Sycamore Trails Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to update resident care plan to include a resident's possession and suspected use of illegal substances. This affected one (#54) of three residents reviewed for care planning. The facility census was 80. Findings include: Review of medical record for Resident #54 revealed admission date of 10/23/24 admitted to hospice on 11/22/23. Diagnoses including cirrhosis of the liver, chronic obstructive pulmonary disease, anemia, depression and history of cocaine abuse. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #54 required extensive one person assistance for toileting and supervision for bed mobility, eating and transfers. A brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. Review of the progress note dated 03/10/24 revealed staff had found a plastic baggie with an unknown substance lying on the floor next to the bed. The Director of Nursing (DON) was informed. Review of the progress notes revealed 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, observation, staff and resident interviews, the facility failed to ensure treatments orders were completed as ordered. This affected one (#55) of three residents reviewed for implementation of treatments. The facility census was 80. Findings include: Review of medical record for Resident #55 revealed admission date of 01/16/24. Diagnoses include congestive heart failure, type two diabetes mellitus, and depression. Additional diagnosis added on 04/25/24 of aftercare following surgical amputation, left below the knee amputation and history of Methicillin Resistant Staphylococcus Aureus. The resident remained in the facility. Review of Resident #55's admission Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. Resident #55 required extensive two-person assistance for bed mobility, transfers, toileting and supervision for eating. A care plan for an alteration in skin integrity to the left below knee…

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, physician and pharmacy staff interviews, the facility failed to ensure medications were administered as physician ordered. This affected two (#134 and #55) of three residents reviewed for medication administration. The facility census was 80. Findings include: 1. Review of medical record for Resident #134 revealed admission date of 11/23/23. Diagnoses include paraplegia and schizophrenia, depression and anxiety. Resident #134 remains in the facility. Review of Resident #134's annual Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. Resident #134 required extensive two-person assistance for bed mobility, transfers and supervision for eating. Review of the physician orders revealed an order for Estrogens Conjugated Vaginal Cream 0.625 Milligrams/Gram. Insert 0.5 Grams vaginally one time a day for vaginal dryness. Review of medication administration record (MAR) and the progress note dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, medication administration time review, and policy review, the facility failed to administer physician ordered medications and ensure medications were timely order to have available for administration. This affected four #21, #41, #58 and #63 of eight residents reviewed for medication administration. The facility census was 79. Findings include: 1. Review of medical record for Resident #21 revealed an admission date of 11/23/18, with diagnoses of other seizures, epilepsy, intractable, without status epilepticus, and hemiplegia, chronic obstructive pulmonary disease and unspecified affecting left nondominant side. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #21 was cognitively intact. Review of physician orders dated 11/14/23, to administer Oxcarbazepine tablet, 300 milligrams (mg), give 2 tablets by mouth at bedtime for epilepsy and give 1 tablet by mouth, one time a day for epilepsy; Pepcid tablet (famotidine) 20 mg,…

