Laurels Of Massillon, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to notify Resident #94's responsible party after a fall. This affected one resident (Resident #94) of three residents reviewed for notifications. The census was 121. Findings include: Record review of Resident #94 revealed an admission date of 04/05/22 with diagnoses including myelodyspastic syndrome, Alzheimer's Disease and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #94 was cognitively intact. Review of the progress note dated 11/28/23 and timed at 3:34 A.M. revealed Resident #94 had a fall with no injury. A note at 10:05 A.M. revealed her hand was swollen and bruised. An x-ray was ordered. A note at 12:36 P.M. revealed there was no fracture. There was no indication the responsible party was notified. Review of the Change in Condition report titled SBAR, dated 11/28/23 revealed it was not completely filled out including notification of responsible party. Review of the post-fall evaluation…

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 policy review, the facility failed to follow infection control standards during Resident #56's pressure ulcer dressing change. This affected one resident (Resident #56) of three residents reviewed for pressure ulcers. The facility census was 119. Findings include: Resident #56 was admitted to the facility on [DATE] with diagnoses including diabetes, dementia, and high blood pressure. Review of the medical record revealed the resident had a Stage 3 pressure ulcer (a wound with full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed.) located on the coccyx which was to be treated with Triad cream and a clean dressing applied over it. Observation on 05/17/23 at 12:45 P.M. revealed Registered Nurse (RN) #315 prepared her work area and opened her dressing supplies. RN #315 then positioned Resident #56 on her right side and proceeded to unfasten the resident's incontinence brief. The resident had been incontinent of stool. RN #315…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure fall interventions were in place per the plan of care for Resident #100. This affected one (#100) of three residents reviewed for falls. The facility census was 119. Findings include: Review of the medical record for Resident #100 revealed an admission date of 11/16/22. Diagnoses included Alzheimer's disease, dementia, fracture around internal prosthetic right hip joint (03/14/23), age related physical debility, difficulty in walking, and unsteadiness on feet. Review of the care plan dated 11/16/22 revealed Resident #100 was at-risk for falls due to deconditioning, Alzheimer's, hypertension, congestive heart failure, and debility. Interventions included educate resident and family about safety reminders and what to do if a fall occurs, encourage resident to rest when they feel fatigued, provide assistive devices as needed, anti-rollbacks to wheelchair, bed in low position, mat to floor beside bed, and call light touch pad within…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview and policy review, the facility failed to ensure pressure injuries were accurately assessed, measured and documented for Residents #13, #33, #92, and #94. This affected four residents (Residents #13, #33, #92, and #94) of five residents reviewed for pressure injuries. Findings include: 1. Review of the medical record revealed Resident #92 was admitted to the facility 10/02/15 with the diagnoses of end stage renal disease, acquired absence of right leg above the knee, diabetes, restless leg syndrome, hypertension, abnormal weight loss, injury, major depression, gout, constipation, hypothyroidism, ischemic cardiomyopathy, atherosclerotic heart disease, vascular dementia, dysphagia, hyperlipidemia, sleep apnea, anemia, gastro-esophageal reflux disease, peripheral vascular disease, and hear failure. Review of the five-day Medicare Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #92 had moderately impaired cognition and had one…

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 observation, staff interview and policy review, the facility failed to ensure pureed food was the proper consistency. This affected one resident (Resident #92) but had the potential to affect all 13 residents (Resident #5, #9, #14, #15, #27, #31, #33, #34, #47, #77, #78, #92 and #154) who received pureed diets. Finding include: Observation on 03/02/20 at 11:51 A.M. staff gave Resident #92 a meal tray. The pureed food was on a regular plate, the food had a very thin consistency and was running all over the plate mixing into each other. An interview at this time State Tested Nursing Assistant (STNA) #409 verified the pureed food was too runny and looked terrible on the plate. An interview on 03/02/20 at 11:57 A.M. Dietary Manger #410 verified the pureed food for Resident #92 was too runny, and she went to get him a new plate of purred food. Review of the facility policy Mechanically Altered Diet, dated 04/10, revealed mechanically altered diets would be prepared and served as prescribed by the physician. Guests would be provided with the least restrictive diet to optimize…

