Overbrook Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of Medicare (MCR) liability notice letters, and staff interview, the facility failed to ensure residents, whose skilled nursing services ended with days remaining, received at least a 48 hour notice of their skilled service ending prior to their last covered day. They also failed to ensure those residents, whose skilled service ended and remained in the facility, were provided an Advanced Beneficiary Notice (ABN) as required. This affected three residents (#1, #17, and #56) of three residents reviewed for liability notices. Findings include: 1. Review of Resident #1's medical record revealed she was admitted to the facility on [DATE] with a readmission date of 01/08/24. Her diagnoses included schizophrenia, unspecified dementia, delusional disorder, and Bipolar disorder. Her payer status was MCR Part A before being switched to Medicaid (MCD). Review of a Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review Checklist revealed Resident #1 had a MCR Part A skilled…

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, staff and representative interviews, and record reviews, the facility failed to ensure timely and adequate nail care was completed for a resident who was dependent upon staff for Activities of Daily Living (ADLs). This affected one resident (#18) out of the three residents reviewed for ADL's during the annual survey. The facility census was 61. Findings include: Record review for Resident #18 revealed the resident was admitted to the facility on [DATE] and had diagnoses including senile degeneration of the brain, encounter for palliative care, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/13/24, revealed the resident was assessed to be rarely/never understood. The resident was assessed to be dependent upon staff for personal hygiene. Review of the care plan, revised 09/18/23, revealed the resident had an ADL self-care performance deficit. Interventions included showers two times a week with hair and nail care. Review of the care plan, dated 04/03/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident's pressure ulcer was assessed weekly for signs of healing/ infection as per the plan of care. This affected one resident (#59) of three residents reviewed for pressure ulcers. Findings include: Review of Resident #59's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included a stroke with hemiplegia/ hemiparesis affecting his left, non-dominant side, peripheral vascular disease status post peripheral vascular angioplasty, muscle weakness, need for assistance with personal care, cognitive communication deficit, aphasia, attention and concentration deficit, unspecified protein-calorie malnutrition, adult onset diabetes mellitus, congestive heart failure and anemia. Review of Resident #59's nursing admission assessment dated [DATE] revealed the resident was admitted to the facility with some bruising and skin tears to his upper extremities. He was not known to have…

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, interviews, and record reviews, the facility failed to ensure oxygen tubing was changed according to physician orders. This affected one resident (#43) reviewed for respiratory care during the annual survey. The facility census was 61. Findings include: Record review for Resident #43 revealed the resident was admitted to the facility on [DATE] and had diagnoses including acute and chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/15/24, revealed the resident was assessed to have mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 12. The resident was assessed to have been administered oxygen therapy during the review period. Review of the care plan, dated 06/13/24, revealed the resident had altered respiratory status. Interventions included oxygen administration at two to four liters per minute by nasal cannula. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to ensure orders for as needed psychotropic medications included a duration of therapy and additionally failed to ensure psychotropic medications were administered for appropriate indications. This affected two residents (#18 and #25) out of the five residents reviewed for unnecessary medications during the annual survey. The facility census was 61. Findings include: 1. Record review for Resident #18 revealed the resident was admitted to the facility on [DATE] and had diagnoses including senile degeneration of the brain, encounter for palliative care, anxiety, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/13/24, revealed the resident was assessed to be rarely/never understood. The resident was assessed to have received anti-anxiety medications during the review period. Review of the active physicians order, dated 02/07/24, revealed an order for 0.5 milligrams (mg) of Ativan (an anti-anxiety medication) to be…

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

Based on staff interview, resident interview, medical record review, and policy review, the facility failed to ensure that all allegations of abuse/mistreatment were reported immediately to the administrator of the facility. This affected one of 69 residents (Resident #15). Findings include: Interview with Licensed Practical Nurse (LPN) #75 on 01/29/24 at 5:03 A.M. revealed that, approximately a week prior, State Tested Nursing Assistant (STNA) #76 had bragged to her about cursing at Resident #15 because he cursed at her. LPN #75 stated she had reported this to Registered Nurse (RN) #77, who was working that night and was her supervisor. LPN #75 stated she did not know if the administrator was aware of the allegation or not. Review of the medical record for Resident #15 revealed an admission date of 07/30/16 and diagnoses including hemiplegia following a cerebral infarction, diabetes, and bipolar disorder. Review of a Minimum Data Set (MDS) assessment completed 12/08/23 revealed a brief interview for mental status score of 15, indicating intact cognition. Review of the record did…

