returned to the facility from a Leave of Absence (LOA) and informed the nurse when he got into his lock box he had $350.37 missing from his box. Resident #49 stated he had the box locked all day in his room and had the key on his bag out with him all day. Police were informed and took a report from Resident #49. A social service note dated 06/16/25 at 8:48 A.M. indicated Resident #49 had voiced concerns which were documented on appropriate forms. Resident #49 wanted out of the facility and indicated the prior two days were tough 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 medical record review and interview, the facility failed to provide restorative nursing programs to maintain a resident's ability to ambulate. This affected two (Residents #26 and #82) of three residents reviewed for restorative services. Findings include: 1. Review of Resident #26's medical record revealed diagnoses including cerebrovascular disease, hypertension, dizziness and giddiness, type two diabetes mellitus, unsteadiness on her feet, lumbar region intervertebral disc degeneration, discogenic back pain, and generalized weakness related to a stroke. A Physical Therapy (PT) Discharge summary dated [DATE] revealed a restorative nursing program had been completed for ambulation with the interdisciplinary team to facilitate Resident #26 maintaining her current level of performance and to prevent decline. A care plan initiated 03/14/25 indicated Resident #26 was on a restorative ambulation program to increase confidence and safety with gait once daily six to seven times per week for 15 minutes per…

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

Based on medical record review and interview, the facility failed to ensure medications were administered in accordance with physician orders and set parameters. This affected one (Resident #103) of three residents reviewed for medication administration. Findings include: Review of Resident #103's medical record revealed diagnoses including hypertensive heart disease, paroxysmal atrial fibrillation (irregular heart rhythm), atherosclerotic heart disease, malignant neoplasm of the scrotum and prepuce (a movable sheath of skin that covers the head of the penis), and pleural effusion. On 05/29/25 orders were started for midodrine HCL (a medication that belongs to the class of medications called alpha-adrenergic agonists. It works by causing blood vessels to tighten, which increases blood pressure.) 5 milligrams (mg) three times a day with instructions to hold the medication for a systolic blood pressure (top number of the blood pressure) greater than 120. Review of Resident #103's June Medication Administration Record (MAR) revealed midodrine was administered the morning of 06/03/25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to provide restorative range of motion (ROM) programs in accordance with physician orders for one (Resident #96) of three residents reviewed for restorative services. Findings include: Review of Resident #96's medical record revealed diagnoses including hemiplegia (paralysis/weakness of one side of the body) affecting the right dominant side, type two diabetes mellitus with diabetic neuropathy, morbid obesity, need for assistance with personal care, generalized anxiety disorder and depression. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #96 was cognitively intact with no rejection of care. Resident #96 had impaired functional ROM of both the upper and lower extremity on one side of her body. Review of a care plan initiated 02/27/23 indicated Resident #96 was on a restorative program for active/passive range of motion. Interventions indicated passive range of motion (PROM) (movement of a joint or body part without…

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 physician orders, policy review, and interview, the facility failed to ensure medications were administered as ordered. Two medication errors were identified out of 27 opportunities resulting in a 7.4% medication error rate. This affected one (Resident #74) of two residents observed for medication administration. Findings include: On 06/17/25 at 7:57 A.M., Licensed Practical Nurse (LPN) #200 was observed administering medication to Resident #74. Among medications administered were divalproex sodium (three 250 milligram tablets and one 500 milligram tablet) and vitamin B-6 100 milligrams (mg). Review of Resident #74's physician orders revealed an order dated 02/20/25 for pyridoxine HCl (vitamin B-6) 50 mg every day. There were orders dated 05/08/25 for three divalproex sodium tablet delayed release tablets to be administered in the morning for mood disorder and one divalproex sodium extended release tablet 500 mg in the evening for mood disorder. On 06/18/25 at 9:40 A.M., LPN #200 verified she administered all medications that had been included 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 observation and interview, the facility failed to ensure infection control was maintained during incontinence care. This affected one resident (Resident #94) of three residents reviewed for incontinence care. The facility census was 100. Findings included: Review of the medical record for Resident #94 revealed an admission date of 11/22/20. Diagnosis included Alzheimer's Disease, quadriplegia, tracheostomy status, and dysphagia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 was rarely or never understood, dependent on staff for all activities of daily living (ADL'S), and was incontinent of bladder and bowel. Observation on 04/07/25 at 9:25 A.M. of incontinence care for Resident #94 revealed Certified Nursing Assistant (CNA) #283 and #311 gathered supplies, provided privacy, washed hands and donned gloves. CNA #311 removed Resident #94's brief soiled with medium stool and urine. CNA #311 provided peri care, then with the same gloves on she touched the barrier…

