Highland Oaks Health Center

Based on employee record review and staff interview, the facility failed to ensure Certified Nursing Assistants (CNA) were provided 12 hours of continuing education per year. This had the potential to affect all 85 residents residing in the facility. Findings Include: 1. Review of the employee file for CNA #106 revealed a hire date of 06/10/22. Further review of the employee file revealed no evidence of 12 hours of continuing education per year. 2. Review of the employee file for CNA #119 revealed a hire date of 08/28/19. Further review of the employee file revealed no evidence of 12 hours of continuing education per year. 3. Review of the employee file for CNA #208 revealed a hire date of 02/08/21. Further review of the employee file revealed no evidence of 12 hours of continuing education per year. On 01/22/25 at 5:45 P.M., interview with Human Resource (HR) #187 and the Director of Nursing (DON) verified the employees had not completed the 12 hours of continuing education per year.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility contracts, interviews, and policy review the facility failed to ensure medications were available for administration as ordered. This affected four residents (#1, #31, #85, and #191) of seven residents reviewed for medication review. Findings included: 1. Medical record review revealed Resident #31 was admitted to the facility on [DATE] at 5:05 P.M., with diagnoses including diffuse traumatic brain injury with loss of consciousness, hemiplegia, depression, gastro-esophageal reflux, insomnia, chronic kidney disease, deformity of the head, atrial fibrillation, chronic pain, and iron deficiency anemia. Review of Resident #31's current orders dated 01/2025 revealed meropenem two grams intravenous every eight hours (6:00 A.M., 2:00 P.M., and 10:00 P.M.) and vancomycin 750 mg intravenous every 12 hours (goal trough range 15-20 mcg/ml) at 8:00 A.M. and 8:00 P.M. Review of Resident #31's Medication Administration Record (MAR) dated 12/16/24 to 01/15/25 revealed 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, observation, interview and policy review the facility failed to ensure medications were properly stored, medication carts were locked when unsupervised, and insulin medications were dated when opened. This had the potential to affect all 22 of 22 residents on 200 hall, all 14 of 14 residents on 300 hall, and all 22 of 22 residents on 400 hall. Findings included: 1. Observation of medication administration on 01/15/25 at 7:51 A.M., with Registered Nurse (RN) #110 revealed the RN left the medication cart unlocked with the keys in the lock and walked into Resident #67's room to administer medications. The medication cart was not in RN #110's view. Interview on 01/15/24 at 8:33 A.M., with RN #110 confirmed he left the 400-medication unlocked and left the keys in the lock and the medication cart was not in his view. 2. Observation on 01/16/25 at 10:16 A.M. of the 400 hall medication cart revealed the medication cart was left unlocked and unattended. No staff were observed on the 400 hall. The surveyor waited a few minutes and then walked down to 300 hall…

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, interviews and facility policy review, the facility failed to maintain appropriate infection control practices to prevent the potential spread of infection in the area of tracheostomy care, dressing change, medication administration and enhanced barrier precautions (EBP). This affected ten residents (Residents #1, #9, #22, #30, #31, #54, #61, #74, #191, #240) of 85 residents who require enhanced barrier precautions and four residents (#1, #10, #67, and #191) of 20 residents reviewed for infection control practices. Additionally, the facility failed to ensure the infection control log was accurate and tracked bacteria from nosocomial infections and infection control polices were reviewed annually. This had the potential to affect all 85 residents residing in the facility. Findings Included: 1. Observation on 01/13/25 during the initial tour of the facility revealed no evidence of the facility implementing EBP for those residents observed having tracheostomy, enteral tubes,…

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 concern log, review of personnel files, interviews, and policy reviews the facility failed to ensure residents were treated with respect and dignity by nursing staff. This affected one resident (#9) of six residents interviewed on 300 halls. Findings included: Medical record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including anxiety, depression, respiratory disease, diabetes, difficulty walking, and was currently under hospice care. Interview on 01/13/25 at 9:15 A.M., and 01/21/25 at 1:58 A.M., with Resident #9 revealed Registered Nurse (RN) #126 was rude and rough with care such as pulling on her arms when administering insulin. Resident #9 reported several residents had voiced complaints about RN #126 and she had observed RN #126 make another staff member cry. The RN works on 3rd shift. Interview on 01/13/25 at 11:10 A.M., with Resident #78 revealed there's a nurse on nightshift, but she could not recall her name, that…

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 probate court local rules of practice, and interview the facility failed to ensure a resident had a legal guardian when the resident no longer had the ability to maintain capacity. This affected one resident (#19) of one resident reviewed for notification. The facility census was 85. Findings Include: Review of the medical record for Resident #19 revealed an initial admission date 03/08/16 of secondary Parkinsonism, diabetes mellitus, aphasia, hyperlipidemia, bipolar disorder, depressive episodes, schizoaffective disorder, bipolar type, anxiety disorder, schizophreniform and dementia. Review of the letter of guardianship dated 10/03/14 revealed the resident was deemed incompetent. A family member of the resident was named the resident's guardian of person only indefinitely. Review of the removal of guardianship dated 11/14/17 revealed the resident's family member was removed as the resident's guardian for failure to file guardianship reports. Review of the resident'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.

Based on review of resident financial records and staff interview, the facility failed to notify a resident that received Medicaid benefits when the amount in the resident's account reached $200 less than the SSI resource limit for one person, and that, if the amount in the account, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI. This affected one of six residents whose financial records were reviewed (#19). The facility handled the funds for 52 residents. The facility census was 85. Findings Include: Review of the financial records for Resident #19 revealed the facility managed her funds. Review of the resident's quarterly resident fund statement revealed the balance in the resident's account had been greater than $1800.00 since 10/01/24. On 10/01/24 the balance was $1881.99. The current balance in the account was $1950.97. On 01/22/25 at 8:50 A.M. interview with the Business Office Manager (BOM) #132 confirmed the Resident #19 received Medicaid benefits and that the resident's balance was within the $200 of the resource limit.…

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 code status binder, interview, and policy review the facility failed to ensure resident code status was consistent and accurate. This affected three residents (#54, #85, and #191) of three reviewed for advance directives. Findings included: 1. Medical record review revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of liver, type two diabetes, urinary tract infection, anemia, paroxysmal atrial fibrillation, congestive heart failure, cardiomegaly, hyperlipidemia, anxiety, history of acute kidney, ileus, acute pulmonary edema, conjunctival hemorrhage, severe sepsis with septic shock, sepsis, encephalopathy, bacteriuria, liver disease, diarrhea, infectious gastroenteritis and colitis, muscle weakness, difficulty walking, need for assistance with personal care. Review of Resident #54's census tab revealed the resident was admitted [DATE] and was discharged on [DATE] and no anticipated to return (short-term general…

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 notify legal representatives of changes in orders or medical conditions. This affected two residents (#19, #85) of two residents reviewed for medical provider notifications. The facility census was 85. Findings include: 1. Record review revealed Resident #85 was admitted to the facility on [DATE] with diagnoses including vascular dementia with agitation, post-traumatic stress disorder, and idiopathic gout. Review of a nursing note dated 11/27/24 at 12:42 P.M. by Registered Nurse (RN) #188 revealed the provider evaluated and gave an order for an x-ray of Resident #85's right ankle. There was no evidence Resident #85's representative was made aware of the new order. Review of a nursing note dated 12/01/24 at 4:24 P.M. by Licensed Practical Nurse (LPN) #219 revealed Resident #85's temperature was 100.7, he was achy and not feeling well. A COVID test was completed and negative. There was no evidence Resident #85's representative was made aware of the new…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, policy review, and record review, the facility failed to report an allegation of sexual abuse. This affected one resident (#27) of seven residents reviewed on the memory care unit. The facility census was 85. Findings include: Record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including dementia, hypertension, angina pectoris, attention and concentration deficit following cerebral infarction, and personal history of a traumatic brain injury. Record review revealed Resident #27 had a court appointed legal guardian of person and estate as of 05/14/24 related to being deemed an incompetent adult in the probate court. Resident #27 resided on the facility secured memory care unit. Review of a care plan dated 07/22/24 revealed Resident #27 may demonstrate inappropriate behaviors including agitation. The care plan was not specific to what the inappropriate behaviors were and did not include evidence of sexually inappropriate behaviors for the 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 staff interviews, policy review, and record review, the facility failed to thoroughly investigate an allegation of sexual abuse. This affected one resident (#27) of seven residents reviewed on the memory care unit. The facility census was 85. Findings include: Record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including dementia, hypertension, angina pectoris, attention and concentration deficit following cerebral infarction, and personal history of a traumatic brain injury. Record review revealed Resident #27 had a court appointed legal guardian of person and estate as of 05/14/24 related to being deemed an incompetent adult in the probate court. Resident #27 resided on the facility secured memory care unit. Review of a care plan dated 07/22/24 revealed Resident #27 may demonstrate inappropriate behaviors including agitation. The care plan was not specific to what the inappropriate behaviors were and did not include evidence of sexually inappropriate behaviors 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 record review, review of email correspondence to the local Ombudsman, and staff interview, the facility failed to ensure the local Ombudsman was notified of a resident's transfer to the hospital as required. This affected one resident (#88) of one residents reviewed for hospitalization. Findings include: Review of Resident #88's closed medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included nodular sclerosis Hodgkin lymphoma, metabolic encephalopathy, end stage renal disease, dependence on hemodialysis, myoclonus (sudden, involuntary muscle jerking/ spasms), hypertension, and adult onset diabetes mellitus. Review of Resident #88's progress notes revealed a nurse's note dated 10/29/24 at 8:10 P.M. that indicated the resident was sent to the emergency room for an evaluation at the request of his family. The progress note did not specify what change in condition the resident had that prompted the family to want him sent to the emergency room, but transportation…