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

Based on observation, interview and facility policy review the facility failed to store, prepare, and serve food in a sanitary manner and resident refrigerator temps were not monitored and adjusted as needed for increased temperatures. The food storage issue had the potential to affect all 74 residents receiving food from the facility kitchen (Residents #48 and # 276 do not receive food from the kitchen). The preparing and serving of food issue had the ability to affect all ten residents (Residents #6, #20, #25, #28, #31, #32, #40, #46, #51, and #69) who received pureed corn and one Resident (#30) who received a meatloaf sandwich. The resident refrigerator issue affected all thirteen residents (Residents #2, #5, #11, #19, #30, #32, #39, #41, #52, #60, #65, #67 and #68) who had personal refrigerators in their rooms. The nursing unit refrigerator issues had the potential affected all residents receiving items from those refrigerators in the facility. The facility census was 76. Findings included: 1. Observation on 10/25/22 at 11:10 A.M. of the walk-in refrigerator in the facility…

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 new Pre-admission Screening and Resident Review (PASARR's) were completed for residents receiving new mental illness diagnoses after their admission into the facility. This affected six (Resident #14, #23, #28, #40, #46, and #65) of six residents reviewed for PASARR's. Findings include: 1. A review of Resident #46's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses at the time of her admission included anxiety disorder and bipolar disorder. Her diagnoses list was updated to include the diagnoses of major depressive disorder on 09/13/19 and schizo-affective disorder on 10/26/21. A review of Resident #46's PASARR Identification Screen dated 09/13/18 revealed the resident was not identified as having had any mental illness diagnoses at the time the assessment was completed. A mood disorder was not marked despite the resident having the diagnoses of major depressive disorder and bipolar disorder at the time 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, interview and facility policy review the facility failed to maintain proper hand hygiene while providing care services to Resident #48's gastrostomy tube and during dining observation. This affected one Resident (#48) of one resident reviewed for tube feeding and 23 residents receiving meals in their room on the 200 hall (Residents #4, #6, #10, #11, #18, #12, #14, #27, #30, #33, #34, #36, #41, #43, #44, #46, #53, #56, #65, #68, #69, #123, #124). The facility census was 76. Findings included: 1. Review of Resident #48's medical record revealed he was initially admitted on [DATE] with a readmission on [DATE] with the diagnoses of quadriplegia, contracture of the right hand, essential hypertension, dysphagia, contracture of the left knee, and unspecified intracranial injury without loss of consciousness. Review of Resident #48's annual Minimum Data Set (MDS) dated [DATE] revealed severely impaired cognition and an abdominal gastrostomy tube. Observation on 10/25/22 at 10:48 A.M. of Licensed…

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 and procedure review, the facility failed to notify a resident's physician of a change in condition related to a significant weight gain. This affected one (Resident #23) of 24 resident records reviewed. The census was 76. Findings include: Review of Resident #23's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included chronic congestive heart failure (CHF), chronic kidney disease, hypertensive heart disease, diabetes, A-fib and depression and schizoaffective disorder. Review of Resident #23's minimum data set (MDS) assessment dated [DATE] revealed his cognition was intact, he required extensive assistance of two or more staff members for bed mobility, transfers, dressing, and toilet use. He required extensive assistance of one staff member for personal hygiene. Review of physician orders revealed an order dated 09/24/22 for daily weights due to congestive heart failure (CHF) and notify physician if greater than…