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 and resident interviews, review of staffing records/schedules and policy review, the facility failed to provide timely Activities of Daily Living (ADL's) assistance. This affected one (#11) out of three residents reviewed for ADL assistance and had the potential to affect 21 (#11, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34) residents on the 300 and top of the 100 hallway assignment. The facility census was 82. Findings include: Review of medical record for Resident #11 revealed admission date of 05/27/22 with a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition on The resident was admitted with diagnoses including anxiety, depression, sleep apnea and stage three kidney disease. The resident remains in the facility. The quarterly Minimum Data Set (MDS) dated [DATE] revealed she required extensive two-person assistance for transfers, toileting, one person assistance for bed mobility and supervision 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, staff and resident interviews, review of staffing records/schedules and policy review, the facility failed to ensure there was sufficient staffing to provide timely assistance with Activities of Daily Living (ADL's). This affected one (#11) out of three residents reviewed for ADL assistance and had the potential to affect 21 (#11, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34) residents on the 300 and top of the 100 hallway assignment. The facility census was 82. Findings include: Review of medical record for Resident #11 revealed admission date of 05/27/22 with a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition on The resident was admitted with diagnoses including anxiety, depression, sleep apnea and stage three kidney disease. The resident remains in the facility. The quarterly Minimum Data Set (MDS) dated [DATE] revealed she required extensive two-person assistance for transfers, toileting, one person…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interviews and policy review, the facility failed to ensure infection control procedures were followed during wound care. This affected one (#14) of three residents reviewed for wound care. Facility census was 82. Findings include: Review of medical record for Resident #14 revealed admission date of 03/10/24. Diagnoses include diabetes mellitus type two, necrotizing fasciitis, acute osteomyelitis left ankle and foot. The resident remains at the facility. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #14 had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. Resident #14 required extensive one person assistance for toileting and supervision for eating, bed mobility and transfers. Review of Resident #14's physician orders revealed an order to cleanse wound with normal saline, pat dry with non-sterile gauze and reapply wound vacuum negative pressure on Mondays, Wednesdays and Fridays with a start date of 03/25/24. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of controlled substance records, staff interview, and review of facility policy, the facility failed to ensure a resident's narcotic medication administration was accurately documented in the medical record. This affected #81 of three residents reviewed. The census was 78. Findings include: Review of Resident #59's medical record revealed an admission date of 09/19/23. Diagnoses included end stage renal disease, hypertensive heart failure, hemiplegia, type two diabetes mellitus, and chronic leg ulcer. Review of a quarterly Minimum data Set (MDS) assessment dated [DATE] revealed Resident #59 was severely cognitively impaired. Review of physician orders revealed an order dated 11/02/23 for Percocet (narcotic pain medication oxycodone and acetaminophen) five and 325 milligrams (5-325 mg) give 5-325 every four hour as needed (PRN) for pain. Give every four hours PRN for general discomfort repositioning, relaxation, distraction and comfort measures provided and ineffective.…

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

Based on observation, staff interview, and policy review, the facility failed to properly prepare medications for administration. This affected six (#9, #14, #47, #26, #51, #44) out of six residents reviewed for medication administration. The census was 57. Findings include: Observation of Licensed Practical Nurse (LPN) #136's medication cart on 08/31/23 at 6:42 A.M. revealed there were six medication cups stacked on top of each other with names on each cup (Resident 9, #14, #47, #26, #51, and #44). Each of the medication cups contained pre-poured medications. Interview with LPN #136 on 08/31/23 at 6:45 A.M. confirmed she had pre-poured the six resident's (#9, #14, #47, #26, #51, #44) medications. She indicated she was not aware she shouldn't pre-pour the medications for the residents. Review of the policy titled Medication Administration, dated 11/01/21, revealed when medications are administered by mobile cart taken to the resident's location (room, dining area, etc.) medications are administered at the time they are prepared. Medications are not pre poured either in advance 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 medical record review, observation, and staff interview, the facility failed to ensure residents received enteral feeding as ordered. This affected one (#28) out of three residents reviewed for enteral feeding. The facility identified a total of three residents who required enteral feeding. The census was 57. Findings include: Review of medical record for Resident #28 revealed an admission date of 03/05/20. Resident #28's medical diagnoses included lymphoma, atrial fibrillation, diabetes, and cerebrovascular accident. Review of Resident #28's annual Minimum Data Set (MDS) assessment, dated 07/12/23, revealed Resident #28 was severely cognitively impaired. Resident #28's functional status was extensive assistance for bed mobility and total dependence for transfers and eating. Resident #28 was coded as having a feeding tube. Review of Resident #28's physician orders, dated 08/25/23, revealed an order for Jevity 1.2 calories to infuse at 60 milliliters (ml) an hour (hr) times 24 hours via G-tube (feeding tube). Observation of the G-tube for Resident #28 on 08/30/23 at 11:02…