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 staff interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for two residents (#30, #38) in the area of dental and dialysis. This affected two residents (#30, #38) of 20 sampled residents. The facility census was 85. Findings Include: 1. Review of the medical record for Resident #30 revealed an initial admission date of 08/30/23 with the latest readmission of 12/10/24 with the diagnoses including but not limited to partial traumatic amputation of left foot, osteomyelitis, sepsis, diabetes mellitus with neuropathy, hypertension, hyperlipidemia, osteoarthritis, gastro-esophageal reflux disease, constipation, edema, nausea and vomiting and anemia. Review of the resident's plan of care revealed no care plan addressing the resident's dialysis or potential for infection related to the central line. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was not assessed. 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 complete a significant change minimum data set ( MDS) for one resident (#40) within 14 days of the resident being admitted to hospice services. This affected one resident (#40) of 20 residents reviewed for assessments. The facility census was 85. Findings Include: Record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including abdominal aortic aneurysm without rupture, malignant neoplasm of prostate, and unspecified dementia. Review of a social services note dated 12/16/24 at 3:28 P.M. revealed Resident #40's family requested a referral be sent to hospice. Review of orders revealed Resident #40 admitted to hospice services on 12/17/24 for a diagnosis of senile degeneration of the brain. Review of minimum data set (MDS) assessments revealed a significant change assessment for Resident #40 was not completed within 14 days of the resident's admission to hospice. Interview on 01/15/24 at 10:27 A.M. with MDS Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and facility policy review, the facility failed to ensure a significant change Pre-admission Screening and Resident Review (PASARR) was completed when a mental health diagnosis was newly added. This affected one resident (#38) of four residents reviewed for PASARR. The facility census was 85. Findings Include: Review of the medical record for Resident #38 revealed an initial admission date of 02/02/23 with the latest readmission of 06/02/23 with the diagnoses including but not limited to metabolic encephalopathy, sepsis, acidosis, epilepsy, solitary pulmonary nodule right upper lobe, dementia with behavioral disturbances, esophageal thickening, diabetes mellitus, hypertension, anxiety disorder, mood disorder, insomnia, dental caries and added on 09/20/24 schizophrenia. Review of the plan of care dated 11/22/24 revealed the resident suffers from schizophrenia and is at risk for change in ability, thinking, perception, behavior and personality. Interventions included assist…

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 a pre-admission screening and resident review (PASARR) assessment was correct upon resident admission to the facility. This affected one resident (#85) of four residents reviewed for PASARRs. The facility census was 85. Findings include: Record review revealed Resident #85 was admitted to the facility on [DATE] with diagnoses including vascular dementia with agitation, post-traumatic stress disorder (PTSD), and idiopathic gout. Review of a PASARR completed on 11/21/24 revealed no evidence of PTSD being listed as a serious mental illness. Interview on 01/14/25 at 1:46 P.M. with Social Services Director (SSD) #190 confirmed PTSD was not listed on Resident #85's PASARR.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a significant change Pre-admission Screening and Resident Review (PASARR) contained correct developmental disability diagnoses. This affected one resident (#23) of four residents reviewed for PASARR assessments. The facility census was 85. Findings include: Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, altered mental status, schizophrenia, and moderate intellectual disabilities. Review of a significant change PASARR completed on 08/05/24 revealed no evidence Resident #23 had a diagnosis of moderate intellectual disabilities. Interview on 01/14/25 at 1:46 P.M. with Social Services Director (SSD) #190 confirmed moderate intellectual disabilities was not listed on Resident #23's PASARR.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and facility policy review, the facility failed to develop a comprehensive plan of care for three residents (#30, #31, #38). This affected three residents (#30, #31, #38) of 20 sampled residents. The facility census was 85. Findings Include: 1. Review of the medical record for Resident #30 revealed an initial admission date of 08/30/23 with the latest readmission of 12/10/24 with the diagnoses including but not limited to partial traumatic amputation of left foot, osteomyelitis, sepsis, diabetes mellitus with neuropathy, hypertension, hyperlipidemia, osteoarthritis, gastro-esophageal reflux disease, constipation, edema, nausea and vomiting and anemia. Review of the resident's plan of care revealed no care plan addressing the resident's dialysis or potential for infection related to the central line. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was not assessed. The assessment indicated 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, policy review, and interview, the facility failed to ensure comprehensive care plans were up to date. This affected two residents (#21 and #71) of three residents reviewed for care planning. The facility also failed to complete quarterly care conferences. This affected one resident (#1) of three residents reviewed for care planning. The facility census was 85. Findings include: 1. Record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including anoxic brain damage, unspecified dementia, and bipolar disorder. Review of a minimum data set (MDS) completed on 11/15/24 revealed Resident #21 exhibited no behaviors. Review of a care plan last revised on 11/18/24 revealed Resident #21 did not have a care plan for sexually inappropriate behaviors in place. Review of a nursing note dated 11/21/24 at 1:17 P.M. by Registered Nurse (RN) #188 revealed Resident #21 was found in a male resident's room with her shirt up. Resident was redirected out of the male resident'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 Based on record review, interview, and facility policy review, the facility failed to complete a discharge summary that included a recapitulation of the resident's stay. This affected one resident (#87) of one resident reviewed for discharge. The facility census was 85. Findings Include: Review of the closed medical record for Resident #87 revealed an initial admission date of 10/11/24 with the diagnoses including but not limited to traumatic subdural hemorrhage, rhabdomyolysis, diabetes mellitus, hyperlipidemia, hypertension, benign prostatic hyperplasia, obesity, diverticulosis, osteoarthritis, incisional hernia, dysphagia, generalized muscle weakness and disorders of kidney and ureter, renal mass. The resident was discharged to his own home on [DATE]. Review of the baseline care plan dated 10/11/24 revealed the baseline care plan will identify my care needs, risk, strengths and goals for the first 48 hours. Interventions included the resident will be receiving skilled care and his discharge planning, goals,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interview, the facility failed to ensure a resident who was dependent on staff for personal care received the assistance needed with nail care. This affected one resident (#57) of two residents reviewed for activities of daily living (ADL's). The facility census was 85. Findings Include: Review of the medical record for Resident #57 revealed an initial admission date of 12/28/22 with the diagnoses including but not limited to Alzheimer's disease, dementia, chronic kidney disease, hypertension, vitamin D deficiency and dysphagia. Review of the plan of care dated 01/06/23 revealed the resident required staff assistance to complete activities of daily living (ADL) tasks completely and safely. Interventions included allow resident sufficient time to complete all or parts of task, do not rush resident, encourage resident to do as much as safely possible for self, observe the deterioration in ADL abilities and report if occurs, provide adequate resident periods between…