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 food service carts were maintained in a sanitary manner. This affected all 69 residents (Resident #1, #3, #4, #5, #6, #7, #8, #10, #16, #18, #19, #20, #21, #22, #24, #28, #29, #31, #32 #40, #41, #42, #44, #45, #47, #49, #51, #52, #54, #55, #56, #57, #60, #61, #62, #63, #64, #65, #66, #67, #69, #70, #71, #76, #77, #80, #82, #87, #88, #89, #91, #92, #93, #94, #95, #98, #100, #102, #154, #155, #156, #157, #158, #159, #160, #161, #162, #164, and #308) who were served from the metal meal storage carts on the 100, 200 and 300 hallways. Findings include: Observation on 03/02/20 at 12:20 P.M. revealed the metal food storage cart on the 100 hallway with the residents meals was soiled with food and dried liquid. The cart had a red substance spilled on the outside of the cart, a white substance spilled on the inside of the cart on the door, and a brown sticky substance on the outside of the cart by the handle. An interview at this time State Tested Nursing Assistant (STNA) #408 verified the carts were soiled Observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, family interview, staff interview and policy review, the facility failed to ensure Resident #49 was always treated with respect and dignity. This affected one resident (Resident #49) of 32 residents reviewed in the initial sample. Findings include: Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with the diagnoses of Parkinson's disease, dysphagia, pneumonia, dementia, delusional disorder, low back pain, major depressive disorder, anxiety disorder, chronic obstructive pulmonary disease, atherosclerotic heart disease, congestive heart failure, atrial fibrillation, hypertension, and psychotic disorder with delusions. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 had moderately impaired cognition and required supervision after being set-up for eating. Interview on 03/02/20 at 4:29 P.M. with Resident #49 and Family Member #500 revealed, the staff was not very nice at times. Resident #49 indicated…

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, record review and policy review, the facility failed to ensure Resident #43's concerns regarding missing property were resolved timely. This affected one (Resident #43) of one residents reviewed for missing property. Findings include: Resident #43 was admitted on [DATE] with diagnoses including polyneuropathy, need for assistance with personal care, anxiety disorder, and major depressive disorder. Resident #43's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed her cognition was intact. Interview on 03/03/20 at 2:31 P.M. with Resident #43 revealed she was missing cell phone accessories and a gift care around Christmas time. Resident #43 revealed the concern was reported, and she had not hear anything back. Review of the facility grievance log for the last six months revealed no evidence Resident #43 had a concern regarding missing items. Review of Resident #43's Guest Satisfaction Concern/ Suggestion form dated 02/06/20, revealed the resident was missing one USB cable, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure comprehensive assessments were accurate for Resident #13's wounds and Resident #104's discharge location. This affected two residents (Resident #13 and Resident #104) of 25 residents reviewed for comprehensive assessments. Facility census was 111. Findings include: 1. Review of Resident #13's medical record revealed an admission date of 09/20/19 and diagnoses including Parkinson's disease, peripheral vascular disease, hypertension, osteomyelitis and right heel unstageable pressure ulcer (obscured full-thickness and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar). Review of an admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #13 had three stage two pressure ulcers (partial-thickness skin loss), two unstageable pressure ulcers and two deep tissue injuries (DTI), a pressure-related injury to subcutaneous tissues under intact skin. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Resident #33 and Resident #68 was offered activities to meet their activity needs and interests. This affected two (Resident #33 and Resident #68) of four residents reviewed for activities. Findings include: 1. Resident #33 was admitted on [DATE] with diagnoses Alzheimer's disease and muscle weakness. Resident #33's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed her cognition was severely impaired. Observation on 03/02/20 at 9:06 A.M., 03/02/20 at 2:31 P.M., 03/03/20 at 10:19 A.M., and on 03/03/10 at 2:51 P.M. revealed the resident was sitting in the common area far from being able to view the television. Resident #33 was not engaged in television or socializing with staff or residents. Resident #33's back was towards any staff walking by, and residents in her area were not conversing. Review of Resident #33's quarterly Activity Re-evaluation, dated 01/06/20, revealed the resident initiated independent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Resident #33's fall precaution interventions were in place at all times. This affected one (Resident #33) of three residents reviewed for falls. Findings include: Resident #33 was admitted on with diagnoses including Alzheimer's disease and muscle weakness. Resident #33's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed her cognition was severely impaired, she required two person extensive assistance with bed mobility, transfers, and one person extensive assistance with dressing. Resident #33's comprehensive care plan related to being at risk for falls, revised 06/24/19, revealed the resident should wear non-skid foot wear when out of bed, and to encourage the resident to wear appropriate footwear as needed. Observation on 03/02/20 at 9:06 A.M. revealed Resident #33 was sitting in her wheelchair in a common area with socks that were not non-skid. Interview on 03/02/20 at 11:09 A.M. with Registered Nurse (RN)…