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, staff and resident interview, and policy review, the facility failed to ensure residents received meals as preferred and requested. This affected three (#24, #25, and #48) out of three residents reviewed for meal preferences. The census was 57. Findings include: 1. Medical record review for Resident #24 revealed an admission date of 01/10/14. Resident #24's medical diagnoses included epilepsy and non-Alzheimer's dementia. Review of Resident #24's quarterly Minimum Data Set (MDS) assessment, dated 08/09/23, revealed Resident #24 was moderately cognitively impaired. He required supervision for eating. Review of the menu for 08/30/23 revealed breakfast was to consist of a westem omelet, hash browns, wheat toast, margarine, and jelly. The lunch meal was to consist of baked tilapia, buttered noodles, peas and carrots, wheat bread, margarine, banana and strawberries. Review of the breakfast meal ticket for Resident #24 on 08/30/23 at 8:10 A.M. revealed it said one salt, one pepper, 3/4 cup of cold cereal, four ounces of assorted juice, eight…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to conduct initial and quarterly care conferences. This affected four (Residents #173, #174, #33, and #14) of six residents reviewed for care conferences. Additionally, the facility failed to update residents care plans. This affected two (Residents #24 and #34) of six residents reviewed for care planning. The facility census was 72. Findings include: 1. Review of Resident #173's medical record revealed an admission date of 07/26/22. Diagnoses included type II diabetes mellitus, schizophrenia, bipolar disorder, and pneumonia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #172 was cognitively intact. Further review revealed no documentation of Resident #173 having an initial care conference with staff members. A comprehensive care plan was initiated on 08/09/22. 2. Review of Resident #174's medical record revealed an admission date of 08/02/22.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, resident interview, and review of facility policy, the facility failed to provide adequate grooming services for two (Residents #60 and #2) of two reviewed for grooming. Additionally, the facility failed to ensure residents received scheduled/preferred showers. This affected three (Residents #33, #14, and #46) of three residents review for bathing. The census was 72. Findings included: 1. Medical record review for Resident #60 revealed an admission date of 05/31/19. Medical diagnoses included cerebrovascular attack (CVA), seizure disorder, and respiratory failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was rarely or never understood and required extensive assistance with bed mobility, transfers, personal hygiene, and toileting. Resident #60 was totally dependent upon staff for bathing and was frequently incontinent of urine and stool. Review of Resident #60's care plan dated 05/09/22 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview and policy review, the facility failed to ensure a root cause analysis was completed on a resident who suffered a fall with a fracture. This affected one (Resident #62) of four residents reviewed for falls. The facility also failed to ensure water temperatures in resident rooms were below 120 degrees Fahrenheit (F). This had the potential to affect 57 (Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #12, #14, #15, #16, #17, #18, #19, #21, #22, #23, #24, #26, #27, #29, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #43, #44, #45, #46, #47, #48, #50, #51, #52, #53, #54, #55, #56, #57, #59, #60, #61, #62, #63, #64, #65, #67 and #68) residents who resided on the 100, 200 and 300 halls. The census was 72. Findings include: 1. Record review revealed Resident #62 was admitted to the facility in 2013. Diagnoses included epilepsy, chronic respiratory failure, cardiac arrest, and dysphagia. Review of the care plan dated 01/11/22 revealed Resident #62 had urinary…