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 Payroll Based Journal (PBJ) report, review of schedules and time detail punches, and interview, the facility failed to ensure accuracy of information sent to Centers for Medicare and Medicaid (CMS). This had the potential to affect all 101 residents. Findings include: Review of the facility's PBJ report for the fourth quarter of 2024 revealed the facility had a one star staff rating and excessively low weekend staffing during the quarter. During review of staffing sheets and time punches with the Administrator on 03/04/25 between 10:45 A.M. and 1:45 P.M., the time punch detail report and the schedules for 01/17/25, 01/20/25, 01/24/25, 01/27/25, 02/03/25, 02/06/25, and 02/08/25 did not have matching information. The administrator identified an issue with time punches of employees no longer working for the facility not showing up on the time punch detail. On 03/04/25 at 2:57 P.M., the Administrator stated she was not employed during the fourth quarter (July to September) of 2024 so she could not give feedback into staffing levels at the time. The time punches…

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, medical record review, interview, and facility policy review, the facility failed to ensure surgical wound treatments were completed per physician order. This affected one resident (#25) of three residents reviewed for wound care. The facility census was 96. Findings include: Review of the medical record for Resident #25 revealed an admission date of 10/27/23 with diagnoses including dementia, unspecified mood affective disorder, anxiety disorder and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment completed on 09/26/24 revealed Resident #25 had severely impaired cognition and was independent but required substantial assistance with bathing. Further review of the MDS revealed Resident #25 had surgical wounds. Review of the physician orders revealed an order dated 10/02/24 for wound care for the mid-upper back daily every day shift and as needed (PRN). The treatment was to cleanse area with normal saline, apply skin prep to surrounding tissue or periwound, apply silver alginate to the base of the wound, and secure with boarded…

