The Laurels Of Middletown

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and review of the facility policy, the facility failed to provide timely care and services to treat a urinary tract infection. This affected one (#298) out of three residents reviewed for change of condition. The facility census was 97. Findings include: Review of the medical record for Resident #298 revealed an admission date of [DATE] with medical diagnoses of pneumonia, chronic obstructive pulmonary disease, atrial fibrillation, hypertension, and neuromuscular dysfunction of the bladder. Further review of the medical record revealed Resident #298 was discharged to the hospital on [DATE] and expired at the hospital. Review of the medical record for Resident #298 revealed an admission Minimum Data Set (MDS) assessment, dated [DATE], which indicated Resident #298 had moderate cognitive impairment and required maximum staff assistance for bed mobility and transfers and was dependent for toilet hygiene and bathing. Review of the medical record for Resident #298…

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, resident and staff interviews and policy review, the facility failed to ensure a resident was observed to take their medications at the time of administration. This affected one (#74) of five residents reviewed medication administration. The facility census was 97. Findings include: Review of medical record for Resident #74 revealed admission date of 04/09/24. The resident was admitted with diagnoses including alcohol dependence, epilepsy, dementia without behavior, anxiety and metabolic encephalopathy. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #74 had a Brief Interview Mental Status (BIMS) score of 10 indicating impaired cognition. The activities of daily living were not assessed. Review of Resident #74's medical record revealed a physician orders for 500 micrograms of Vitamin B daily, 50000 of Vitamin D daily, 125 milligrams of Depakote twice daily, 81 milligrams aspirin daily and 500 milligrams Keppra twice daily. Review for Resident #74's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the medical record for Resident #298 revealed an admission date of [DATE] with medical diagnoses of pneumonia, chronic obstructive pulmonary disease, atrial fibrillation, hypertension, and neuromuscular dysfunction of the bladder. Further review of the medical record revealed Resident #298 was discharged to the hospital on [DATE] and expired at the hospital. Review of the medical record for Resident #298 revealed an admission Minimum Data Set (MDS) assessment, dated [DATE], which indicated Resident #298 had moderate cognitive impairment and required maximum staff assistance for bed mobility and transfers and was dependent for toilet hygiene and bathing. Review of the medical record for Resident #298 revealed physician orders dated [DATE] for 16 French indwelling catheter for neuromuscular dysfunction of bladder and an order dated [DATE] for repeat urinalysis with culture for dysuria one time only. Review of the medical record for Resident #298 revealed a nurse progress note, dated [DATE] at 5:15…

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 interview and policy review, the facility failed to ensure staff followed proper infection control procedure when administering intravenous medication. This affected one (#50) out of five residents observed for medication administration. Facility census was 97. Findings include: Review of medical record for Resident #20 revealed admission date of 04/22/24. Diagnoses include osteomyelitis, anxiety, and heart failure. Review of Resident #20's admission Minimum Data Set (MDS) dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. She was independent with activities of daily living. Observation on 05/21/24 at 9:23 A.M. with Licensed Practical Nurse (LPN) #309 of the Peripherally Inserted Central Catheter (PICC) line medication administration for Resident #20 revealed LPN #309 cleansed the tip of the needleless connector of the PICC line with an alcohol swab and then intentionally dropped the line and it landed on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to complete weekly wound evaluations of a surgical wound. This affected one (#105) out of three residents reviewed for wound care. The facility census was 101. Findings include: Review of the medical record for Resident #105 revealed an admission date of 02/20/24 with medical diagnoses of status post left below the knee amputation (BKA), diabetes mellitus with neuropathy, depression, bipolar disorder, anemia, and hypertension. Review of the medical record revealed Resident #105 discharged to the hospital on [DATE]. Review of the medical record for Resident #105 revealed an admission Minimum Data Set (MDS) assessment, dated 02/27/24, which indicated Resident #105 was cognitively intact and required supervision with bed mobility and moderate staff assistance with toilet hygiene, transfers, and bathing. The MDS indicated Resident #105 admitted with a surgical wound and treatment was in place. Review of the medical record 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, staff and guardian interviews, and policy review, the facility failed to provide the correct location for discharge on a discharge notice. This affected one (Resident #204) of three residents reviewed for proper discharges. The facility census was 101. Findings include: Review of the medical record for Resident #204 revealed an admission date of 07/23/22 with medical diagnoses of paranoid schizophrenia, end stage renal disease, and anxiety. Resident #204 was discharged to an acute care hospital on [DATE] for increased behaviors and agitation. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #204 was cognitively intact and required supervision at times with bed mobility, toileting, and transfers. Review of the nursing progress note dated 09/01/23, revealed the dialysis center would no longer provide dialysis to Resident #204 because of his increased behaviors and an episode where Resident #204 pulled out his dialysis tubing and experienced…