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 self-reported incident (SRI), review of the facility investigation, staff interviews and facility policy review, the facility failed to ensure one resident (#73) was free from physical and verbal abuse. This affected one of one resident reviewed for abuse. The facility census was 76. Findings Included: Review of the medical record for Resident #73 revealed an initial admission date of 02/02/22 with the admitting diagnoses including chronic obstructive pulmonary disease, cervicalgia, generalized weakness, difficulty in walking, repeated falls, reduced mobility, chronic respiratory failure, low back pain, arthritis, asthma, hypertension, fecal impaction, hypothyroidism, hyperlipidemia and personal history of COVID-19. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #73 had no cognitive deficit as indicated by a Brief Interview for Mental Status of 15. The resident required extensive assistance of two staff for bed transfer, bed mobility…

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 review, the facility failed to ensure one resident (#66) was free from restraints. This affected one of one resident reviewed for restraints. The facility census was 76. Findings Include: Review of the medical record for Resident #66 revealed an initial admission date of 06/21/22 with the latest readmission of 08/15/22 with the admitting diagnoses including dementia with severe agitation, protein calorie malnutrition, fracture of the sacrum, fracture of the rim of the right pubis, schizoaffective disorder, fracture of fifth lumbar, hyperlipidemia, chronic atrial fibrillation, anxiety disorder, gastro-esophageal reflux disease, low back pain, fracture of left pubis, nondisplaced fracture of zone one of sacrum, encephalitis, anemia, vascular dementia, herpes virus vesicular dermatitis, hypothyroidism, major depressive disorder, allergic rhinitis, osteoarthritis and hypertension. Review of the plan of care dated 08/17/22 revealed the resident used a physical restraint, tilt-n-space wheelchair related to comfort,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately in the areas of active diagnoses, falls, and range of motion. This affected three (Resident #40, #46, and #63) of 24 residents reviewed for assessments. Findings include: 1. A review of Resident #46's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included protein- calorie malnutrition. The diagnosis was added to her diagnoses list on 09/07/22. A review of Resident #46's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed section (I.) coded the resident's active diagnoses. The section for nutritional diagnoses (I 5600) included a place to code malnutrition (protein or calorie) as an active diagnosis, but it was not marked despite the resident having that diagnosis since 09/07/22. On 10/27/22 at 10:02 A.M., an interview with the Director of Nursing (DON) was held and she was informed Resident #46's quarterly MDS assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview and facility policy review, the facility failed to ensure one resident's (#233) baseline plan of care addressed Clostridium difficile infection (c-diff) and isolation to prevent the potential spread of c-diff. This affected one of 24 sampled residents. Findings Included: Review of the medical record for Resident #233 revealed an admission date of 10/20/22 with the admitting diagnoses of acute post-hemorrhagic anemia, hemorrhage of anus and rectum, atrial fibrillation diabetes mellitus, chronic kidney disease, congestive heart failure, hyperlipidemia, gastro-esophageal reflux disease, depression, anxiety, hypothyroidism and presence of cardiac pacemaker. Review of the admission nursing assessment dated [DATE] revealed the resident was admitted to the facility following an acute care hospital stay with the diagnoses of gastro-intestinal bleed, anemia and c-diff. The assessment indicated the resident was continent of bowel. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interview, the facility failed to ensure a comprehensive care plan was developed for a resident with the diagnosis of schizo-affective disorder. This affected one (Resident #46) of 24 residents reviewed for care plans. Findings include: A review of Resident #46's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included schizo-affective disorder (a mental health condition including schizophrenia and mood disorder symptoms). A review of Resident #46's active care plans revealed the resident did not have a care plan in place to address her diagnosis of schizo-affective disorder. None of the existing care plans addressed any behaviors related to her diagnosis of schizo-affective disorder. On 10/27/22 at 10:10 A.M., an interview with State Tested Nursing Assistant (STNA) #105 revealed Resident #46 was known to yell out when needing to go to the bathroom or after she already did and needed to be changed. She denied 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 interview and record review the facility failed to ensure the care plan of Resident #14 was revised with changes in physician's orders. This affected one Resident (#14) of five residents reviewed for respiratory concerns. The facility census was 76. Findings included: Review of Resident #14's medical record revealed she was initially admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, chronic kidney disease stage one, cardiomyopathy (disease that makes it difficult for the heart to pump blood), and nonrheumatic aortic stenosis (narrowing of the heart's aortic valve). Review of Resident #14's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively independent and received oxygen therapy. Review of Resident #14's physician order dated 10/21/22 revealed administer oxygen at two liters/minutes via a nasal cannula for shortness of breath or when her pulse oximetry is below 90%, check pulse oximetry in one or 30 minutes, discontinue oxygen when the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and facility policy and procedure, the facility failed to follow physician orders in regard to obtaining daily weights . This affected one (Resident #23) of 24 resident records reviewed. The census was 76. Findings include: Review of Resident #23's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included chronic congestive heart failure (CHF), chronic kidney disease, hypertensive heart disease, diabetes, A-fib and depression and schizoaffective disorder. Review of the minimum data set (MDS) assessment 08/22/22 revealed his cognition was intact, he required extensive assistance of two or more staff members for bed mobility, transfers, dressing, and toilet use. He required extensive assistance of one staff member for personal hygiene. Review of physician orders revealed an order dated 09/04/22 for daily weights due to congestive heart failure (CHF) and notify physician if greater than three pounds. Further review revealed no documentation…