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 interview the facility failed to ensure laboratory testing (stools for occult blood) were obtained timely for Resident #101. This affected one resident (#101) of three residents reviewed for laboratory testing. Findings include: Review of the medical record revealed Resident #101 was admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease, right and left lower extremity amputation, hypertension, and duodenal ulcer. The resident also had chronic anemia (a common type of anemia that occurs when the body has low levels of hemoglobin). Further review of the medical record revealed the resident had lab test results indicating a low hemoglobin level of 8.1 grams per deciliter of blood (g/dL of blood) on 07/22/24 and a level of 8.9 g/dL on 09/11/24. Per physician orders, three stools for occult blood (a stool sample obtained to determine if there is hidden blood in the stool) were initially ordered on 07/22/24. A second and third order for the samples 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 observation, medical record review, interview and policy review the facility failed to maintain accurate medical records related to resident care. This affected one resident (#25) of three residents reviewed for wound care. The facility census was 96. Findings include: Review of the medical record for Resident #25 revealed an admission date of 10/27/23 with diagnoses including dementia, unspecified mood affective disorder, anxiety disorder and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment completed on 09/26/24 revealed Resident #25 had severely impaired cognition and was independent but required substantial assistance with bathing. Further review of the MDS revealed Resident #25 had surgical wounds. Review of the physician orders revealed an order dated 10/02/24 for wound care for the mid-upper back daily every day shift and as needed (PRN). The treatment was to cleanse area with normal saline, apply skin prep to surrounding tissue or periwound, apply silver alginate to the base of the wound, and secure with boarded foam. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review the facility failed to ensure newly hired employees were screened for tuberculosis (TB) prior to their first day of work, the blood glucose testing (BGT) machine was sanitized and disinfected appropriately after use, appropriate infection control was maintained during Resident #30's wound care, and staff donned appropriate personal protective equipment during tracheostomy care. This affected one resident (Resident #106) on the secured memory care unit (SMCU) who required BGT testing and had the potential to affect two additional residents (Residents #96 and #3) who required BGT testing on the second floor SMCU, one (Resident #30) of two residents reviewed for pressure wounds, one (Resident#100) of one resident reviewed for tracheostomies, and the lack of employee TB screening had the potential to affect all residents who resided in the building. The facility census was 104. Findings include: 1. Review of eight employee files revealed Human…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure residents who required staff assistance and/or were dependent on staff for activities of daily living including grooming, hygiene, eating and/or toileting received adequate and timely assistance to maintain their highest practicable well-being. This affected four residents (#4, #51, #64 and #214) of five sampled residents reviewed for activities of daily living. The facility census was 104. Findings include: 1. Review of the medical record revealed Resident #4 was admitted on [DATE] with diagnoses that included schizophrenia, type 2 diabetes, seizures, dementia, extrapyramidal and movement disorder, and paraplegia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 scored a three on the Brief Interview for Mental Status (BIMS) which indicated severe cognitive impairment. The MDS also revealed Resident #4 was dependent for bathing and hygiene. Review of the Plan of Care dated 02/23/24 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the grievance/complaint log, review of the facility investigation, and interview with staff the facility failed to thoroughly investigate an allegation that a staff member took photographs of Resident #102 with her cell phone and failed to investigate a missing electric razor for Resident #64. This affected two residents (Resident #64 and #102) of three resident reviewed who filed formal concerns with the facility. Findings include: 1. Review of the medical record revealed Resident #102 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, hypertension, spinal stenosis, anxiety disorder, major depressive disorder, and benign prostatic hyperplasia. Review of the grievance/complaint log dated 06/28/24 revealed Resident #102 had a complaint concerning pictures being taken of him. The resolution was to erase the pictures from the telephone. Review of the grievance form dated 06/28/24 revealed Resident #102 filed a formal complaint…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure Resident #13, who required setup assistance with meals, received the breakfast meal and was assisted with set up in a timely manner. This affected one (Resident #13) of thirty-one residents who required setup assistance on the secured memory care unit (SMCU). The census on the SMCU was 34. Findings include: Review of Resident #13's medical record revealed the Resident #13 was admitted on [DATE] with diagnoses including senile degeneration of the brain, anxiety disorder and unspecified dementia with mood disturbance. