Hawthorn Glen Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review , the facility failed to provide social services to maintain the resident's mental health after a traumatic incident. This affected three residents, (Residents # 18, #32 and #38) of five residents reviewed following a traumatic incident. The facility total census was 61. Findings Include: 1.Record review of Resident #18 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #18 include breast cancer, depressive disorder, and dysphagia. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and required moderate assistance for Activity of Daily Living skills. Review of Resident #18 State Reported Incident (SRI) dated 04/11/25 revealed the resident alleged a man came into her room and tried to remove her outer wear pants. He ran his hand down her leg. Review of Resident #18 SRI dated 06/29/25 revealed the resident alleged a staff person held down her hand. Review 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, staff interview, review of planned menu, substitution log, and policy review, the facility failed to follow the menu for residents ordered a puree diet. This affected five (Residents #8, 26, 43, and 55) of five residents ordered a puree diet. The facility also failed to have a dietician sign off on meal substitutions. This had the potential to affect all residents residing in the facility. The facility census was 61.Review of the puree menu for lunch on 07/30/25 revealed beef enchiladas, seasoned black beans, corn, Mexican street cornbread, snickerdoodle cookie, and coffee/tea.Observation on 07/30/25 at 11:13 A.M. revealed puree food being served was enchiladas, corn, black beans, and pie.Interview 07/30/25 at 11:17 A.M. with Dietary Director (DD) #101 verified that the residents with an order for a puree diet were being served enchiladas, corn, black beans, and pie. DD #101 verified that the Mexican street cornbread was not prepared for puree diets but was listed on the menu. DD #101 also verified that pie was substituted for the snickerdoodle cookie.Review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to provide a therapeutic diet as ordered by the physician. This affected one resident (Resident # 26) of one resident reviewed for therapeutic diets. The facility total census was 61. Findings Include: Record review of Resident #26 revealed the resident was admitted to the facility on [DATE]. The resident received hospices services. Diagnoses for Resident #26 include hypertension, dementia, obesity, and cancer antigen. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition and was totally dependent on staff for dressing and hygiene, transfers and eating. The resident received a regular puree nectar thick liquids diet and nutritional supplement three times a day. Additionally, the resident had a physician order, the Resident may have thin liquids and pleasure food with staff supervision only. With the resident positioned upright, small sips from cup, without…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, review of Emergency Medical Services (EMS) report, review of emergency room (ER) records, review of hospital records, staff interviews, review of personnel record, review of job descriptions, and review of facility policy, the facility failed to ensure residents were free from accidents while being transported by the facility's bus. This affected one (#25) of the three residents reviewed for accidents. The facility census was 64. Findings include: Review of the medical record for Resident # 25 revealed the resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Diagnoses included major depressive disorder, cerebral infarction (stroke), dementia, anxiety, chronic kidney disease, morbid obesity, congestive heart failure (CHF), essential primary hypertension, pneumonia, and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had impaired cognition and was dependent on staff for activities 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.

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 fall interventions were implemented to address the root cause of resident's falls. This affected one (#7) of three residents reviewed for falls. The census was 57. Findings included: Medical record review for Resident #7 revealed an admission date of 05/01/23. Diagnoses included stroke, aphasic, non-Alzheimer's dementia, hemiplegia, and seizure disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #7 was rarely or never understood. His functional status was a setup or clean-up assistance for eating, partial/moderate assistance for toileting and transfers, and the resident was independent for bed mobility. Review of the care plan updated 07/01/24 for Resident #7 revealed an intervention dated 05/23/23 to review information on past falls and attempt to determine the root cause of the falls. Review of an unwitnessed fall note on 07/25/24 at 5:46 A.M. revealed Resident #7 was attempting…