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, interviews and facility policy review, the facility failed to treat one resident (#11) for a urinary tract infection (UTI) in a timely manner. Additionally, the facility also failed to provide one resident (#1) with routine indwelling urinary catheter care. This affected two residents (#11, #1) of three residents reviewed for catheter or UTI. The facility census was 85. Findings Include: 1. Review of the medical record for Resident #11 revealed an initial admission date of 05/07/21 with the latest readmission of 07/05/22 with the diagnoses including but not limited to osteoarthritis, major depressive disorder, mood disorder, constipation, Major depressive disorder, irritable bowel syndrome, hypertension, dysphagia, acute failure to thrive, insomnia, anxiety and palliative care. Review of Resident #11's progress notes dated 10/01/24 at 10:53 A.M. revealed the resident believed she had a urine infection. The hospice nurse visited and was aware. The entry indicated a urine was sent 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, Registered Dietician (RD) recommendation review, interview and facility policy review, the facility failed to implement dietary recommendations and obtain physician ordered daily weights for one resident (#30). This affected one resident (#30) of two residents reviewed for nutrition. The facility census was 85. Findings Include: Review of the medical record for Resident #30 revealed an initial admission date of 08/30/23 with the latest readmission of 12/10/24 with the diagnoses including but not limited to partial traumatic amputation of left foot, osteomyelitis, sepsis, diabetes mellitus with neuropathy, hypertension, hyperlipidemia, osteoarthritis, gastro-esophageal reflux disease, constipation, edema, nausea and vomiting and anemia. Review of the plan of care dated 09/05/23 revealed the resident required increased caloric, protein, and/or nutrient needs, protein intake encourage, food related diet noncompliance with therapeutic diet restriction, end stage renal disease (ESRD), weight…

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 hospital records, observation, interview, and policy review the facility failed to ensure residents had oxygen orders, respiratory medications were administered as ordered, respiratory supplies were stored properly, and emergency tracheostomy supplies were readily available. This affected three residents (#57, #67, #191) of three residents reviewed for respiratory care and medication observation. Findings included: 1. Record review revealed Resident #191 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, sepsis, tracheostomy, gastrostomy, hypertension, atrial fibrillation, acute kidney failure, protein-calorie malnutrition, anxiety, hyperlipidemia, and tobacco use. A. Review of Resident #191's current order revealed no evidence of oxygen orders. Observation on 01/13/25 at 10:24 A.M., revealed there was a used tracheostomy mask lying on the resident's bedside table she was using,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, interviews and facility policy review, the facility failed to ensure a resident who required dialysis services received ordered care. This affected one resident (#30) of one resident reviewed for dialysis. The facility census was 85. Findings include Review of the medical record for Resident #30 revealed an initial admission date of 08/30/23 with the latest readmission of 12/10/24 with the diagnoses including but not limited to partial traumatic amputation of left foot, osteomyelitis, sepsis, diabetes mellitus with neuropathy, hypertension, hyperlipidemia, osteoarthritis, gastro-esophageal reflux disease, constipation, edema, nausea and vomiting and anemia. Review of the resident's plan of care revealed no care plan addressing the resident's dialysis or potential for infection related to the central line. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was not assessed. The assessment indicated 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, staff interview and facility policy review, the facility failed to assess, implement and monitor one resident (#38) with known post traumatic stress disorder (PTSD) for triggers and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. This affected one resident (#38) of five residents reviewed for behavioral-emotional needs. The facility census was 85. Findings Include: Review of the medical record for Resident #38 revealed an initial admission date of 02/02/23 with the latest readmission of 06/02/23 with the diagnoses including but not limited to metabolic encephalopathy, sepsis, acidosis, epilepsy, solitary pulmonary nodule right upper lobe, dementia with behavioral disturbances, esophageal thickening, diabetes mellitus, hypertension, anxiety disorder, mood disorder, insomnia, dental caries and added on 09/20/24 schizophrenia. Review of the plan of care dated 02/02/23 revealed the resident presents with diagnoses of post traumatic stress…

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 interviews, the facility failed to ensure a resident received referrals for psychiatric services and failed to ensure a resident had interventions in place to address aggressive behaviors. This affected one resident (#71) of one reviewed for choices and one resident (#85) two reviewed for dementia care. Findings included: 1. Medical record review revealed Resident #85 was admitted to the facility on [DATE] with diagnoses including dementia, post-traumatic stress disorder, insomnia, generalized anxiety, and wandering. Review of Resident #85's current orders dated 01/2025 revealed the resident was ordered clonazepam 0.25 milligrams (mg) 0.25 mg in the morning 0.5 mg in the evening and every eight hours needed for agitation and anxiety. The resident was also ordered Zyprexa (antipsychotic) 2.5 mg in the morning and 5 mg at 4:00 P.M. There was no indication for use. Review of Resident #85's hospital notes dated 11/22/4 indicated the resident was on Zyprexa for anxiety and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the medical record for Resident #19 revealed an initial admission date of secondary Parkinsonism, diabetes mellitus, aphasia, hyperlipidemia, bipolar disorder, depressive episodes, schizoaffective disorder, bipolar type, anxiety disorder, schizophreniform and dementia. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors. The assessment indicated dementia, anxiety disorder, depression, bipolar disorder and schizophrenia were active diagnoses. The resident received antipsychotic, antianxiety, antidepressant and hypoglycemic medications. Review of the pharmacy recommendation dated 04/08/24 revealed the pharmacist recommended the following labs, basic metabolic panel (BMP), hemoglobin A1c (Hgb A1c), liver function test (LFT) and complete blood count (CBC) every six months. The physician addressed the recommendation on 04/15/24 and agreed with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and policy review the facility failed to ensure residents were free from unnecessary medications when pain medication failed to have parameters and failed to ensure sliding scale insulin was followed per orders. This affected three residents (#74, #85, and #191) of six reviewed for unnecessary medication review. The facility census was 85. Findings included: 1. Medical record review revealed Resident #85 was admitted to the facility on [DATE] with diagnoses including dementia, post-traumatic stress disorder, gout, insomnia, generalized anxiety, hypertension, hyperlipemia, and wandering. A. Review of Resident #85's orders and medication administration record dated 12/22/24 to 01/21/25 revealed the resident was ordered lidocaine patch 5% apply one patch on in the morning and remove at night. Do not wear it for more than 12 hours in a 24-hour period. The resident refused to apply the patch 11 times and refused to have the patch removed 10 times. Interview on 01/22/25 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 medical record review, review of hospital records, interviews, and policy review the facility failed to ensure psychotropic drugs were administered as ordered, properly assessed, and had appropriate diagnoses. This affected three residents (#19, #85, and #191) of six reviewed of unnecessary medication review. Findings included: 1. Medical record review revealed Resident #85 was admitted to the facility on [DATE] with diagnoses including dementia, post-traumatic stress disorder, insomnia, generalized anxiety, and wandering. Review of Resident #85's current orders dated 01/2025 revealed the resident was ordered clonazepam 0.25 milligrams (mg) 0.25 mg in the morning 0.5 mg in the evening and every eight hours as needed for agitation and anxiety. There was no evidence of a stop date for the as needed clonazepam order. The resident also ordered Zyprexa (antipsychotic) 2.5 mg in the morning and 5 mg at 4:00 P.M. There was no indication for use. Review of Resident #85's hospital notes dated 11/22/24 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 medical record review, staff interview and facility policy review, the facility failed to ensure physician ordered laboratory tests were obtained as ordered. This affected two residents (#19, #38) of five residents reviewed for unnecessary medications. The facility census was 85. Findings Include: 1. Review of the medical record for Resident #19 revealed an initial admission date of secondary Parkinsonism, diabetes mellitus, aphasia, hyperlipidemia, bipolar disorder, depressive episodes, schizoaffective disorder, bipolar type, anxiety disorder, schizophreniform and dementia. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the resident's monthly physician orders identified an order dated 06/08/19 for the laboratory tests complete blood count (CBC), thyroid stimulating hormone (TSH), hemoglobin A1c (HgbA1c), vitamin D level, vitamin B 12 level and lipid panel annually in July. Review of the medical record…

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, interviews and facility policy review, the facility failed to ensure one resident (#38) received routine dental care. This affected one resident (#38) of one resident reviewed for dental services. The facility census was 85. Findings Include: Review of the medical record for Resident #38 revealed an initial admission date of 02/02/23 with the latest readmission of 06/02/23 with the diagnoses including but not limited to metabolic encephalopathy, sepsis, acidosis, epilepsy, solitary pulmonary nodule right upper lobe, dementia with behavioral disturbances, esophageal thickening, diabetes mellitus, hypertension, anxiety disorder, mood disorder, insomnia, dental caries and added on 09/20/24 schizophrenia. Review of the resident's admission observation and data collection dated 02/02/23 revealed the resident had her own natural teeth. The assessment indicated the resident's teeth had no cavities or broken teeth. Review of the plan of care dated 02/16/23 revealed the resident had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and interview, the facility failed to ensure a complete and accurate record. This affected three residents (#57, #11, #85) of 20 sampled residents. The census was 85. Findings Include: 1. Review of the medical record for Resident #57 revealed an initial admission date of 12/28/22 with the diagnoses including but not limited to Alzheimer's disease, dementia, chronic kidney disease, hypertension, vitamin D deficiency and dysphagia. Review of the resident's plan of care revealed no care plan addressing the resident's oxygen use. Review of the resident's comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident had not utilized oxygen therapy. Review of the resident's monthly physician orders identified no orders for oxygen use. Review of the resident's progress note dated 01/13/25 at 4:44 P.M. revealed the resident had reported new onset of wheezing and shortness of breath. The Nurse…