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 reviews, observations, staff interview, review of facility policies, and review of the facility legionella water prevention program, the facility failed to implement transmission based precautions for residents with Coronavirus (COVID-19) like symptoms. This affected four Residents (#8, #24, #46, and #72) and had the potential to affect all residents of the facility. The facility also failed to have a sufficient legionella prevention plan. This had the potential to affect all the residents of the facility. The facility also failed to ensure staff washed their hands when distributing meals to residents. This affected two (#1 and #37) residents observed during meals. The census was 81. Findings include: 1. Review of Resident #8's medical record revealed an admission date of 08/14/14. Diagnoses listed included schizophrenia, aphasia, anxiety disorder, and hypertension. Further review revealed a physician order for contact and droplet precautions (transmission-based precautions) related to COVID-19 dated 04/16/21. Review of Resident #24's medical record revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record reviews, resident and staff interviews, and review of facility's resident care guidelines, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, and personal and oral hygiene. This affected two (#16 and #22) of four residents reviewed for Activities of Daily Living (ADLs). The facility census was 81. Findings include: 1. Review of Resident #16's medical record revealed an admission dated of 05/02/19, with diagnoses including; dementia with behavioral disturbance, altered mental status, aphasia, anxiety disorder, heart failure, major depressive disorder, need for assistance with personal care, and COVID-19 on 12/10/20. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had severe cognitive impairment, requesting two staff persons for bed mobility and transfer, and the limited assistance of one staff to eat. The assessment also…

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, and staff and resident interviews, the facility failed to provide each resident with an ongoing program of individual activities, consistent with the comprehensive assessment, designed to meet their specific interests in order to promote psychosocial well-being. This affected one (#83) of four residents reviewed for activities. The facility census was 81. Findings include: Review of Resident #83's medical record revealed an admission date of 03/18/21, with diagnoses including: diabetes mellitus type 2 with diabetic neuropathy, morbid obesity, injury of kidney, hypertension, chronic embolism and thrombosis, anxiety disorder, and major depressive disorder. Review of an admission minimum data set (MDS) assessment dated [DATE] revealed the resident was alert and oriented, with good memory and recall. The resident required the physical assistance of two staff for bed mobility and transfer, and did not walk. Review of the resident's physician orders dated 03/18/21 revealed an…

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 reviews, observations, staff interviews, review of facility policy, the facility failed to accurately document pressure ulcer treatments and accurately document resident's pressure ulcers. This affected two (#16 and #21) of five residents reviewed for pressure ulcers. The census was 81. Findings include: 1. Review of Resident #16's medical record revealed an admission date of 05/02/19. Diagnoses listed included altered mental status, aphasia, anxiety disorder, hypertension, hyperlipidemia, insomnia, muscle weakness, and major depressive disorder. Resident #16 was assessed as requiring extensive of assistance of two staff members for activities of daily living (ADL), not having a pressure ulcer, and being cognitively intact. Review of wound evaluation notes dated 02/16/21 revealed Resident #16 had a new in-house acquired stage III pressure ulcer to the coccyx measuring 1.02 centimeters (cm) x 0.87 cm x 0.1 cm. Review of physician orders revealed an order dated 02/19/21 for cleanse buttocks…