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 exhibited severe cognitive impairment. Review of Resident #13's Nutritional Problem Care Plan revealed an intervention dated 04/05/24 to provide meals per the diet order (regular diet, dysphagia mechanical texture, thin liquids consistency with fortified pudding twice daily and fortified cereal daily). Resident #13 could have pleasure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #62 received adequate and timely treatment, including the administrative of laxative medication to address constipation. This affected one (Resident #62) of one resident reviewed for bowel regimen. Findings include: Review of the medical record revealed Resident #62 was admitted on [DATE] with diagnoses that included dementia, major depression, delusional disorders, anxiety, and abnormal weight loss. Review of a physician order dated 08/29/22 revealed Resident #62 was ordered Milk of Magnesia Oral Suspension (laxative) five milliliter (ml) by mouth every 24-hours as needed for constipation. Review of the plan of care dated 09/18/23 revealed Resident #62 was a risk for constipation. Interventions included to monitor bowel movement and observe for signs and symptoms of complication of constipation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 had a score of 00 on the Brief Interview for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to provide vision care for Resident #27 in a timely manner. This affected one (Resident #27) of three residents reviewed for communication and sensory. Facility census was 104. Findings include: Review of the medical record revealed Resident #27 was admitted on [DATE] with diagnoses that included schizophrenia, anxiety, major depressive disorder, intellectual disabilities, and dementia. Review of the Plan of Care dated 04/10/24 revealed Resident #27 had impaired visual function. Interventions included to arrange consultation with eye care practitioner as needed and observe/document/report to medical provider acute eye problems. Review of an eye care group visit summary dated 04/26/24 revealed Resident #27 had new eyeglasses fitted. Review of a social service note dated 04/30/24 timed at 1:50 P.M. revealed Resident #27 stated even though he saw the eye doctor last week and got new glasses he was still having visual difficulties. Resident #27 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to ensure skin impairment for Resident #64 was accurately assessed at the time of identification and to promote optimal healing. This affected one (Resident #64) of three residents reviewed for skin concerns. Facility census was 104. Findings include: Review of the medical record revealed Resident #64 was admitted on [DATE] with diagnoses that included congestive heart failure, anxiety, major depressive disorder, respiratory failure, Alzheimer's disease, right knee osteoarthritis, and impulse disorder. Review of the plan of care dated 05/27/24 revealed Resident #64 was at risk for impaired skin integrity related to impaired mobility and need for assistance with most activities of daily living. Interventions included to complete Skin at Risk assessment as needed, weekly skin checks, educate on the need for turning, encourage to turn and reposition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, fire and police department report review, hospital record review, facility investigation review, policy review and interview, the facility failed to provide adequate supervision to Resident #112, who was admitted to the facility on [DATE] due to being an elopement risk with a need for placement on a secured unit, had verbalized his desire to leave the facility, was identified as an elopement risk on admission and received a recent diagnosis of dementia with psychosis, from exiting the second floor secured unit without staff knowledge. This affected one resident (#112) of four residents reviewed for staff supervision and elopement. The facility census was 110. Findings include: Review of Resident #112's medical record revealed an admission date of 06/07/24 with admission diagnoses including right clavicle fracture, vascular dementia 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 and interview, the facility failed to ensure the resident and resident's representative's preferences were followed regarding having side rails on his bed. This affected one (Resident #113) of three residents reviewed for preferences. The facility census was 112. Findings include: Review of the closed medical record for Resident #113 revealed an admission date of 03/26/24 with diagnoses including diabetes mellitus, end stage renal disease and congestive heart failure. Resident #113 was discharged on 04/30/24. Review of the form titled, Installation of Bed Rail or Assist Bar Not Used as a Restraint, signed by Resident #113's representative on 03/26/24, indicated the resident requested both right and left half side rails. Review of the facility assessment titled, Bed Safety Evaluation, dated 03/26/24 revealed Resident #113 wanted grab rails but had not expressed the desire to have bed rails or an assist device on their bed. This assessment was completed by Licensed Practical Nurse (LPN) #205 and the request for side rails from the Installation of Bed Rail or…