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, and staff interview, the facility failed to ensure a resident was seen by an ophthalmologist for treatment of cataracts as referred by the optometrist. This affected one (Resident #65) of three residents reviewed for vision/ hearing. Findings include: A review of Resident #65's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included cataract extraction status of an unspecified eye. A review of Resident #65's Medicare (MCR) 5 day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. Her vision was indicated to be adequate with the use of corrective lenses. No behaviors or rejection of care was noted. A review of Resident #65's active care plans revealed she had a care plan in place for having impaired peripheral visual function related to a stroke and left sided vision loss. She required large print to be able to see/ read. Interventions included arranging…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview , the facility failed to ensure interventions were in place for pressure ulcers. This affected one (Resident #29) of five residents reviewed for pressure ulcers. The census was 76. Findings include: Review of the medical record revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses included ASHD, gastroesophageal reflux disease (GERD), osteoporosis, and chronic pain syndrome. Review of the minimum data set (MDS) assessment 09/06/22 revealed her cognition was not intact. She required limited assistance of one staff member for transfers, dressing and personal hygiene. She required supervision with set up help only for bed mobility and toileting. Review of the physician orders revealed an order dated 07/25/22 for heel float boot to the left foot while in bed. Resident #29 has a Stage 2 (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) pressure ulcer to the left heel. Observations on 10/26/22 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview and facility policy review, the facility failed to ensure one resident's (#40) contracture prevention devices were implemented as physician ordered. This affected one of five residents reviewed for limited range of motion. Findings Included: Review of the medical record for Resident #40 revealed an initial admission date of 04/07/21 with the admitting diagnoses of dementia, reduced mobility, schizoaffective disorder, allergic rhinitis, dysphagia, personal history of COVID-19, pseudobulbar affect, hypertension, obesity, anemia, polyneuropathy, anxiety disorder, bipolar disorder, major depressive disorder and generalized muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive impairment. The resident was dependent on two staff for activities of daily living. The assessment indicated the resident had no deficits in range of motion to upper or lower extremities. The assessment 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 observation, interview, record review, and policy review the facility failed to ensure dietary intake was accurately measured and documented and failed to ensure nutritional supplements were administered as ordered . This affected two Resident (#48 and #69) of seven residents reviewed for nutrition. The facility census was 76. Findings included: 1. Review of Resident #48's medical record revealed he was initially admitted on [DATE] with a readmission on [DATE] with the diagnoses of quadriplegia contracture right hand, essential hypertension, dysphagia, contracture left knee, and unspecified intracranial injury without loss of consciousness. Review of Resident #48's annual Minimum Data Set (MDS) dated [DATE] revealed severely impaired cognition and an abdominal gastrostomy tube. Review of Resident #48's weights revealed on 04/26/2022, the resident weighed 154.6 pounds (lbs.) and on 07/18/2022, the resident weighed 149 pounds which was a -3.62 % Loss. Review of Resident #48's nutrition 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 observation, interview, and record review the facility failed to ensure resident oxygen was delivered at the flow rate ordered by the physician and respiratory equipment was stored properly. This affected two Resident (#14 and #31) of five residents reviewed for respiratory concerns. The facility census was 76. Findings included: 1. Review of Resident #14's medical record revealed she was initially admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, chronic kidney disease stage one, cardiomyopathy (disease that makes it difficult for the heart to pump blood), and nonrheumatic aortic stenosis (narrowing of the heart's aortic valve). Review of Resident #14's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively independent and received oxygen therapy. Review of Resident #14's physician order dated 10/21/22 revealed administer oxygen at two liters/minutes via a nasal cannula for shortness of breath or when her pulse oximetry is below 90%, check…