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 facility policy review, the facility failed to ensure an appropriate reason for the use of an antibiotic for one resident (#11). This affected one resident (#11) of three residents reviewed for antibiotic use. The facility census was 85. Findings Include: Review of the closed medical record for Resident #11 revealed an initial admission date of 07/05/21 with the latest readmission of 05/07/22 with the admitting diagnoses including but not limited to osteoarthritis, major depressive disorder, mood disorder, constipation, irritable bowel syndrome, hypertension, malignant neoplasm of female genital organ, dysphagia, tract infection, insomnia, unspecified, palliative care, and anxiety disorder. Review of the resident's discontinued physician orders revealed an order dated 10/22/24 for Cipro 500 milligrams (mg) by mouth twice daily until 10/29/24 for a urinary tract infection. Review of the medical record revealed no laboratory results or documentation related to the order 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, interview and facility policy review, the facility failed to ensure two residents (#30, #40) received vaccinations as requested. This affected two residents (#30, #40) of five residents reviewed for immunizations. Findings Include: 1. Review of the medical record for Resident #40 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to dementia, urinary tract infection (UTI), chronic obstructive pulmonary disease, convulsions, Rheumatoid arthritis, malignant neoplasm of prostate, benign neoplasm of prostate, diabetes mellitus and hyperlipidemia. Review of the resident's admission immunization consent packet dated 10/08/24 revealed the resident consented to have the influenza vaccine, pneumonia vaccine and COVID-19 vaccine. Review of the resident's November 2024 Medication Administration Record (MAR) revealed the resident received the influenza vaccination on 11/06/24. Review of the resident's medical record revealed no documented evidence the resident received the requested pneumonia vaccination as requested. On 01/22/25…

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.

Based on record review and interview, the facility failed to ensure two residents (#30, #40) received vaccinations as requested. This affected two residents (#30, #40) of five residents reviewed for immunizations. Findings Include: 1. Review of the medical record for Resident #40 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to dementia, urinary tract infection (UTI), chronic obstructive pulmonary disease, convulsions, Rheumatoid arthritis, malignant neoplasm of prostate, benign neoplasm of prostate, diabetes mellitus and hyperlipidemia. Review of the resident's admission immunization consent packet dated 10/08/24 revealed the resident consented to have the COVID-19 vaccine. Review of the resident's medical record revealed no documented evidence the resident received the requested COVID-19 vaccination as requested. On 01/22/25 at 2:20 P.M., interview with the Director of Nursing (DON) verified the resident had in fact requested the COVID-19 vaccination and was not provided as requested. 2. Review of the medical record for Resident #30…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, staff interview, and policy interview, the facility failed to ensure a resident received appropriate wound care to a surgical site and to a non-pressure ulcer on his right foot. They also failed to ensure wounds were assessed upon admission and weekly thereafter to monitor for healing. This affected one (#56) of three residents reviewed for wounds/ dressing changes. Findings include: Review of Resident #56's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included status post transmetatarsal amputation of the right foot on 11/06/24, osteomyelitis of the right foot and ankle, partial traumatic amputation of two or more right lesser toes, diabetes mellitus, peripheral vascular disease, and a chronic, non-pressure ulcer of the right heel. Review of Resident #56's hospital records revealed they included a Discharge summary dated [DATE]. The discharge summary from the hospital revealed the resident's care was being handed off to a primary…

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, review of an Omnicell (medication dispensing system) Inventory list, and staff interview, the facility failed to ensure a resident identified as having a urinary tract infection received antibiotic therapy timely, after it was ordered. This affected one (#91) of three residents reviewed for urinary tract infections. Findings include: Review of Resident #91's medical record revealed the resident was admitted to the facility on [DATE]. She remained in the facility until her discharge from the facility to home on [DATE]. Her diagnoses included a malignant neoplasm of the anus, hemiplegia and hemiparesis following a stroke affecting her right dominant side, aphasia, and dysphagia. Review of Resident #91's nurses' progress notes revealed a nurse's note dated 10/13/24 at 9:46 A.M. that indicated the resident's indwelling urinary catheter was noted to be leaking. The nurse attempted to irrigate the indwelling urinary catheter without any results. The indwelling urinary catheter was changed with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident representative interview, staff interview, and policy review, the facility failed to ensure appropriate care and treatment was provided to a resident that had a gastrostomy tube. This affected one ( #91) of one residents reviewed for gastrostomy tubes. Findings include: Review of Resident #91's medical record revealed she was admitted to the facility on [DATE]. She remained in the facility until she was discharged home on [DATE]. Her diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following a stroke, dysphagia (difficulty swallowing), aphasia (difficulty with speech), and gastrostomy status (placement of a tube into the stomach from the abdominal wall for the administration of nutritional supplements). Review of Resident #91's physician's orders revealed she had an order in place to receive Jevity 1.5 cal. 240 milliliters (ml) per feeding tube three times a day as needed (prn), if she did not eat her meals by mouth. The physician's orders did not include any…

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, review of controlled drug use records, staff interview, and policy review, the facility failed to ensure controlled medications administered to a resident, as indicated on the medication administration records, were also properly documented on controlled drug use record sheets for reconciliation purposes. This affected one (#91) of three residents reviewed for controlled medication use. Findings include: Review of Resident #91's medical record revealed she was admitted to the facility on [DATE]. She remained in the facility until her discharge from the facility to home on [DATE]. Her diagnoses included a malignant neoplasm of the anus, hemiplegia and hemiparesis following a stroke affecting her right dominant side, aphasia (difficulty with speech), and gastrostomy status. Review of Resident #91's physician's orders revealed the resident had the use of Morphine Sulfate (controlled narcotic pain medication) concentrate 20 milligrams (mg)/ milliliter (ml) 0.5 ml (10 mg) orally every hour 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 observation, staff interview, and policy review, the facility failed to ensure medications were properly dated when first accessed/ used. This involved three of four medication administration carts and affected a total of eight residents (#30, #32, #50, #54, #55, #63, #75, and #77). The facility's census was 87. Findings include: 1 a.) On 09/23/24 at 10:09 A.M., an observation of the 400 hall medication administration cart with Licensed Practical Nurse (LPN) #35 revealed there were three multi-use vials of Lantus (slow acting insulin) 100 units/ milliliter (ml) 10 ml vials in the top drawer of the medication administration cart for Resident #32. The vials were stored in one bag and all three vials had been opened. The label on the bag the insulin vials were stored in provided directions under a high alert. The directions indicated the insulin should be refrigerated and, once opened, it should be discarded after 28 days. There was a place on the label to indicate the date when the vial had been opened. A…

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

Based on record review, observations and interviews, the facility failed to follow infection control protocols. This affected 18 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, and #18) of 26 residents residing on the memory care unit. The facility census was 95. Findings included: Review of the incident log revealed the facility had 33 residents with COVID-19. Review of current census revealed 19 residents still remained COVID positive with 18 of those residents residing on the memory care unit. During the initial tour on 09/03/24 between 7:46 A.M. and 7:58 A.M., revealed one room was identified on the memory care unit to have droplet precautions in place. Interview on 09/03/24 at 10:31 A.M. with Licensed Practical Nurse (LPN) #176 revealed the memory care unit has quite a few COVID positive residents. Residents who wander are encouraged to stay in their room, but they do not because they are confused so they are then encouraged to wear a mask and they are also noncompliant with that. LPN #176 stated the staff just try to keep the residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and interview, the facility failed to investigate an allegation of misappropriation within the required five days. This affected one resident (#20) of one resident reviewed for misappropriation. The facility census was 95. Findings include: Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, type II diabetes, and chronic kidney disease. Review of care plan dated 08/29/24 revealed Resident #20 did not have behaviors or a history of confusion. Review of a self-reported incident (SRI) initiated on 07/26/24 revealed Resident #20 reported his wallet was missing on 07/25/24. The room was searched, common areas searched, and an investigation was begun. Further review of the SRI revealed it was not completed until 08/07/24 which was outside of the required five-day period. Interview on 09/05/24 at 9:34 A.M. with the Administrator revealed the SRI was initiated and submitted on 07/26/24. The Administrator…