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 and staff interview the facility failed to implement non-pharmacological intervention prior to administering as needed anti-anxiety medication, Alprazolam, for Resident #49. This affected one resident (Resident #49) of five residents reviewed for unnecessary medications. Findings include: Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with the diagnoses of Parkinson's disease, dysphagia, pneumonia, dementia, delusional disorder, low back pain, major depressive disorder, anxiety disorder, chronic obstructive pulmonary disease, atherosclerotic heart disease, congestive heart failure, atrial fibrillation, hypertension, and psychotic disorder with delusions. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 had moderately impaired cognition and received an anti-anxiety medication for seven days. Review of the March 2020 physician's orders revealed Resident #49 had an order dated 01/23/20 for 0.25…

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 record review, observations, interviews and policy review, the facility failed to maintain standard infection control practices when Resident #1's food tray was delivered to the room without proper implementation of contact isolation precautions and during Resident #33's dressing change. This affected one resident (Resident #1) and had the potential to affect three additional residents (Resident #41, #51, and #93) residing on the hall who received lunch trays, and affected one resident (Resident #33) of two residents observed during dressing changes. Findings include: 1. Medical record review revealed Resident #1 was admitted on [DATE] with diagnoses including anemia and cerebral palsy. On 03/02/20 at 11:57 A.M., observation revealed a contact isolation sign posted on Resident #1's room door and personal protective equipment (PPE) located outside of the room's doorway. Observation of the lunch tray service revealed State-Tested Nursing Assistant (STNA) #420 removed Resident #1's tray from the service…

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, record review and policy review, the facility failed to ensure two residents (Resident #19 and #99) of five residents reviewed for pneumococcal and influenza vaccines received the education addressing the benefits and risks of the pneumococcal and influenza vaccines or the date when re-offered the vaccines. The facility census was 111. Findings include: Review of Resident #19's Acknowledgement of Receipt of Vaccine Information Sheet (VIS), revealed the resident declined the pneumonia polysaccharide vaccine and the influenza vaccine; however, the medical record failed to include a date confirming when Resident #19 received the education addressing the benefits and risks or the date when the resident was re-offered the vaccines. Review of Resident #99's Acknowledgement of Receipt of Vaccine Information Sheet (VIS), revealed the resident declined the pneumonia polysaccharide vaccine and the influenza vaccine; however, the medical record failed to include a date confirming when Resident #99 received the education addressing the benefits and risks or the date when 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 observation, record review and interview the facility failed to ensure pots and pans were stored in a sanitary manner to prevent contamination. This had the potential to affect all 109 residents residing in the facility. Findings include: Observation on 02/10/19 at 9:00 A.M. of the kitchen, with Certified Dietary Manager (CDM) #500 revealed there seven pots and pans that were observed to be wet on the storage rack. Interview on 02/10/19 at 9:10 A.M. with CDM #500 revealed pots and pans were not to be stacked wet and were to be air dried before putting away. CDM #500 verified the seven pots and pans as observed above had not been properly dried before being put away. Review of the facility policy, titled Dish Machine Practices, dated 04/2010 revealed dishes shall be air-dried and never stored wet.