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

Based on record review and staff interview, the facility failed to ensure a Registered Nurse (RN) was present for eight consecutive hours on 04/30/22, 05/08/22, 05/27/22, 05/28/22, 06/04/22, and 06/05/22. This had the potential to affect all 51 residents residing in the facility. The census was 51. Findings include: Review of staffing sheets dated 04/30/22, 05/08/22, 05/28/22, and 06/04/22 revealed there was not an RN scheduled on any of the dates. Review of the staffing sheet for 05/27/22 revealed an RN was scheduled for only three consecutive hours. Review of the staffing sheet for 06/05/22 revealed there was not an RN scheduled on 06/05/22. Review of signed statement per the Director of Nursing (DON) dated 06/09/22 revealed the DON was present in the facility for six consecutive hours on 06/05/22. Interview on 06/09/22 at 11:00 A.M. with the DON confirmed she was present in the facility for six consecutive hours on 06/05/22 and the facility did not have an RN present for eight hours on this date. Interview on 06/08/22 at 4:20 P.M. with the Administrator confirmed the facility 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 medical record review, review of staffing schedules, staff interview, and review of the facility policy, the facility failed to ensure medications were administered as ordered by the attending physician. This affected four (#11, #21, #26 and #13) of six residents reviewed for medications. The facility census was 51. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 03/20/18 with diagnoses including spinal stenosis and schizoaffective disorder. Review of the Minimum Data Set (MDS) for Resident #11 dated 02/27/22 revealed resident was cognitively impaired and required supervision and physical assistance of one staff with activities of daily living (ADL's.). Review of the April 2022 Medication Administration Record (MAR) for Resident #11 revealed the following medications were left blank in the MAR on 04/30/22: Ativan one milligram (mg) due at 10:00 P.M., Gabapentin 100 mg due at 8:00 P.M. Review of the nurse progress notes for Resident #11 dated 04/30/22 and 05/01/22 revealed the notes contained no documentation regarding…

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 act on pharmacy recommendations following the monthly Medication Regimen Reviews (MRR's). This affected four (#11, #21, #32, and #13) out of five residents reviewed for MRR's. The facility census was 50. Findings include: 1. Review of Resident #11's medical record revealed the resident was admitted on [DATE] with diagnoses that included but were not limited to spinal stenosis of the cervical region, bipolar disorder (depressed, severe with psychotic features), chronic obstructive pulmonary disease, and unspecified anxiety disorder. Review of most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition, had no behaviors, did not wander, and did not refuse care. Review of the medical record revealed Resident #11 had physician orders for hydroxychloroquine 200 milligrams (mg) by mouth daily, esomeprazole 40 mg by mouth daily, multi-vitamin by mouth once daily, vitamin D 3 1000…

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 ensure hand hygiene was completed during meal services for residents. This affected five (#12, #30, #15, #17 and #9) randomly observed residents observed during meal service. The facility census was 51. Findings include: Observation on 06/06/2022 from 12:06 P.M. to 12:12 P.M. revealed dietary delivered meal cart to 100-Hall. State Tested Nursing Assistant (STNA) #238 delivered a lunch tray to Resident #15 and did not sanitize hands before she retrieved the next tray from food cart. STNA #238 delivered tray to Resident #12, removed lids from dishes, opened the resident's milkshake, and left room without sanitizing her hands. STNA #238 returned to the food cart, retrieved the next tray, and delivered tray to Resident #30, and left the room without sanitizing her hands. Interview on 06/06/2022 at 12:12 P.M. with STNA #238 verified she did not sanitize or wash her hands after she delivered meal trays to Residents #15, #12, and #30. STNA #238 stated she was supposed to sanitize her hands after every tray.…

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

Based on record review, observation, staff interview, review of the facility policy and review of the employee handbook, the facility failed to provide feeding assistance to residents in a dignified and respectful manner. This affected one (#13) of five facility-identified residents who were dependent on staff for assistance with eating. The census was 51. Findings include: Review of the medical record for Resident #13 revealed an admission date of 03/05/22 with a diagnosis of unspecified dementia with behavioral disturbance. Review of the Minimum Data Set (MDS) for Resident #13 dated 03/11/22 revealed the resident had severe cognitive impairment and was totally dependent on the assistance of one staff with eating. Review of the care plan for Resident #13 dated 05/19/22 revealed the resident has an activities of daily living (ADL) self-care performance deficit related to dementia with behaviors, fibromyalgia, Alzheimer's, convulsions, restlessness and agitation and falls. The resident required extensive assistance by staff to eat. Observation on 06/09/22 at 8:12 A.M. revealed State…