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

Based on interview, observation and record review, the facility failed to ensure food was properly stored in the refrigerator, freezer, and dry storage areas. This affected all residents except Residents #51 #60 and #63 who do not eat food from the kitchen. The census was 72. Findings include During observation of the dry storage area on 08/15/22 at 8:44 A.M., there was a bag of gravy and a bag of oats in that had expiration dates of 07/30/22. Bags of dry pasta (spiral, macaroni and bowtie) was left open to air and undated. In the freezer, a bag filled with balls of raw cookie dough was left open to air and undated and a bag of breakfast sausage patties was left undated. In the refrigerator, a sheet cake of carrot cake and a sheet cake of yellow cake were not fully covered, chicken in what appeared to be barbeque sauce in Tupperware was left undated, sliced cucumber and lunch meat were found to be undated. During interview on 08/15/22 at 8:44 A.M., Kitchen Manager #228 confirmed all above findings regarding food storage. Review of facility policy titled Food Storage, dated November…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and resident interview, the facility failed to timely respond to a resident's request to return to bed and use the bed pan. This affected one (Resident #46) of two residents reviewed for accommodations of needs and dignity. Additionally, facility failed to ensure residents were able to eat meals in the dining room. This affected all residents accept Residents #51, #60 and #63 who did not eat food from the kitchen. The census was 72. Findings include: Medical record review for Resident #46 revealed an admission date of 12/19/20. Medical diagnoses included arthritis due to bacteria in the right hip, diabetes, osteomyelitis unspecified site and chronic respiratory failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 was cognitively intact and required extensive assistance with bed mobility, transfers, and personal hygiene. The resident was occasionally incontinent of urine and always continent of bowel.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to notify a resident's representative of changes in condition that required physician intervention. This affected two (Residents #62 and #34) of two residents reviewed for notification for change in condition. The census was 72. Findings include: 1. Record review revealed Resident #62 was admitted on [DATE]. Medical diagnoses included epilepsy, chronic respiratory failure, cardiac arrest, and dysphagia. Review of progress notes dated 08/08/22 revealed Resident #62 was found on the floor in his bathroom attempting to transfer himself from the toilet to the wheelchair. Vital signs were within normal limits but he complained of pain to his right elbow. The physician was texted and awaiting reply. Neurological checks were initiated. There was no documentation the resident's representative was notified. Review of fall investigation dated 08/08/22 revealed Resident #62 was assisted to the toilet by staff and reminded to use the call light when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide ongoing re-evaluation for the need of a seatbelt/restraint and failed to initiate a care plan with interventions for the use of a seatbelt/restraint. This affected one (Resident #62) of one resident reviewed for physical restraints. The facility census was 72. Findings included: Medical record review for Resident #62 revealed an admission date 12/17/13. Medical diagnoses included epilepsy, chronic respiratory failure, cardiac arrest, and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was moderately cognitively impaired and required extensive assistance with bed mobility, transfers, and toileting. Review of Resident #62's physician orders revealed an order dated 01/23/21 to place a seatbelt when seated in wheelchair. Review of Resident #62's care plan dated 01/22/22 revealed the resident was at risk for falls with an intervention in place 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 interview and record review, facility failed to ensure residents received requested vision services. This affected one (Resident #55) of two residents reviewed for vision services. Facility census was 72. Findings include: Record review revealed Resident #55 was admitted on [DATE]. Diagnoses included heart failure, diabetes type two, end stage renal disease on dialysis, anemia and hypertension. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was cognitively intact and was independent with set up assistance. The resident did not wear corrective lenses. During interview on 08/15/22 at 4:33 P.M., Resident #55 revealed he had not seen the eye doctor and would like to see someone about getting glasses. He said he had asked several nurses and spoke with the social worker about getting an appointment but had not heard an update. During interview on 08/17/22 at 10:33 A.M., the Administrator and Social Services Staff (SS) #118 confirmed Resident's #55 had requested to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, review of facility policy, and review of manufacturer's guidelines, the facility failed to ensure medications were stored and labeled properly. This affected two (Residents #6 and #25) of five residents reviewed for medications. The census was 72. Findings included: 1. Record review revealed Resident #6 was admitted on [DATE]. During observation 08/15/22 at 10:32 A.M., revealed there was a cup of medication pills sitting on Resident #6's bedside table. During interview on 08/15/22 at 10:36 A.M., Licensed Practical Nurse (LPN) #109 confirmed the medicine cup of pills for Resident #6 was sitting on the bedside table. She stated the resident was slow to take her medications and that was why she left them at the bedside. She stated the resident had been assessed to take her own medications. Review of the medical record revealed no assessments stating Resident #6 could self administer medications. During interview on 08/15/22 at 10:40 A.M., Infection…