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 follow the direction of the telehealth nurse practitioner timely for a change in pain medication for a resident. This affected one (Resident #113) out of three residents reviewed for pain medication. The facility census was 112. Findings include: Review of the closed medical record for Resident #113 revealed an admission date of 03/26/24 with diagnoses including diabetes mellitus, end stage renal disease and congestive heart failure. Resident #113 was discharged on 04/30/24. Review of Resident #113's care plan dated 04/20/24 revealed he had a complaint of pain related to impaired mobility, multiple medical issue and normal aging process. Interventions included to notify the medical provider and resident representative if interventions were unsuccessful. Review of the physician's orders for Resident #113 revealed he had an order dated 04/23/24 for Hydrocodone-Acetaminophen 5/325 milligrams (mg) (Norco) one tablet every four hours as needed for pain for…

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

Based on record review and interview, the facility failed to ensure accurate documentation in the medical record for medication administration. This affected one (Resident #113) of three residents reviewed for accurate medical records. The facility census was 112. Findings include: Review of the closed medical record for Resident #113 revealed an admission date of 03/26/24 with diagnoses including diabetes mellitus, end stage renal disease and congestive heart failure. Resident #113 was discharged on 04/30/24. Review of the physician's orders for Resident #113 revealed an order dated for 04/29/24 for nursing staff to obtain his blood sugar before meals (7:00 A.M., 11:00 A.M. and 4:00 P.M.) and to administer Insulin Lispro (medication for diabetes) per the sliding scale directions. Review of the medication administration record (MAR) for Resident #113 revealed he was to have his blood sugar obtained at 7:00 A.M. The nursing staff had not documented this as completed in his medical record. Review of the nursing progress note dated 04/30/24 at 8:25 A.M. revealed the nurse checked his…