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 the residents code status was accurately documented on the resident's chart. This affected one (#19) out of three residents reviewed for advance directives. The facility census was 51. Findings included: Record review for Resident #19 revealed she was admitted to the facility on [DATE]. Diagnosis included atrial fibrillation, dementia, gastroesophageal reflux disease, transient ischemic attack, muscle weakness, asthma, kidney disease stage three, anemia, hypotension, and Alzheimer's disease. Review of the quarterly minimum data set (MDS) assessment, dated 04/01/22, revealed Resident #19 had impaired cognition as evidenced by her brief interview for mental status (BIMS) score of 10. Further review of the MDS assessment revealed she required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, personal hygiene, and supervision from staff with eating. Further review of the hard chart for 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 medical record review, observation and staff interview, the facility failed to ensure the facility developed care plans for resident care needs regarding resting hand splints and oxygen therapy. This affected two (#26 and #152) of 13 residents reviewed for care plans. The facility census was 51. Findings include: 1. Resident #26 admitted to the facility on [DATE] with diagnoses that included but were not limited to unspecified hemiplegia affecting non-dominant left side, history of traumatic brain injury, unspecified cerebrovascular disease, type II diabetes, unspecified anxiety disorder, unspecified major depressive disorder, and chronic pain syndrome. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact, no behaviors, no wandering, and did not reject care. Resident #26 was a two-person assist and required extensive assist with all ADL's. Resident #26 had functional limitation in range of motion to one side. Review of the medical record…

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

Based on record review, staff interview, and facility policy, the facility failed to complete a thorough and accurate fall investigation. This affected one (#40) out of three residents reviewed for falls. The facility census was 51. Findings include: Review of the medical record for Resident #40 revealed an admission date of 06/17/21. Diagnoses included dementia, Coronavirus Disease 2019 (COVID-19), amnesia, generalized anxiety disorder, and schizoaffective. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #40, dated 01/21/22, revealed the resident had impaired cognition. Resident #40 had a brief interview of mental status (BIMS) score of 99, indicating the resident chose not to respond. The resident required extensive assistance for hygiene, toileting, dressing, transfer, and bed mobility. Resident #40 required supervision for walking in the room/corridor, locomotion on/off the unit, and eating. No hallucination, delusions, or rejection of care were noted on the assessment. Review of the Morse Fall Scale Assessment for Resident #40 dated 09/01/21 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 medical record review, observations, staff interview, and policy review, the facility failed to ensure residents had active physician orders to receive oxygen therapy and to ensure residents oxygen tubing was labeled and dated. This affected three (#152, #30, and #252) out of eight residents residing in the facility who received oxygen therapy. The facility census was 51. Findings include: 1. Resident #30 admitted to the facility on [DATE] with diagnoses that included but were not limited to chronic obstructive pulmonary disease (COPD), acute diastolic congestive heart failure, d unspecified acute kidney failure. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #30 received oxygen therapy. Resident #30 required supervision and setup assistance for eating and extensive two-staff assistance with all other Activities of Daily Living (ADL's). Review of care plan dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure residents were free from unnecessary psychotropic medications by ensuring there was an end date for as needed (PRN) antianxiety (lorazepam) medication. This affected one (#9) of five residents reviewed for psychotropic medications. The facility census was 51. Findings include: Review of Resident #9 admitted on [DATE] with diagnoses that included but were not limited to Pick's disease, nondisplaced fractures of third and fifth metatarsal bones, unspecified convulsions, type II diabetes, and unspecified dementia. Review of most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had severely-impaired cognition, had no behaviors, rejected care one to three days per week, and did not wander. Resident #9 was a two person assist and required extensive assistance for ADL's. Review of care plan dated 05/03/2022 revealed Resident #9 used anti-depressant and anti-anxiety medications related to depression and anxiety.…

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 the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of Centers for Medicare and Medicaid Services (CMS) memorandum QSO-22-09-ALL , review of the staff Coronavirus Disease 2019 (COVID-19) vaccination list/matrix, review of the facility policy and staff interview, the facility failed to implement their vaccination policy and monitor staff members to ensure that 100% (percent) of staff received the COVID-19 vaccine, have a pending request for exemption, or have been identified as appropriate for a temporary delay per Centers for Disease Control (CDC) guidance. The vaccination rate for the facility was calculated at 98.75%. The facility's census was 51. Findings include: Review of the facility staff COVID-19 vaccination matrix revealed the facility had a total of 80 employees. Further review of the COVID-19 vaccination matrix revealed the facility had 40 employees fully vaccinated for COVID-19, 1 employee (Dietary Aide #360) partially vaccinated for COVID-19, and 39 employees who had not…