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, policy review, and staff interview, the facility failed to ensure food was properly stored in the dry food storage area to prevent spoilage/ possible contamination from insects and/ or rodents. This had the potential to affect all residents in the facility who received food from the kitchen. The facility's census was 95. Findings include: Observations of the food storage area in the facility's basement on 08/05/24 at 11:25 A.M. revealed the facility was utilizing the basement for the storage of refrigerated and frozen food items, as well as dry food. The basement was noted to have one large room that contained a box freezer, walk in refrigerators, walk in freezers, and some storage of dry food goods on shelves along the wall. The back end of the basement was noted to have a series of three rooms. One of the three rooms was a small room on the right that was being used for the storage of dry food. It was located next to the center room in the back that had some medical supplies and other random items stored in that room. There was a strong sewer odor present in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of quotes for equipment replacement, review of a facility issued check, review of the administrator's notes, review of daily temperature log sheets, review of correspondence with the facility's chemical supplier, and staff interview, the facility failed to ensure the hot water tank that supplied the washing machines were properly maintained in a working order to provide adequate hot water to the washers or utilize appropriate bleach or bleach alternative products to properly disinfect/ sanitize linens and residents' personal clothing. This affected all residents that resided in the facility. The facility's census was 95. Findings include: Observations of the facility's laundry room on 08/05/24 at 11:15 A.M. revealed they had two washing machines that were used to process the facility and residents' laundry. The hot water tank that provided the washing machines with hot water was leaking and was currently not in use according to Maintenance Director #100 (who accompanied the surveyor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of quotes for equipment replacement, review of a facility issued check, and staff interview, the facility failed to ensure the hot water tank that supplied the washing machines were properly maintained in a working order to provide adequate hot water to the facility's washing machines to be able to properly disinfect/ sanitize linens and the residents' personal clothing. This affected all residents that resided in the facility. The facility's census was 95. Findings include: Observations of the facility's laundry room on 08/05/24 at 11:15 A.M. revealed they had two washing machines that were used to process the facility and residents' laundry. The hot water tank that provided the washing machines with hot water was leaking and was currently not in use, according to Maintenance Director #100 (who accompanied the surveyor during tour of the building). The leaking of water was noted to be coming out from under the hot water tank. Maintenance Director #100 indicated the bottom of the hot…

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 work invoices, review of quotes for plumbing work that needed to be done, and staff interview, the facility failed to ensure the basement area utilized for food storage was maintained in a clean/ sanitary manner as a leaking sewer pipe was not timely repaired. This had the potential to affect all residents residing in the facility. The facility census was 95. Findings include: On 08/05/24 at 11:25 A.M., an observation of the facility's basement revealed they were utilizing the basement for the storage of refrigerated and frozen food items, as well as dry food goods. The basement was noted to have one large room that contained a box freezer and some storage of dry food goods on shelves along the wall. Further back was a walk in refrigerator and a walk in freezer. Towards the back of the basement there were three rooms. A small storage room at the back left corner, a larger storage room in the back center, and a dry food storage area in the back right corner. There was a strong sewage odor present in the basement that was more prevalent the further back…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview the facility failed to ensure residents received laboratory testing as ordered by the physician. This affected one (Resident #34) of three residents reviewed for laboratory services. The facility census was 91. Findings include: Review of the medical record for Resident #34 revealed an admission date of 02/22/24 with diagnoses including osteomyelitis to left foot, aftercare of surgical removal of two toes on left foot, type two diabetes mellitus, and vascular dementia. Review of the admission Minimum Data Set (MDS) assessment for Resident #34 dated 02/29/24 revealed the resident had intact cognition and required minimal assistance of one person for activities of daily living. Review of the hospital discharge instructions for Resident #34 dated 02/22/24 revealed the hospital physician wrote an order for the resident to have the following laboratory blood tests drawn once per week: complete blood count, sedimentation rate, C-reactive protein, creatinine kinase.…

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 facility policy review, the facility failed to ensure medications were appropriately packaged, labeled, and secured. This affected three medication carts of three medication carts (Connections 300 Hall, Front 500 Hall and Back 500 Hall) observed and one medication room (Connections 300 Nurses' Station) of one medication room observed. The facility census was 85. Findings included: 1. Observation on 12/07/23 at 8:01 A. M. of the Connections 300 Hall medication cart revealed 18 whole or one-half pieces of medication loose in the second drawer of the medication cart. This was verified during the observation by Registered Nurse (RN) #157. She also verified it was not proper storage to have loose medication in the drawers of the medications cart. 2. Observation on 12/07/23 at 8:39 A.M. of the Front 500 Hall medication cart revealed 20 whole or one-half pieces of medication loose in the second drawer of the medication cart. There was also a multi-dose bottle of Lantus insulin…

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, facility policy review and interview, facility failed to prepare foods in a sanitary manner and failed discard food items that were out of date/expired. This had the potential to affect 84 of 84 residents who received meal trays from the kitchen. The facility census was 85. Findings included: 1. On 12/04/23 from 8:39 A.M. to 9:12 A.M. observations made during the initial tour of the kitchen revealed the following concerns: A plastic container with cheddar cheese which expired on 12/03/23. A container of dried, crispy onions with a best by date of 10/27/23. A dented can of strawberry pie filling. Two bags of baby spinach with a use by date of 11/25/23. There was no operational thermometer in the walk-in refrigerator. Interview on 12/04/23 at 9:12 A.M. with Director of Food Services (DFS) confirmed the above findings/concerns at the time of the observations. 2. On 12/06/23 at 11:15 A.M. observation of tray line/meal preparation revealed of the lunch meal, which included corned beef hash and scrambled eggs revealed the following concerns: At 11:22 A.M., [NAME]…

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, resident record review, and facility policy review, the facility failed to ensure Preadmission Screening and Resident Reviews (PASARRs) were updated appropriately. This affected four residents (#13, #16, #26, #63) of nine residents reviewed for PASARR. The facility census was 85. Findings include: 1. Review of Resident #16's medical record revealed she was admitted to the facility on [DATE] with diagnoses including schizophrenia (entered 10/31/18), anxiety disorder (entered 10/31/18), and other specified depressive episodes (entered 06/20/19). Review of Resident #16's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/05/23, revealed she was severely cognitively impaired, had active diagnoses of anxiety, depression, and schizophrenia, and had verbal and physical behavioral symptoms directed toward others one to three days of the seven-day assessment reference period. Review of Resident #16's physician order, dated 06/26/23, identified she was to receive Haldol decanoate (a long acting…

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, staff interview, and facility policy review, the facility failed to ensure residents had comprehensive care plans in place to address pressure ulcers, schizophrenia, anxiety, and insomnia. This affected four resident's (#4, #13, #30, and #188) of 26 residents reviewed for care plans. Findings include: 1. A review of Resident #4's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included insomnia. A review of Resident #4's physician's orders revealed he had an order to receive Melatonin (a supplemental sleep aid) 10 milligrams (mg) by mouth every night at bedtime. The order had been in place since 09/20/23. A review of Resident #4's active care plans revealed he did not have a care plan in place to address his diagnosis of insomnia or the use of Melatonin as a sleep aid. Findings were verified by the Director of Nursing (DON). On 12/12/23 at 2:50 P.M., an interview with the DON confirmed she was not able to find a care plan for the resident to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure residents and representatives were invited to participate in care conferences and care plans were updated to reflect residents' current conditions. This affected four residents (#8, #29, #47, and #68) of five residents reviewed for care planning. The facility census was 85. Findings include: 1. Record review revealed Resident #29 admitted to the facility on [DATE] with diagnoses including dementia, contusion of the head, atherosclerotic heart disease without angina, atrial fibrillation, psychosis not due to a substance or known condition, hyperlipidemia, ischemic cardiomyopathy, encephalopathy, cognitive communication deficit, insomnia, and dysphagia. Review of the care conferences revealed Resident #29 had a care conference on 10/10/22 and did not have another care conference until 04/19/23. Interview on 12/05/23 at 5:01 P.M. with Social Services Director (SSD) #178 revealed care conference invitation cards were sent out monthly based on 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, facility policy review and interview, the facility failed to develop and implement a comprehensive infection control program to prevent the spread of infection. The facility failed to ensure hand hygiene was performed when passing residents their meals in their rooms and failed to ensure a glucometer was cleaned and disinfected after use. This had the potential to affect eight residents (#2, #14, #16, #27, #52, #57, #193, and #195) observed during lunch service and three residents (#11, #44, and #57) who required blood glucose monitoring using the shared glucometer from the 500 front medication cart. The facility census was 85. Findings included: 1. Observation on 12//11/23 at 7:59 A.M. as Licensed Practical Nurse (LPN) #187 prepared to obtain a finger stick blood sugar (FSBS) from Resident #11 revealed LPN #187 obtained her supplies and cleaned the glucometer with Swovo Medical and Commercial Disinfecting Wipe for approximately 10 seconds. LPN #187 then completed hand hygiene, applied (donned) gloves and proceeded to Resident #11's room. LPN #187 used a tissue…