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

Based on observation, interview, and policy review the facility failed to ensure a clean and sanitary kitchen. This had the potential to affect 104 residents receiving meals from the kitchen. The facility identified two residents (#162 and #163) who received nothing by mouth. The facility census was 106. Findings include: Observation during the initial kitchen tour on 04/17/24 at 11:35 A.M. with [NAME] #19 and Corporate District Manager #109 revealed the following concerns: In the walk-in refrigerator: a 46 ounce (oz) container of Sysco nectar thick lemon water dated 11/2/23 and a use by date of 02/28/24, a 46 oz container of Sysco honey thick lemon water dated 01/23/24 with a use by date of 04/09/24, a five-pound container of ricotta cheese open and undated, a one-quarter pan of barbecue pork with a date of 04/06/24 and a use by date of 04/12/24, and a one-quart container of fruit cocktail open and undated. In the reach in refrigerator a one-quarter pan of previously cooked green beans was found undated, open to air, and an undated container of prepared tuna fish sandwich spread.…

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 interviews, the facility failed to ensure safe smoking procedures. This affected one (Resident #235) of three (Residents #235, #258, and #259) residents reviewed for smoking. The facility identified 24 residents (#204, #205, #209, #212, #217, #221, #223, #224, #226, #228, #233, #234, #235, #237, #242, #243, #249, #255, #258, #259, #261, #273, #309, and #312) who smoked. The census was 114. Findings Include: Review of the medical record for Resident #235 revealed an admission date of 08/25/23. Diagnoses included but were not limited to multiple sclerosis, morbid obesity, bipolar disorder, major depressive disorder, anxiety disorder, post-traumatic stress disorder, and tobacco use. Review of the psychology note dated 09/11/23 for Resident #235 revealed she was having a multiple sclerosis flare up and was having hallucinations. Review of the 09/11/23 smoking assessment for Resident #235 revealed she required a smoking apron for safety. Review of Resident #235's care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, facility self-reported incident (SRI) review, and facility policy review the facility failed to implement their abuse policy to thoroughly investigate and timely report allegations of resident-to-resident abuse. This affected seven residents (#8, #16, #17, #34, #39, #84, and #112) of seven residents reviewed for abuse. The facility census was 111. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 11/06/20. Diagnoses included Alzheimer's disease, diabetes, chronic obstructive pulmonary disease (COPD), mild intellectual disability, and cognitive communication deficit. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was moderately cognitively impaired. He required setup help for eating, oral hygiene, toileting, dressing, and hygiene and displayed no behaviors. Review of the nurse's progress note dated 09/11/23 revealed Resident #16 was at the nurse's station when another 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 record review, interview, facility self-reported incident (SRI) review, and facility policy review the facility failed to thoroughly investigate incidents of alleged resident-to-resident abuse. This affected seven residents (#8, #16, #17, #34, #39, #84, and #112) of seven Residents reviewed for abuse. The facility census was 111. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 11/06/20. Diagnoses included Alzheimer's disease, diabetes, chronic obstructive pulmonary disease (COPD), mild intellectual disability, and cognitive communication deficit. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was moderately cognitively impaired. He required setup help for eating, oral hygiene, toileting, dressing, and hygiene and displayed no behaviors. Review of the nurse's progress note dated 09/11/23 revealed Resident #16 was at the nurse's station when another resident (Resident #17) came up and grabbed milk out of his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, facility self-reported incident (SRI) review, and policy review the facility failed to report an allegation of resident-to-resident abuse within the required time frames to the state agency. This affected two residents (#84 and #112) of seven residents reviewed for abuse. The facility census was 111. Findings include: Review of the medical record for Resident #112 revealed an admission date of 06/28/23 and a discharge date of 09/19/23. Diagnosis included schizophrenia, chronic obstructive pulmonary disease (COPD), obesity, diabetes, anemia, impulse disorder, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #112 was severely cognitively impaired. She required supervision and one person assistance for toileting and hygiene, and supervision for bed mobility, transfers, dressing, and eating. She displayed delusional and verbal behaviors of threatening and screaming at others. Review of the telehealth notification note 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 record review and interview, the facility failed to timely notify Resident #103's physician and guardian when the resident failed to return to the facility following a leave of absence (LOA). This finding affected one (Resident #103) of three residents reviewed for notification of change. Findings include: Review of Resident #103's medical record revealed the resident was initially admitted on [DATE], readmitted on [DATE] and discharged on 07/31/23 with diagnoses including traumatic subdural hemorrhage without loss of consciousness, anxiety disorder and schizophrenia. Review of Resident #103's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed his cognition was intact. Review of the facility Resident Sign Out Log form indicated Resident #103 signed the form for a leave of absence (LOA) on 07/31/23 at 3:40 P.M. Interview on 08/09/23 at 8:33 A.M. with Resident #103's guardian stated she was not aware Resident #103 did not return by 12:00 A.M. on 07/31/23 until the next day. Interview on 08/09/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Resident #103 received a safe and orderly discharge after the resident did not return from a leave of absence (LOA). This affected one resident (Resident # 103) out of three residents reviewed for discharge. Findings include: Review of Resident #103's medical record revealed the resident was initially admitted on [DATE], readmitted on [DATE] and discharged on 07/31/23 with diagnoses including traumatic subdural hemorrhage without loss of consciousness, anxiety disorder and schizophrenia. Review of Resident #103's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition. Resident #103 had a guardian for medical care. Review of Resident #103's physician orders did not reveal an order for a LOA from the facility. The medical record also did not reveal care planned interventions related to a LOA. Review of the facility Resident Sign Out Log form indicated Resident #103 signed for a LOA on 07/31/23 at 3:40 P.M. 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 observation, staff interview, record review, review of facility infection control policies, and review of the Centers for Disease Control and Prevention (CDC) website the facility failed to implement infection control procedures for use of Personal Protective Equipment (PPE), isolation and COVID-19 screening. This had the potential to affect all 95 residents currently residing in the facility. Findings include: During the annual survey entered on 05/09/22 the facility was identified as in outbreak status (use of N-95 mask, shield or goggles and twice a week COVID testing for all staff and residents) due to six staff/contract members testing positive for COVID-19 between 05/04/22 and 05/09/22. 1. Review of a crosscheck of staff testing positive for COVID in the current outbreak with the screening logs revealed there was no evidence State Tested Nurse Aide (STNA) #819 screened in prior to work the day she tested positive for COVID-19. STNA #819 punched in on 05/04/22 at 6:53 P.M. The facility went 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.