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 interview, the facility failed to provide adaptive equipment during meal service. This affected one (Resident #62) of one resident reviewed for adaptive equipment. The census was 72. Findings included: Record review revealed Resident #62 was admitted on [DATE]. Medical diagnoses included epilepsy, chronic respiratory failure, cardiac arrest, and dysphagia. Review of the care plan dated 01/11/22 revealed Resident #62 was at risk for altered nutritional status including but not limited to respiratory failure, cardiac arrest, history of anoxic brain injury. He needed adaptive equipment, and assistance at meals. Interventions were for adaptive equipment with elevated lip and suction bowels, built up silverware and sippy cup. Encourage and assist as needed to consume foods and no straws. Review of annual Minimum Data Set (MDS) assessment, dated 07/27/22 revealed Resident #62 was moderately cognitively impaired. He required supervision for eating with one person physical…

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 personal funds account balances, facility surety bond, and interview, the facility failed to ensure the surety bond was sufficient to cover account balances. This had the potential to affect 38 Residents (#2, #5, #8, #11, #16, #18, #19, #20, #22, #25, #27, #28, #30, #32, #33, #35, #36, #37, #38, #39, #43, #46, #48, #50, #57, #62, #63, #64, #66, #67, #70, #71, #73, #77, #81, #87, #90, and #92) whom had a personal funds account managed by the facility. Facility census was 104. Findings include: Review of trial balance of all residents personal fund accounts managed by the facility revealed a total balance of $24,706.83 on 07/11/19. Review of facility surety bond dated 09/01/18 revealed a bond amount of $20,000.00 to cover resident trust funds. Interview on 07/12/19 at 11:27 A.M. with business office manager (BOM) #30 confirmed the surety bond was not sufficient to cover resident personal fund accounts as the account balances exceeded the amount of the surety bond. The facility confirmed the insufficient surety bond had the potential to affect 38 Residents (#2, #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 record review and interview, the facility failed to ensure the ombudsman, residents and/or their representatives were notified of transfer or discharge in writing. This affected five (#3, #22, #68, #92 and #100) of five residents reviewed. The facility census was 104. Findings include: 1. Resident #3 was admitted to the facility [DATE]. Review of the progress notes dated [DATE] revealed Resident #3 was being sent to a local hospital for suicidal ideations. 2. Resident #100 was admitted to the facility on [DATE]. The resident was sent out to local hospital on [DATE] for a blood transfusion from a gastrointestinal bleed and expired on [DATE] at the hospital. 3. Record review revealed Resident #92 was admitted on [DATE]. Review of progress notes dated [DATE] revealed the resident returned from the hospital at 10:29 A.M., but was transferred to the hospital again at 10:48 P.M. Further review of the medical record revealed there was a a transfer/discharge form but it didn't have the correct components…

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

Based on observation, staff interview, record review, and review of Food From Outside Sources and In-Room Refrigerators Policy, the facility failed to ensure food items were properly labeled, covered, discarded and the pantry refrigerator was maintained at an acceptable temperature. This had the potential to affect 68 residents (#2, #3, #4, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #22, #23, #24, #25, #27, #28, #29, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #42, #43, #44, #46, #47, #48, #50, #51, #54, #56, #58, #59, #62, #64, #65, #66, #67, #68, #69, #71, #73, #74, #77, #79, #81, #82, #85, #90, #95, #96, #97, #150, #250) whom resided on the 100, 200, and 300 halls. The facility census was 104. Findings include: Observation on 07/11/19 at 3:02 P.M. of the refrigerator located on the 300 hall for residents whom resided on the 100, 200, and 300 halls revealed a temperature of 54 degrees Fahrenheit (F), a plastic bag of deli sliced meat dated 05/15/19 for Resident #24, a lunch tray with an uncovered dessert dated 07/11/19 for Resident #23, one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff and resident interview, the facility failed to ensure a resident was provided dignity when staff placed her name on the front of her shirt. This affected one (#33) of one resident reviewed for dignity. The census was 104. Findings included: Medical record review for Resident #33 revealed an admission date of 08/10/18. Medical diagnoses included heart failure, peripheral vascular disease, and dementia. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #33 was cognitively intact. Her functional status was extensive assistance for bed mobility, transfers, toileting use and she was supervision for eating. Observation of Resident #33 in the hallway, in her wheelchair, on 07/09/19 at 3:35 P.M. revealed she had a pink shirt on, with her first name printed in big black letters on the front of the shirt. Interview on 07/09/19 at 3:39 P.M. with Resident #33 revealed she didn't like her name printed on the front of shirt, but said what am I going 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 complete a Pre admission Screen and Record Review (PASARR) when a resident was diagnosed with a mental illness. This affected one (#2) of one resident reviewed for PASARR. The facility census was 104. Findings include: Review of Resident #2's medical record revealed the resident had a PASARR screening completed on 02/18/16 indicating the resident had no indication of serious mental illness nor a developmental disability. The resident was admitted to the facility on [DATE]. On 03/14/18 the resident was diagnosed with unspecified psychosis not due to a substance or known physiological condition, and on 12/11/18 the resident was diagnosed with anxiety disorder. Review of most recent quarterly Minimum Data Set (MDS) assessment revealed the resident was not cognitively intact, had hallucinations, but no other behaviors. The resident was coded as receiving seven days of anti-psychotic and anti-depressant medication and one day of anti-anxiety medication.…