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, review of invoice documents, facility policy review and interview, the facility failed to ensure immunizations were provided timely and as requested. This affected two residents (#9 and #34) and had the potential to affect 38 additional residents identified on a facility log to have consented to receiving a pneumococcal vaccine in September 2023 without evidence of administration. The facility census was 85. Findings included: 1. Record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including respiratory disease, heart disease, hepatitis, and diabetes. Review of Resident #34's immunization consent form dated 09/11/23 revealed the resident consented to receive the pneumococcal, influenza (flu), and COVID vaccine. Review of Resident #34's immunization record revealed the resident had received a pneumococcal vaccine in 11/11/21 from an outside care setting. There was no evidence of the type of pneumococcal vaccine the resident had received at that time.…

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, resident funds documentation review, and facility policy review, the facility failed to ensure staff were not witnesses for Resident #32's and #62's account and failed to ensure money was dispersed timely upon the death of Resident #288. This affected three residents (#32, #62, and #288) of five residents reviewed for personal funds. The facility census was 85. Findings include: 1. Review of Resident #32's medical record revealed she was admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain, nonexudative age-related macular degeneration, and mixed hyperlipidemia. Review of Resident #32's admission Minimum Data Set (MDS) 3.0 assessment, dated 08/10/23, revealed she was severely cognitively impaired. Review of Resident #32's Resident Fund Management Services Authorization and Agreement to Handle Resident Funds, dated 08/03/23, revealed the witness for the authorization was Business Office Manager (BOM) #179. Interview on 12/13/32 at 8:35 A.M. with BOM #179…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interviews, and policy review the facility failed to ensure the resident's code status/advance directives were consistent in the medical record and failed to include the resident in the decision-making process related to his code status. This affected one resident (#34) of 24 residents reviewed for advanced directive. Findings include: Record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, bipolar, anxiety, heart disease, atrial fibrillation, diabetes, seizures, knee pain, and depression. Review of Resident #34's current orders dated 12/2023 revealed on 07/05/22 the resident's code status was a do-not-resuscitate comfort care (DNRCC). The resident's original order dated 05/27/21 indicated the resident was a full code. Further review of Resident #34's medical record revealed no evidence of a signed advanced directive for DNRCC. Interview on 12/06/23 at 3:21 P.M., with the Administrator confirmed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to provide adequate supervision and effective/necessary intervention for Resident #68 to prevent potential incidents of resident to resident sexual abuse toward Resident #77. This affected two residents (#68 and #77) of six residents reviewed for abuse. The facility census was 85. Findings included: Record review revealed Resident #68 admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, hypertension, hyperlipidemia, gout, vascular dementia, and insomnia. Review of nursing note dated 08/18/23 at 6:01 P.M. revealed Resident #68 was sitting in the dining room and began to make sexual statements during conversations with female residents. Staff did redirect Resident #68, but he circled back to sexual statements and was speaking of orgies with female residents. Staff were instructed to encourage Resident #68 to sit at tables with mostly male residents. Record review revealed Resident #77 admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to report and/or investigate an injury of unknown origin for Resident #29. This affected one resident (#29) of one resident reviewed for reporting requirements. The facility census was 85. Findings include: Record review revealed Resident #29 admitted to the facility on [DATE] with diagnoses including dementia, atherosclerotic heart disease without angina, atrial fibrillation, psychosis not due to a substance or known condition, hyperlipidemia, ischemic cardiomyopathy, congestive heart failure, anxiety disorder, other depression episodes, mood (affective) disorder, and insomnia. Review of orders revealed Resident #29 had an order for a mat to the floor by the bed on 10/23/21. Review of nursing note from 01/12/23 at 3:36 A.M. by Licensed Practical Nurse (LPN) #194 revealed a nursing aide summoned her to Resident #29's room while resident was in bed to observe new discoloration to the right eye and redness under the left eye, with no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. A review of Resident #4's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included unspecified dementia without behavioral disturbances and bipolar disorder. A review of Resident #4's PASARR Identification Screen dated 07/07/23 revealed the PASARR was completed for a Preadmission Screening (PAS) from the community. Section (E.) of the PASARR was to document all the diagnoses the resident had of any mental disorders that were listed below. The diagnoses listed below included mood disorder, but mood disorder was not marked despite the resident's diagnoses including bipolar disorder (which was a mood disorder). The PASARR result notice indicated the resident did not have any indications of a serious mental illness and/ or developmental disability based on the PASARR Identification Screen that was submitted. On 12/12/23 at 4:23 P.M., an interview with SSD #178 revealed she was the one who was responsible for PASARR's. She confirmed Resident #4's PASARR Identification Screen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and facility policy review the facility failed to ensure effective fall interventions were in place for Residents #29 and #44, and the facility failed to ensure 15-minute checks were completed for Resident #19 when he made statements of self-harm. This affected three (Residents #19, #29, and #44) of five residents reviewed for accidents and hazards. The facility census was 85. Findings include: 1. Record review revealed Resident #19 admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain, pneumonia, hydronephrosis, dementia with agitation, atherosclerotic heart disease with angina, hypertension, cardiac arrhythmia, myocardial infarction, hyperlipidemia, depression, and anxiety. Review of a quarterly Minimum Data Set (MDS) assessment completed on 09/28/23 revealed Resident #19 had severely impaired cognition, mild depression, and hallucinations. Review of orders revealed Resident #19 was ordered lorazepam (anti-anxiety) 0.5…

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, policy review and interview, the facility failed to ensure a bowel protocol was followed for Resident #9, failed to ensure adequate and proper urinary catheter care was documented and orders were followed for a trial removal of a urinary catheter for Resident #186 and failed to ensure proper infection control measures were maintained during urinary catheter care to prevent Resident #13 from developing a urinary tract infection. This affected one resident (#9) of one resident reviewed for dialysis and two residents (#186 and #13) of two residents reviewed for urinary catheters. Findings included: 1. Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, dependent on renal dialysis, anemia, diabetes, severe protein-calorie malnutrition, dementia, mild with other behavioral disturbance, and hypertension. Review of Resident #9's quarterly Minimum Date Set (MDS) dated [DATE] revealed the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interviews the facility failed to ensure residents received nutritional supplements as ordered. This affected one resident (#9) of one resident reviewed for dialysis and one resident (#68) of two residents reviewed for nutrition. Findings include: 1. Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, anemia in chronic kidney disease, dependence on renal dialysis, type one diabetes mellitus with unspecified complications, unspecified sequelae of cerebral infarction, dysphagia following cerebral infarction, unspecified severe protein-calorie malnutrition, vitamin D deficiency, unspecified dementia, mild, with other behavioral disturbance, hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, and chronic bronchitis. Review of Resident #9's current orders dated 12/2023 revealed Ensure Clear twice daily and to start Mighty Shake at bedtime when available.…

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, resident record review, and facility policy review, the facility failed to ensure Resident #39's enteral tube placement was confirmed prior to administering medications. This affected one resident (#39) of one resident reviewed for tube feeding. The facility census was 85. Findings include: Review of Resident #39's medical record revealed she was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke) due to unspecified occlusion, malignant neoplasm of female breast, asthma, and essential hypertension. Review of Resident #39's quarterly Minimum Data Set (MDS) assessment, dated 10/31/23, revealed she was cognitively intact and had a feeding tube. Review of Resident #39's physician order, dated 07/25/23, identified her enteral tube placement was to be checked by air bolus and aspirating stomach contents before medications and tube feed bolus delivery. Observation on 12/07/23 at 8:81 A.M. of Licensed Practical Nurse (LPN) #187 preparing the morning…