Based on record review, policy review and staff interview the facility failed to ensure residents and/or responsible parties received quarterly statements of resident personal funds account activity. This affected ten (Residents #1, #7, #12, #13, #14, #17, #19, #55, #63 and #72) of ten residents reviewed of 71 residents identified as having personal funds accounts managed by the facility. This had the potential to affect all but 24 (Residents #10, #30, #33, #36, #37, #39, #42, #46, #49, #50, #51, #53, #58, #62, #64, #70, #77, #80, #81, #86, #92, #295, #296 and #345) who did not have a personal funds account managed by the facility. The facility census was 95. Findings include: Review of the resident personal funds list provided by the facility during the annual survey beginning on 05/09/22 revealed all but 24 (Residents #10, #30, #33, #36, #37, #39, #42, #46, #49,#50, #51, #53, #58, #62, #64, #70, #77, #80, #81, #86, #92, #295, #296 and #345) had an account that was actively managed by the facility. Review of ten (Residents #1, #7, #12, #13, #14, #17, #19, #55, #63 and #72) of the…

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

Based on funds account review, staff interview and policy review the facility failed to ensure residents who receive Medicaid benefits were notified when their account balance reached $200 less than the Supplemental Security Income (SSI) resource limit. This affected six (Residents #1, #7, #12, #17, #19, and #72) of 10 residents reviewed for personal funds accounts. The facility indicated they managed personal funds accounts for 71 residents. The facility census was 95. Findings include: 1. Review of Resident #12's financial statement revealed a balance of $2,990.25 on 05/10/22 and a balance of $2,984.51 on 04/01/22. 2. Review of Resident #72's financial statement revealed a balance of $3,032.26 on 05/10/22 and a balance of $2,882.77 on 04/01/22. 3. Review of Resident #19's financial statement revealed a balance of $4,994.48 on 05/10/22 and a balance of $5,261.71 on 06/03/21. 4. Review of Resident #7's financial statement on 05/10/22 revealed a balance of $2,028.39 and a balance of $2,383.26 on 04/01/22. 5. Review of Resident #1's financial statement revealed a balance of $5,300.81…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to notify the Legal Guardian of Resident #90 prior to discharge to another facility. This affected one of two residents reviewed for discharge from the facility. The facility census was 95. Findings include: Resident #90 was admitted to the facility on [DATE]. Diagnoses included unspecified psychosis not due to a substance or known physiological condition, type two diabetes mellitus, major depressive disorder, bipolar disorder and opioid dependence in remission. Review of the discharge-return not anticipated Minimum Data Set (MDS) dated [DATE] revealed Resident #90's memory was okay. Her decision making was indicated as modified independence. She was independent with her activities of daily living. Review of the medical record revealed Resident #90 had a Legal Guardian (LG). Review of the nursing notes dated 05/01/22 timed at 10:00 A.M. revealed Resident #90 was discharged to a sister facility with all of her belongings with the assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review the facility failed to ensure ongoing treatment of pressure ulcers for Resident #46. This affected one (Resident #46) of seven residents reviewed for pressure and non pressure skin impairment. The facility identified seven residents with wounds as listed on the weekly wound report. The facility census was 95. Findings include: Review of Resident #46's medical record revealed admission on [DATE], and a readmission on [DATE]. Diagnoses included end stage renal disease, type two diabetes, hypertension, atrial fibrillation, dependence on renal dialysis, chronic obstructive pulmonary disease, heart failure, and chronic respiratory failure. Review of the 04/04/22 Quarterly Minimum Data Set Assessment (MDS) revealed the resident was independent for daily decision making, required extensive assist of one for transfers and bed mobility and was independent for eating. The resident was at risk for pressure ulcers, with current stage III (Full thickness tissue loss.…

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

Based on observation, record review, interview and policy review the facility failed to ensure the ongoing assessment of the resident's condition and monitoring for complications before and after hemodialysis. This affected one (Resident #46) of one resident reviewed for dialysis. The facility identified two residents receiving dialysis. Findings include: Review of Resident #46's medical record revealed a 10/30/21 admission with a 05/07/22 readmission. Diagnoses included end stage renal disease, type two diabetes, hypertension, atrial fibrillation, dependence on renal dialysis, chronic obstructive pulmonary disease, heart failure, and chronic respiratory failure. The resident had a dialysis therapy plan of care initiated 12/10/21 including onsite dialysis services. Interventions included administer medications per medical provider's orders, and observe for side effects and effectiveness. On dialysis days, administer medications, before, during or after dialysis according to medical providers orders. Report abnormal findings to medical provider, nephrologist/ dialysis center,…

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

Based on record review, interview and review of policy the facility failed to ensure the influenza vaccine was offered to Resident #8. This affected one (Resident #8) of five residents reviewed for vaccines. Findings include: Review of the medical record for Resident #8 revealed an admission date of 04/16/19 with diagnoses including Lymphedema, type two diabetes, hypertension, chronic obstructive pulmonary disease, severe morbid obesity, chronic obstructive lung disease, fibromyalgia, anxiety disorder and major depressive disorder. Review of the 02/11/22 annual Minimum Data Set (MDS) 3.0 assessment revealed the resident was independent for daily decision making. Review of Section O of the MDS assessment, revealed the resident did not receive the influenza (flu) vaccine. Review of Resident #8's medical record contained no evidence of a flu vaccination consent form to indicate the resident was offered and declined having the flu vaccine administered. Interview 05/13/22 at 10:53 A.M. with the Director of Nursing verified the facility had no evidence of Resident #8 receiving a consent…

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.