Based on observation, record review and interview the facility failed to maintain an effective pet control program to prevent gnats in the kitchen. This had the potential to affect all 109 residents residing in the facility. Findings include: Observation on 02/10/19 at 9:00 A.M. of the kitchen with the Certified Dietary Manager (CDM) #500 revealed when CDM #500 picked up the juice nozzle gnats flew out around the nozzle tray. CDM #500 verified the gnats flying around and stated she did not know were they came from. Observation on 02/11/19 at 10:28 A.M. with CDM #500 of the kitchen revealed gnats flying around the dishwasher area. CDM #500 verified the presence of the gnats at that time. On 02/12/19 at 11:45 A.M. gnats were observed flying around the juice machine in the kitchen area. CDM #500 verified the presence of the gnats and indicated the facility had a pest control come to the facility yesterday evening. Interview on 02/13/19 at 11:50 A.M. with CDM #500 verified gnats should not be flying around in the kitchen. Review of a pest control service work sheet, dated 02/11/19 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure all falls were thoroughly investigated and failed to ensure comprehensive, individualized and effective fall/safety interventions and increased supervision were in place to prevent falls for Resident #49. The facility also failed to ensure a treatment cart, containing medications and treatment supplies was securely locked when unattended by staff. This affected one resident (Resident #49) of three residents reviewed for falls and had the potential to affect 20 residents, Resident #97, #98, #53, #82, #5, #108, #107, #77, #50, #32, #37, #26, #34, #58, #36, #39, #85, #30, #49 and #17 identified by the facility to be cognitively impaired and independently mobile. The facility census was 109. Findings include: 1. Review of Resident #49's medical record revealed the resident was admitted to the facility on [DATE] after hip surgery for a fracture, dementia, anxiety and unsteadiness on his feet. Record review revealed a fall care plan, 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.

Based on record review and staff interview the facility failed to ensure authorizations to manage resident personal fund accounts were properly obtained prior to managing resident funds. This affected two residents (Resident #100 and #57) of six residents reviewed for personal fund accounts. Findings include: On 02/12/19 at 4:05 P.M. review of the facility personal fund accounts with Administration #600 revealed Resident #100 and Resident #57 did not have completed Resident Trust Fund Authorization forms. Resident #100's form was missing and Resident #57's form was not signed or witnessed. Administration #600 confirmed the Resident Trust Fund Authorization forms were not complete as noted above at the time of the review.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Resident #87's privacy was maintained during an insulin injection. This affected one resident (Resident #87) of two residents observed during insulin injection administration. Findings include: Record review revealed Resident #87 was admitted to the facility on [DATE] with diagnoses including vascular dementia and aphasia. Record review revealed the resident was not interviewable due to her cognitive deficits and diagnoses. During an observation of medication administration with Licensed Practical Nurse (LPN) #460 on 02/11/19 at 5:12 P.M., LPN #460 prepared two insulin injections for Resident #87. Her room was very close to the nurse's station and as LPN #460 turned from the medication cart, Resident #87's roommate was trying to enter the room in her wheelchair. She was assisted into the room by an unidentified nurse who stayed in the room briefly to talk with the roommate. Several other staff members were directly outside the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were accurately coded for dialysis and antipsychotic medications for Resident #45 and related to falls for Resident #49. This affected two residents (Resident #45 and #49) of 30 residents whose assessments were reviewed. Findings include: 1. Record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses of end stage renal disease, atrial fibrillation, malignant neoplasm of the breast, acute respiratory failure with hypoxia, hypertension, dependence on renal dialysis, gastro-esophageal reflux disease, major depressive disorder, constipation, anorexia, nausea with vomiting, kidney failure, pleural effusion, weakness, diabetes, asthma, and anxiety. Record review revealed the resident had received hemodialysis treatments. Review of a physician's orders, dated 11/27/18 revealed Resident #45 was to receive hemodialysis on Monday, Wednesday, and Friday. Review of a physician's…