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, resident record review, and facility policy review, the facility failed to ensure oxygen was administered per physician's order, oxygen tubing was changed per physician's order, and tubing and nebulizer equipment was maintained in a sanitary manner. This affected three residents (#13, #44, and #58) of three residents reviewed for respiratory care. The facility census was 85. Findings include: 1. Review of Resident #44's medical record revealed she was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure unspecified, unspecified asthma, and emphysema. Review of Resident #44's significant change Minimum Data Set (MDS) assessment, dated 10/17/23, revealed she was cognitively impaired and received oxygen therapy. Review of Resident #44's plan of care, dated 11/04/22, revealed she had a potential for shortness of breath while lying flat related to COPD and respiratory failure. One of the interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and facility policy review the facility failed to ensure residents had an effective pain management program. This affected two residents (#186 and #188) of three residents reviewed for pain. Findings include: 1. Record review revealed Resident #188 was admitted to the facility on [DATE] with diagnoses including unspecified cirrhosis of liver, ascites, unspecified protein-calorie malnutrition, essential (primary) hypertension, hypertensive heart disease without heart failure, acute kidney failure, unspecified, solitary pulmonary nodule, hypo-osmolality and hyponatremia, thrombocytopenia, unspecified. Review of Resident #188's current physician's orders and medication administration records (MAR) dated 11/06/23 to 12/06/23 revealed the resident was receiving Oxycodone (opioid pain medication) 5 milligrams (mg) once every six hours for pain as needed and she had received 12 doses. There was no evidence non-pharmacological interventions were attempted or pain was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to maintain communication with the dialysis center. This affected one resident (#9) of one resident reviewed for dialysis. Findings include: Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, anemia in chronic kidney disease, dependence on renal dialysis, type one diabetes mellitus with unspecified complications, unspecified sequelae of cerebral infarction, dysphagia following cerebral infarction, unspecified severe protein-calorie malnutrition, vitamin D deficiency, unspecified dementia, mild, with other behavioral disturbance, hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, and chronic bronchitis. Review of Resident #9's medical record dated 10/01/2023 to 12/11/23 revealed no evidence of notes from the dialysis center regarding care, diet, or treatments. Review of Resident #9's renal failure plan of care 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 interviews, the facility failed to provide medically related social services to ensure Resident #19 maintained the highest practicable psychosocial well-being. This affected one resident (#19) of one resident reviewed for medically necessary social services. This facility census was 85. Findings include: Record review revealed Resident #19 admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain, pneumonia, hydronephrosis, dementia with agitation, atherosclerotic heart disease with angina, hypertension, cardiac arrhythmia, myocardial infarction, hyperlipidemia, depression, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment completed on 09/28/23 revealed Resident #19 had severely impaired cognition, mild depression, and hallucinations. Review of the physician's orders revealed Resident #19 was ordered lorazepam (antianxiety) 0.5 milligrams (mg) every hour as needed, Paxil (anti-depressant) 30 mg once a day, and Seroquel…

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 facility policy review the facility failed to ensure antibiotic medication to treat an infection for Resident #186 was properly ordered/transcribed following a hospitalization to ensure the resident received all doses ordered of the medication. This affected one resident (#186) of five residents reviewed for medication review. Findings include: Review of the facility November 2023 infection control log revealed Resident #186 was admitted with pneumonia and sepsis that was confirmed by chest x-ray on 10/28/23. The log noted the resident received Rocephin (antibiotic) from 11/08/23 to 11/21/23; (however, the resident was noted to be hospitalized from [DATE] to 11/24/23). Record review revealed Resident #186 was originally admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, pneumonia due to other streptococci (bacteria), severe sepsis with septic shock, pulmonary embolism, pulmonary nodule, and chronic obstructive pulmonary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to ensure pharmacy recommendations made as part of the residents' monthly medication regimen review were addressed by the physician and/or addressed timely. This affected three residents (#4, #19, and #25) of five residents reviewed for unnecessary medications. Findings include: 1. A review of Resident #4's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included unspecified dementia and bipolar disorder. A review of Resident #4's physician's orders revealed he had orders to receive Zyprexa (an antipsychotic medication) 10 milligrams (mg) by mouth twice a day. He also had an order to receive Zyprexa 10 mg intramuscular (IM) every eight hours as needed for severe aggression and agitation. A review of Resident #4's monthly medication regimen reviews revealed the resident's medications were reviewed monthly by the consulting pharmacist since his admission to the facility. Recommendations were made based…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy review and interview the facility failed to ensure Resident #189's pulse (heart rate) was obtained prior to the administration of Digoxin, a cardiac glycoside medication, as ordered by the physician to ensure the medication was only administered when necessary. This affected one resident (#189) of three residents observed for medication administration. The facility census was 85. Findings included: Review of Resident #189's medical record revealed he was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke) due to thrombosis, hypertensive heart disease with heart failure, acute systolic (congestive) heart failure, and cardiomyopathy. Review of Resident #189's five day Minimum Data Set (MDS) 3.0 assessment, dated 11/30/23, revealed he was mildly cognitively impaired. Review of Resident #189's physician's orders revealed an order, dated 11/28/23, for Digoxin (a cardiac glycoside that enhances the contractility of the heart, but…

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, review of a medication error report, staff interview, and policy review, the facility failed to ensure Abnormal Involuntary Movement Scale (AIMS) assessments were performed on a resident receiving antipsychotic medications to identify any side effects related to their use. They also failed to ensure a resident did not receive an extra dose of an anti-anxiety medication that was outside the orders given by the physician. This affected two residents (#4 and #28) of five residents reviewed for unnecessary medications. Findings include: 1. A review of Resident #4's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included unspecified dementia and bipolar disorder. A review of Resident #4's physician's orders revealed he had an order to receive Zyprexa (an antipsychotic medication) 10 milligrams (mg) by mouth (po) twice a day (BID). The order had been in place since 07/31/23. Resident #4's electronic medical record (EMR) was absent for any evidence of an AIMS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident record review, policy review and interview the facility failed to maintain a medication error rate of less than five (5) percent (%). The medication error rate was calculated to be 7.69% and included three medication errors of 39 medication administration opportunities. The facility also failed to ensure inhalation medications were administered following manufacturer recommendations for proper use and to prevent compliacations. This affected three residents (#39, #66, and #189) of three residents observed for medication administration. The facility census was 85. Findings included: 1. Review of Resident #189's medical record revealed he was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke) due to thrombosis, hypertensive heart disease with heart failure, acute systolic (congestive) heart failure, and cardiomyopathy. Review of Resident #189's five day Minimum Data Set (MDS) 3.0 assessment, dated 11/30/23, revealed he was mildly cognitively…

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 appropriately communicate dental concerns involving Resident #30. This affected one resident (#30) of four residents reviewed for dental services. The facility census was 85. Findings included: Review of Resident #30's medical record revealed she was admitted to the facility on [DATE] with diagnoses including major depressive disorder, single episode, adjustment disorder, suicide attempt, suicidal ideations, generalized anxiety disorder, unspecified atrial fibrillation, and essential hypertension. Review of Resident #30's quarterly Minimum Data Set (MDS) dated [DATE], revealed she was cognitively intact and did not have any broken or loosely fitting full or partial dentures, or mouth or facial pain. Review of Resident #30's physician orders, dated 07/06/23 revealed the resident may see a dentist as needed. Review of Resident #30's progress note, dated 11/09/23 and documented by Registered Dietitian (RD) #220, revealed Resident #30 reported some dental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and facility policy and procedure review the facility failed to ensure resident financial accounts were maintained within the appropriate limits. This affected two residents (#25 and #43) of six residents whose financial records were reviewed. Findings Include: Review of current state Medicaid resident trust guidelines revealed each resident who utilized Medicaid may not keep more than $2000.00 in a trust account. Also, the same guidelines confirmed the COVID-19 stimulus checks (three total) did not count as monthly income; so it would not affect a resident's medical coverage. However, a resident who utilized Medicaid and received stimulus payment(s) had 12 months to spend that money from the time they received it to stay within the allowable limit. Review of federal COVID-19 stimulus documentation revealed three different economic impact payments made to eligible persons. The following were the dates and payment amounts for individuals: $1200 in April 2020, $600 in…