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 timely provide baseline care plans to resident's and/or their responsible party. This affected one (#43) of 13 residents reviewed for baseline care plans. The total facility census was 104. Findings include: Review of Resident #43's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include hemiplegia, dysphagia, anxiety, depression, insomnia, weakness, hypertension, gastro esophageal reflux disease, hyperlipidemia, chronic obstructive pulmonary disease, alcoholic hepatitis without ascities, iron deficiency anemia, history of falling and history of transient ischemic attack. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, vision and hearing were adequate without assistive devices, had no dental problems. The resident had no behaviors, delusions or hallucinations during the review period. The medical record contained no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to timely review and revise a resident's comprehensive care plans to ensure the care plan accurately reflected the residents status and care needs. This affected one (#12) of 28 resident care plans reviewed during the survey. The total facility census was 104. Findings include: Review of Resident #12's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, hypokalemia, aphasia, falls, partial traumatic amputation of left lower leg, hypoxemia, weakness, hypertension, hyperlipidemia, anemia, chronic ischemic heart disease, peripheral vascular disease, history of transient ischemic attack, nicotine dependence, vitamin D deficiency, hemiplegia and hemiparesis following cerebral infarction, and visual loss. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was alert and oriented, had no delusions, hallucinations, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and staff and resident interview the facility failed to ensure water that was accessible to residents was at an acceptable temperature. This affected one (#11) of one resident reviewed for accidents. The total facility census was 104. Findings include: Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included diabetes mellitus, anemia, irritable bowel syndrome, heart failure, gout, depression, hypertension, obesity, hereditary idiopathic neuropathy, atrial fibrillation, depression, dementia, lack of coordination, and age related debility. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired, had no delusions, hallucinations or behaviors including rejection of care. The resident required extensive assist for all care from staff including eating. The resident was frequently incontinent of both bowel and bladder. The resident was coded 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 observations, medical record review, staff and resident interview and policy review, the facility failed to properly manage Resident #41's pain while providing tracheostomy care. This affected one (#41) of four residents reviewed for pain management program. The facility identified 74 residents who were on a pain management program. Facility census was 104. Findings included: Medical record review for Resident #41 revealed an admission of 05/16/19. Her medical diagnoses included heart failure, neurogenic bladder, quadriplegia, and respiratory failure. Review of admission Minimum Data Assessment (MDS) dated [DATE] revealed Resident #41 was cognitively intact. Her functional status was extensive assistance for bed mobility, eating and toilet use and transfers only occurred once or twice. She was coded for the use of oxygen, suctioning, and tracheostomy care. Review of physician orders for Resident #41 dated 05/17/19 revealed orders for Tylenol Tablet 325 milligram (mg) give every six hours as needed for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure a residents narcotic pain medication was reordered timely. This affected one (#54) of four residents reviewed for pain management program. The facility identified 74 residents who were on a pain management program. Facility census was 104. Findings include: Review of Resident #54's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure with hypercapnia, idiopathic peripheral autonomic neuropathy, end stage renal disease, congestive heart failure, diabetes mellitus, and dependence on renal dialysis. Review of Resident #54's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 was cognitively intact. Her functional status was listed as extensive one person assists for activities of daily living. Review of the physician orders dated 05/27/19 revealed an order for: Hydrocodone- Acetaminophen tablet 5-325 milligrams (mg) give one tablet by mouth every 12…