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. Observations on 02/10/19 at 9:13 A.M. and 2:23 P.M. and on 02/12/19 at 11:53 A.M. revealed Resident #102 was observed to have long, ragged and unclean fingernails. The resident's right hand was observed to be flaccid (limited movement) and her right hand nails were observed to be starting to dig into the palm of her right hand. An interview on 02/12/19 at 11:53 A.M. with Resident #102 revealed it had been awhile since her nails had been cut and they needed to be trimmed. An interview on 02/12/19 at 11:57 A.M. Licensed Practical Nurse (LPN) #300 revealed the nursing assistants were to trim the resident's nails when providing showers unless the resident had diabetes and then the nurses were to trim the nails. An interview on 02/12/19 at 12:00 P.M. with State Tested Nursing Assistant (STNA) #312 revealed activity staff would trim the resident's nails on nail days. She stated the STNA staff very rarely cut nails unless they were long, and the nurses do the nails of the residents who had diabetes. An interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure weight monitoring was completed as ordered for Resident #45 who received hemodialysis. This affected one resident (Resident #45) of three residents reviewed for dialysis. Findings include: Review of Resident #45's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of end stage renal disease, atrial fibrillation, malignant neoplasm of the breast, acute respiratory failure with hypoxia, hypertension, dependence on renal dialysis, gastro-esophageal reflux disease, major depressive disorder, constipation, anorexia, nausea with vomiting, kidney failure, pleural effusion, weakness, diabetes, asthma, and anxiety. Review of a physician's order, dated 11/27/18 revealed Resident #45 was to have her weight done prior to dialysis days on Monday, Wednesday, and Friday. Weights were to be done pre-dialysis on Tuesday, Thursday, and Sunday. Review of the December 2018 Medication Administration Record (MAR) revealed 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 record review and interview the facility failed to timely address a pharmacy recommendation for Resident #45. This affected one resident (Resident #45) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #45's medical record revealed the resident was admitted to the facility on [DATE] with the diagnoses of end stage renal disease, atrial fibrillation, malignant neoplasm of the breast, acute respiratory failure with hypoxia, hypertension, dependence on renal dialysis, gastro-esophageal reflux disease, major depressive disorder, constipation, anorexia, nausea with vomiting, kidney failure, pleural effusion, weakness, diabetes, asthma, and anxiety. Review of the physician's order, dated 11/28/18 revealed Resident #45 had an order for 400 milligrams of Amiodarone HCL once daily for atrial fibrillation. Review of a pharmacy recommendation dated 12/07/18 revealed the pharmacist indicated Resident #45 had been receiving Amiodarone 400 milligrams every day 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure parameters for blood pressure monitoring were followed related to medication administration for Resident #45 and Resident #49 and failed to ensure Resident #49 did not receive more than the maximum dosage of Acetaminophen in a 24 hour period. This affected two residents (Resident #45 and #49) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #45's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of end stage renal disease, atrial fibrillation, malignant neoplasm of the breast, acute respiratory failure with hypoxia, hypertension, dependence on renal dialysis, gastro-esophageal reflux disease, major depressive disorder, constipation, anorexia, nausea with vomiting, kidney failure, pleural effusion, weakness, diabetes, asthma, and anxiety. Review a physician's order dated 01/31/19 revealed Resident #45 had an order for 12.5 milligrams of Metoprolol Tartrate…

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 maintain acceptable infection control practices to prevent the spread of infection during wound care for Resident #49 and Resident #27 and during medication administration for Resident #87. This affected two residents (Resident #27 and #49) of three residents reviewed for wound care and one resident (Resident #87) of two residents observed for insulin administration. Findings include: 1. Review of Resident #49's medical record revealed the resident was admitted to the facility on [DATE] after right hip surgery. Review of the record revealed the resident developed an unstageable area to his right heel on 10/08/18 and a current treatment order, dated 01/03/19 revealed the resident was to have his right heel cleansed with normal saline, with santyl (a debriding agent) applied to wound, covered with alginate (another debriding agent) and then covered with a foam dressing every day. Review of the most recent wound measurements dated 02/07/19…

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.