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

Based on record review, staff interview and policy review, the facility failed to have maintain accurate infection control tracking and logging. This affected nine residents ((#10, #12, #20, #34, #41, #42, #49, #50 and #152) and the had the potential to affect all 54 residents residing in the facility. Findings include: Record review of the facility's Minimum Data Set Matrix revealed nine residents (#10, #12, #20, #34, #41, #42, #49, #50 and #152) were identified by the facility as having an active infection. Review of the facility's infection control log for the last 12 months revealed there was no evidence of tracking or logging infections for the months of 09/2019 and 10/2019. Interview on 11/06/19 at 1:46 P.M. with the Administrator and the Director of Nursing (DON) verified that the facility has not been appropriately tracking and logging infections for the months of 09/2019 and 10/2019. Review of the facility's undated policy titled Infection Control Policy revealed the Unit Managers are to review the yellow order duplicates daily for infection control concerns, then log the…

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

Based on record review, staff interview and policy review, the facility failed to have an Antibiotic Stewardship Program in place. This affected ten residents (#10, #17, #21, #28, #32, #34, #45, #48, #50 and #152) and had the potential to affect all 54 residents residing in the facility. Findings include: Record review of the facility's Minimum Data Set Matrix revealed ten residents (#10, #17, #21, #28, #32, #34, #45, #48, #50 and #152) were identified by the facility as receiving antibiotics. Review of the facility's infection control binder revealed there was no antibiotic tracking. Interview on 11/06/19 at 1:46 P.M. with the Administrator and the Director of Nursing (DON) verified they were supposed to be using McGreer's Definitions of Infections for Long Term Care Facilities. However, they verified there was no evidence of the program. Review of the facility's undated Antibiotic Stewardship Program policy revealed the facility is committed to improving the use of antibiotics to optimize the treatment of infections while reducing the danger of antibiotic resistance.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to provide a copy of the transfer or discharge notification to the Office of the State Long-Term Care Ombudsman for resident's discharges from the facility. This affected four (Resident #12, #32, #50 and #52) of four residents reviewed for discharge notification. The facility census was 54. Findings include: 1. Record review revealed Resident #12 was admitted to the facility on [DATE]. Diagnoses included hypoxemia, Alzheimer's disease, dementia in other diseases classified elsewhere and generalized anxiety disorder. Review of the quarterly Minimum Data Sets (MDS) assessment, dated 08/26/19, revealed the resident to be severely cognitively impaired. Review of the progress notes revealed the resident was discharged to the hospital for a mental status change on 05/14/19. Resident #12 was readmitted to the facility on [DATE]. There was no evidence the Office of the State Long-Term Care Ombudsman was notified of Resident #12's discharge to the hospital…

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 residents received written bed hold notifications within 24 hours of their discharges from the facility. This affected four (Resident #12, #32, #50 and #52) of four residents reviewed for discharge notification. The facility census was 54. Findings include: 1. Record review revealed Resident #12 was admitted to the facility on [DATE]. Diagnoses included hypoxemia, Alzheimer's disease, dementia in other diseases classified elsewhere and generalized anxiety disorder. Review of the quarterly Minimum Data Sets (MDS) assessment, dated 08/26/19, revealed the resident to be severely cognitively impaired. Review of the progress notes revealed the resident was discharged to the hospital for a mental status change on 05/14/19. Resident #12 was readmitted to the facility on [DATE]. Review of Resident #12's record revealed there was no documentation that Resident #12 or Resident #12's representative were provided a written bed hold notification upon…

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 residents on psychotropic medications received gradual dose reductions unless contraindicated. The facility also failed to ensure as needed psychotropic medication orders were limited to 14 days or that a rationale and duration of the as needed psychotropic medication was indicated in the medical record. This affected three (Resident #2, #15 and #43) of five residents reviewed for unnecessary medications. The facility census was 54. Findings include: 1. Record review for Resident #43 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia with behavioral disturbance and anxiety disorder. Review of the quarterly Minimum Data Sets (MDS) assessment, dated 10/05/19, revealed the resident to be severely cognitively impaired. Review of the physician orders, dated 07/23/19, revealed the resident was prescribed Ativan 0.5 milligrams (mg.) every 12 hours as needed for anxiety and agitation related to generalized…