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 physician responded with a rationale for no action taken on recommendations made by the pharmacist in the Medication Regimen Review (MRR). This affected two Residents (#28 and #67) of five residents reviewed for unnecessary medications. The facility census was 76. Findings included: 1. Review of Resident #28's medical record revealed he was admitted to the facility on [DATE] with the diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, essential hypertension, hypothyroidism, and dysphagia. Review of Resident #28's quarterly MDS dated [DATE] revealed he was not cognitively independent and had an active diagnoses of depression, psychotic disorder, and schizophrenia. Review of Note to Attending Physician/Prescriber dated 09/29/21 for Resident #28 revealed the resident had been taking the antipsychotic Zyprexa 5 milligrams every evening since October 2021. The physician was asked to please…

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 a resident receiving an antipsychotic medication was monitored for resident specific target behaviors. This affected one (Resident #46) of five residents reviewed for unnecessary medications. Findings include: A review of Resident #46's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included schizo-affective disorder, bipolar disorder, anxiety disorder, and major depressive disorder. A review of Resident #46's physician orders revealed the resident had an order to receive Seroquel (an antipsychotic medication) 25 milligrams (mg) by mouth (po) every morning and 50 mg po at bedtime for schizo-affective disorder. The order had been in place since 01/18/22. She also had an order to receive Lexapro (an antidepressant) 10 mg po ever night at bedtime for depression. The orders indicated the resident's target behaviors for the antidepressant was sad/ worried facial expressions, decreased appetite…

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, staff interview and review of facility policy and procedure, the facility failed to ensure the facility medication error rates were not 5% or greater, with 30 opportunities for error and two actual observed errors resulting in a medication administration error rate of 6.67% . This affected two (Resident #2 and Resident #36) of three residents observed for medication administration. The census was 76. Findings include: 1. Observation on 10/25/22 at 7:24 A.M. revealed Licensed Practical Nurse (LPN) #27 administer the following medications to Resident #2, Amlidopine 10 mg (milligrams), ASA (aspirin) 81 mg, Cranberry 500 mg tablet, Colace 100 mg, Flovent (asthma therapy)110 mcg (Micrograms) two puffs, Magnesium Oxide (mineral supplement) 400 mg, Potassium 10 meq(milliequivalent), Memantine 10 mg and Vitamin C (supplement) 500 mg . LPN #27 administered Flovent two puffs, one right after the other without waiting in-between. LPN #27 failed to instruct resident on holding breath in and failed to instruct him to rinse his mouth after administration of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to obtain laboratory tests ordered by the physician. This affected two (Resident #44 and #67) of five residents reviewed for unnecessary medications. Findings include: 1. Review of Resident #44's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, cognitive communication disorder, dementia, anxiety, insomnia and depression. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed his cognition was not intact. He required supervision of one staff members physical assistance for bed mobility, extensive assistance of one staff members physical assistance for transfers, dressing and toileting and limited assistance of once staff members physical assistance for personal hygiene. Review of the Physician orders revealed an order on 09/15/22 for PT/INR weekly (Resident receives Coumadin which is a blood thinning medication). Review of the lab results revealed they…

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.