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 pharmacy recommendations were timely and appropriately addressed. This affected four residents (#29, #322, #36 and #62) of six residents reviewed for unnecessary medication use. Findings Include: 1. Resident #29 was admitted to the facility on [DATE] with diagnoses including hypertensive heart and chronic kidney disease, type II diabetes, chronic kidney disease, congestive heart failure, psychosis (08/20/20), hyperlipidemia, peripheral vascular disease, Meniere's disease, Anxiety disorder (03/10/21), dependence on supplemental oxygen, cardiomyopathy, dysphagia, difficulty walking, chronic obstructive pulmonary disease, hydrocephalus, other specified depressive episodes, and old myocardial infarction. Review of Resident #29's medical records revealed a pharmacy recommendation, dated 06/23/21 to review the following medications to consider the benefit/need of them: Haloperidol 0.5 milligrams (mg) twice daily, Ativan 0.5 mg three times daily,…

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

Based on record review, staff interview and facility policy review the facility failed to ensure Resident #27's bathing preference for showers was honored. This affected one resident (#27) of one resident reviewed for choices. Findings Include: Review of Resident #27's medical record revealed an admission date of 06/08/21 with diagnoses including COVID-19, chronic obstructive pulmonary disease, protein calorie malnutrition, cardiomegaly, severe morbid obesity, obstructive and reflux uropathy, hydronephrosis, hypothyroidism, bipolar disorder, major depressive disorder, obstructive sleep apnea, hypertension, adult failure to thrive and generalized muscle weakness. Review of the life enrichment assessment, dated 06/09/21 it was somewhat important for the resident to choose the type of bathing she received. The assessment indicated she preferred showers. Review of the plan of care, dated 06/22/21 revealed the resident required staff assistance to complete activities of daily living (ADL) tasks completely and safely. Interventions included allow resident sufficient time to complete all…

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 a beneficiary notice was provided to Resident #70 in a timely manner. This affected one resident (#70) of three residents reviewed for beneficiary notices. Findings Include: Resident #70 was admitted to the facility on [DATE] with diagnoses including encephalopathy, nontraumatic intracerebral hemorrhage, hypertensive emergency, atrial fibrillation, chronic kidney disease, cardiomegaly, benign prostatic hyperplasia, osteoarthritis, coagulation defect, age related physical debility, hypertension, hyperlipidemia and cerebral infarction. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 02/13/22 revealed Resident #70 had intact cognition. Review of Resident #70's beneficiary notice, dated 03/01/22 revealed his last day of covered of rehabilitation and skilled nursing services was on 03/01/22. Resident #70 was presented the beneficiary notice and was told about his last day of covered services on 03/01/22, when he signed that form…

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 Resident #29's Preadmission Screening and Resident Review (PASARR) was accurate at the time of the resident's admission. This affected one resident (#29) of two residents reviewed for PASARR. Findings Include: Resident #29 was admitted to the facility on [DATE] with diagnoses including hypertensive heart and chronic kidney disease, type II diabetes mellitus, chronic kidney disease, congestive heart failure, psychosis (08/20/20), hyperlipidemia, peripheral vascular disease, Meniere's disease, anxiety disorder (03/10/21), dependence on supplemental oxygen, cardiomyopathy, dysphagia, difficulty walking, chronic obstructive pulmonary disease, hydrocephalus, other specified depressive episodes and old myocardial infarction. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/28/22 revealed the resident was cognitively intact. Review of Resident #29's PASARR document, dated 08/10/20, revealed under section D, titled Indications of…

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

Based on observation, record review, interview and facility policy review the facility failed to ensure Resident #27, Resident #31 and Resident #46, who required staff assistance for activity of daily living (ADL) care received adequate and timely assistance with showers, dressing and/or oral care to maintain proper grooming and hygiene. This affected three residents (#27, #31 and #46) of six residents reviewed for ADL care. Findings Include: 1. Review of Resident #27's medical record revealed an admission date of 06/08/21 with diagnoses including COVID-19, chronic obstructive pulmonary disease, protein calorie malnutrition, cardiomegaly, severe morbid obesity, obstructive and reflux uropathy, hydronephrosis, hypothyroidism, bipolar disorder, major depressive disorder, obstructive sleep apnea, hypertension, adult failure to thrive and generalized muscle weakness. Review of the life enrichment assessment, dated 06/09/21 revealed it was somewhat important for the resident to choose the type of bathing she received. The assessment indicated she preferred showers. Review of the plan of…

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

Based on observation, record review, interview and facility policy and procedure review the facility failed to ensure comprehensive and individualized collaboration of care with the Hospice provider for Resident #31 including changes to guardianship and advance directives and failed to ensure a skin tear and bruising was monitored and treated. This affected one resident (#31) of one resident reviewed for Hospice services and non-pressure related skin conditions. Findings Include: Review of Resident #31's medical record revealed an admission date of 06/27/20 with the admitting diagnoses of dementia with Lewy bodies, COVID-19, heart failure, anxiety disorder, major depressive disorder, psychosis, obstructive sleep apnea, gastro-esophageal reflux disease, osteoarthritis, restlessness and agitation, constipation and dysphagia. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/04/22 revealed the resident's cognition was not assessed. Review of the mood and behavior section revealed the resident displayed no behaviors. The assessment revealed the 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.

Based on observation, record review, interview and facility policy and procedure review the facility failed to ensure interventions were in place to prevent falls for Resident #23. This affected one resident (#23) of six residents reviewed for accidents. Findings Include: Review of Resident #23's medical record revealed an admission date of 12/13/21 with diagnoses including vascular dementia without behavioral disturbances, psychosis and repeated falls. Review of the plan of care, initiated 12/24/21 revealed the resident was at risk for falls related to being unsteady at times, dementia and medications. Interventions included a Dycem (a non-slip, rubber-like plastic material used to stabilize surfaces) to the seat of the resident's wheelchair implemented on 04/06/22. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/02/22 revealed the resident had impaired memory and required extensive assistance of one staff member with bed mobility, dressing, toilet use and personal hygiene. The resident required limited assistance of one staff member with transfers. 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, meal ticket review and facility policy and procedure review the facility failed to ensure Resident #1 and Resident #36 were provided a diet as ordered during the dinner meal on 04/13/22 and failed to ensure weights were documented in the electronic health record and weight loss was reported timely to the dietician as necessary for Resident #11. This affected three residents (#1, #11 and #36) of five residents reviewed for nutrition. Findings include: 1. Review of Resident #1's medical record revealed an admission date of 12/15/21 with diagnoses including Parkinson's Disease, Alzheimer's Disease and chronic obstructive pulmonary disease. Review of the physician's orders revealed the resident had an order (initiated 12/15/21) for a regular, pureed diet with double portions and nectar thickened liquids at meals. Review of the plan of care revealed the resident was malnourished/nutritional risk related to diagnosis, inadequate nutrient/energy intakes and/or metabolic…

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 psychotropic medications were only administered to residents with clinical justification and as needed psychotropic medications were evaluated for duration of use. This affected three residents (#32, #62 and #272) of six residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #36's medical record revealed an admission date of 06/23/18 with diagnoses including heart disease, Alzheimer's Disease, dementia without behavioral disturbance, psychosis, anxiety and cancer of the large intestine. Review of the physician's orders revealed an order (initiated 07/01/21) for the medication Ativan (antianxiety) 0.5 milligrams (mg) twice a day and Ativan 2 mg per milliliter (ml) give 0.5 mg every four hours as needed for restlessness and anxiety. The order for the as needed doses of Ativan did not have a duration indicated. On 04/14/22 at 11:52 A.M. interview with Regional Nurse #200 verified the order for as needed Ativan…

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, staff interview and facility policy and procedure review the facility failed to ensure fluids were readily available for Resident #31 for independent fluid consumption. This affected one resident (#31) of two residents reviewed for hydration. Findings Include: Review of Resident #31's medical record revealed an admission date of 06/27/20 with the admitting diagnoses of dementia with Lewy bodies, COVID-19, heart failure, anxiety disorder, major depressive disorder, psychosis, obstructive sleep apnea, gastroesophageal reflux disease, osteoarthritis, restlessness and agitation, constipation and dysphagia. Review of the plan of care, dated 11/19/21 revealed the resident was on hospice with potential for unavoidable weight loss and nutritional decline and wanted to remain comfortable. Interventions included allow resident to eat and drink as able or as desired, offer alternate and substitute items if needed and weigh monthly or as ordered by physician. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/04/22 revealed…

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