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 provide residents and their representatives with a summary of the baseline care plan. This affected two (Resident #26 and #155) of four residents reviewed for baseline care plans that were admitted within the past year. The facility census was 54. Findings include: 1. Record review for Resident #26 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia without behavioral disturbance, cognitively communication deficit, major depressive disorder, muscle weakness, hypertensive heart disease without heart failure, acute bronchitis, apraxia, contracture of muscle, type two diabetes mellitus, psychotic disorder with delusions due to known physiological condition, vitamin deficiency and history of falling. Review of the baseline care plan revealed the resident's baseline care plan was completed on 12/22/18. There was no documentation that a written summary of Resident #26's baseline care plan was provided to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility's policy and staff interview, the facility failed to ensure a resident's fall risk was assessed and fall interventions were in place to prevent falls. This affected one (Resident #43) of two residents reviewed for accidents. The facility census was 54. Findings include: Record review for Resident #43 revealed the resident was admitted to the facility on [DATE]. Diagnoses included idiopathic gout, Parkinson's disease, dementia with behavioral disturbance, muscle wasting and atrophy, difficulty in walking, cognitive communication deficit and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/05/19, revealed the resident to be severely cognitively impaired and required extensive assistance from staff with bed mobility, transfers and toileting. Resident #43 was reported to have two or more falls with no injury and two or more falls with injury. Review of Resident #43's chart revealed no fall risk assessments completed to assess 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, review of facility policy and staff interview, the facility failed to ensure the drug regimen review recommendations were appropriately addressed by the attending physician in a timely manner and failed to ensure the physician documented their rationale for not changing a resident's medications as indicated in a pharmacy recommendation. This affected one (Resident #44) of five residents reviewed for unnecessary medications. The facility census was 54. Findings include: Record review for Resident #44 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cognitive communication deficit, major depressive disorder, dementia in other diseases classified elsewhere and insomnia. Review of the annual Minimum Data Set (MDS) assessment, dated 10/10/19, revealed the resident to be severely cognitively impaired. Review of the physician orders revealed the resident was prescribed Seroquel 100 milligrams (mg.) at bedtime for dementia in other diseases classified elsewhere…

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

Based on observation, medical record review, and staff interview, the facility failed to ensure medication error rate was less than five percent. There were 29 opportunities with two medication errors for an error rate of 6.9 percent (%). This affected one (#15) of six residents reviewed for observation of medication administration. The facility census was 54. Findings include: Medical record review for Resident #15 revealed an admission date of 05/01/18. Diagnoses included heart failure. Review of the physician orders for Resident #15 revealed there were not any current orders dated 10/01/19 through 11/05/19 for Cymbalta or Potassium. Observation of medication administration to Resident #15 on 11/05/19 at 8:35 A.M. revealed Licensed Practical Nurse (LPN) #22 administered Cymbalta 60 milligram (mg.) and Potassium 10 milliequivalent (meq.). This was observed on the computer screen the LPN was looking at for the resident and the drugs were also included in the packet from the pharmacy which was labeled for Tuesday at 8:00 A.M. A total of 29 opportunities was observed for 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 observation, staff interview and policy review, the facility failed to ensure insulin vials were not expired. This affected one (Resident #1) of six residents reviewed for medication administration. The facility identified there were four residents who received insulin and resided on the 200 hallway. The facility census was 54. Findings include: Observation of administration of Novolog on [DATE] at 10:41 A.M. to Resident #1 revealed Registered Nurse (RN)) #26 took the Novolog vial out of the drawer of the medication cart to draw up insulin and upon checking the date, it said the opening date was [DATE]. The RN went to the refrigerator to pull Novolog to administer it to Resident #1 and the open date was [DATE] and the RN went to get another one which was Novolin R out of the refrigerator and it was dated [DATE]. Interview with RN #26 on [DATE] at 11:18 A.M. verified the above vials were out of date and should have been discarded after 28 or 42 days of open date. Review of the facility's policy titled…

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 the resident code statuses documented in physician progress notes were accurate. The facility also failed to document a resident's transfer to the hospital in the medical record. This affected three (Resident #26, #32 and #44) of 16 residents reviewed for complete and accurate medical records. The facility census was 54. Findings include: 1. Record review for Resident #26 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia without behavioral disturbance, hypertensive heart disease without heart failure, type two diabetes mellitus and psychotic disorder with delusions due to known physiological condition. Review of the annual Minimum Data Set (MDS) assessment, dated 10/26/19, revealed the resident to be severely cognitively impaired. Review of the resident's chart revealed the resident to have an appendix A form indicating her code status to be a Do Not Resuscitate Comfort Care (DNRCC). Resident #26'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.