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 facility staff interview the facility failed to timely respond to pharmacy recommendations, this affected one (#2) of five residents reviewed for unnecessary medications. The total facility census was 104. Findings Include: Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of weakness, shortness of breath, dyspnea, idiopathic peripheral autonomic neuropathy, hypertension, osteoarthritis, depression, constipation, chronic obstructive pulmonary disease, glaucoma repeated falls and hyperlipidemia. Review of the most recent quarterly Minimum Data Set revealed the resident was cognitively impaired, had hallucinations, but no other behaviors. The resident required extensive assist for bed mobility, transfers, dressing, toileting and was supervision for eating. The resident was always incontinent of bowel and bladder. The resident was on a mechanically altered therapeutic diet. Resident #2 was coded as receiving seven days 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 and staff interview, the facility failed to store medications as per manufacturer recommendation for Resident #32. This affected one of four medication carts observed. The facility has seven medication carts. Findings Include: Observation of 200-1 medication cart with Licensed Practical Nurse (LPN) #79 on 07/12/19 at 1:41 P.M. revealed Latanoprost 125 micrograms (mcg.)/25 milliliters (ml.) ophthalmic solution was undated. LPN #79 confirmed there was no date on the bottle and the resident was ordered to have the medication at bedtime with the dose for administration being one drop to each eye. LPN #79 confirmed the medication was initially ordered in April 2019 and the facility re-ordered the medication in May 2019 and no medication had been ordered since May 2019. The LPN verified there was no way to determine how long the bottle of ophthalmic solution had been in use, and should be discarded. Review of the package insert for Latanoprost ophthalmic solution revealed under storage: protect from light, once a bottle is opened for use, it may be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility to ensure a resident with missing dentures was referred to a dentist for treatment. This affected one (Resident #41) of three reviewed for personal property. The census was 104. Findings include: Medical record review for Resident #41 revealed an admission of 05/16/19. Review of the admission Minimum Data Assessment (MDS) assessment dated [DATE] revealed Resident #41 was cognitively intact. Review of progress notes from 06/09/19 through 07/09/19 for Resident #41 revealed no documentation the resident had missing dentures. Interview with the resident's family on 07/09/19 at 10:38 A.M. revealed the resident's dentures had been missing for about three weeks and he reported it to Licensed Social Worker (LSW) #12. LSW #121 went on vacation and whoever was filling in for him couldn't find anything in the medical record he had spoken to anyone about the missing dentures. Interview with LSW #121 on 07/10/19 at 1:38 P.M. revealed the family did speak to him…

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, staff interview and policy review, the facility failed to ensure staff washed their hands after providing care to a resident who was in isolation for Clostridium difficile (C-diff). This affected one (#41) of one resident reviewed for handwashing in C-diff isolation. The facility identified only one resident (#41) in C-diff isolation. The census was 104 Findings include: Medical record review for Resident #41 revealed an admission of 05/16/19. Diagnoses included heart failure, neurogenic bladder, C-diff and respiratory failure. Review of admission Minimum Data Assessment (MDS) assessment, dated 05/23/19, revealed Resident #41 was cognitively intact and had a tracheostomy. Observation of suctioning for Resident #41 on 07/09/19 at 11:01 A.M. revealed Licensed Practical Nurse (LPN) #78 was performing suctioning care and after she completed it she used the hand sanitizer that was on the wall and left the room. Interview with LPN #78 on 07/09/19 at 11:39 A.M. verified she should have washed her hands with soap and water since 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.