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 reviews, observations and staff interviews, the facility failed to ensure the medication error rate was below five percent. A total of 26 medications were observed administered with two medication errors, resulting in error rate of 7.69 percent. This affected two (#136 and #1) of two residents observed for medication administration. The facility census was 81. Findings included: Observations on 04/21/21 at 9:35 A.M., of Licensed Practical Nurse (LPN) #80 administering medication to Resident #136, revealed LPN #80 administered Calcium 500 milligrams (mg) one tablet by mouth. Review of Resident #136's physician's orders revealed an order for Oscal 500/200 mg (Calcium Carbonate and Vitamin D) once daily. Observation was made on 04/21/21 at 10:10 A.M., of LPN #80 administering medication to Resident #1, revealed LPN #80 administered Calcium Citrate 200 mg. Review of Resident #1's physician's orders revealed an order for Calcium Citrate and D3, 315-250 mg (Calcium Citrate with Vitamin D) to give one tablet twice daily. Interview on 04/21/21 04:33 P.M., with 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 observations, medical record review, staff and resident interviews, the facility failed to assist a resident in obtaining routine dental care. This affected one (#26) of four residents reviewed for dental services. The facility census was 81. Findings include: Review of Resident #26's medical record revealed an admission date of 01/03/20, with diagnoses including acute kidney failure, chronic obstructive pulmonary disease, diabetes mellitus type 2, obesity, iron deficiency anemia, congestive heart failure, and dementia without behavioral disturbances. The resident was receiving Medicaid benefits. Review of a quarterly minimum data set assessment for the resident dated 01/21/21 revealed he had good memory and recall. He was not identified as having any oral/dental problems at that time. Review of the resident's current comprehensive plan of care revealed a problem/need which specified the resident was at risk for infection, pain or bleeding in the oral cavity. The goal for the resident was to be be free of infection, pain or bleeding in the oral cavity. Interventions…

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

Based on observations, staff interview and review of the facility policy, the facility failed to ensure the dishwasher and food items were being properly maintained to prevent contamination and spoilage. This affected 99 of 99 residents who receive meals from the facility kitchen. The facility identified for two (#55 and #58) residents who receive nothing by mouth (NPO). The facility census was 101. Findings include: Observations of the facility's kitchen on 01/13/19 at 9:25 A.M., revealed Dietary Aide #99 and Dietary Aide #112, to be actively washing dishes from breakfast. Observation of the dishwasher temperature revealed the dishwasher to be running at 100 degrees Fahrenheit during the wash and 110 degrees Fahrenheit during the rinse. The metal plate on the side of the dishwasher revealed the dishwasher to require a minimum temperature of 120 degrees Fahrenheit during the wash and rinse. Observation of Dietary Aide #99 testing the chemicals in the dishwasher, revealed the chemical to be at 0 parts per million (ppm). Interview with Dietary Aide #99 on 01/13/19 at 9:25 A.M.,…

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 provide a copy of the transfer and discharge notification to the Ombudsman. The facility also failed to provide residents with notifications that included the reasons for their discharges. This affected four (#6, #19, #21 and #38) of eight residents reviewed for discharge notification. The facility census was 101. Findings include: 1. Record review revealed Resident #6 was admitted to the facility on [DATE] with the following diagnoses; muscle wasting and atrophy, unspecified injury at unspecified level of cervical spinal cord, hypotension, concussion without loss of consciousness, vitamin D deficiency, other psychotic disorder, insomnia, gangrene, acquired absence of left leg above knee, type two diabetes and muscle weakness. Review of Resident #6's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, dressing, toileting and personal…

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 ensure residents received bed hold notification. This affected four (#6, #19, #21 and #38) of eight residents reviewed for discharge notification. The facility census was 101. Findings include: 1. Record review revealed Resident #6 was admitted to the facility on [DATE] with the following diagnoses; muscle wasting and atrophy, unspecified injury at unspecified level of cervical spinal cord, hypotension, concussion without loss of consciousness, vitamin D deficiency, other psychotic disorder, insomnia, gangrene, acquired absence of left leg above knee, type two diabetes and muscle weakness. Review of Resident #6's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, dressing, toileting and personal hygiene. Resident #6 also required supervision with eating and total dependence with transfers. Further review of Resident #6's record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview the facility failed to ensure resident's Minimum Data Sets (MDS) assessments assessed the resident's cognition, mood and pain. This affected four Resident's (#5, #84, #105 and #303) of 27 reviewed for MDS. The facility census was 101. Findings include: 1. Record review revealed Resident #84 was admitted to the facility on [DATE] with the following diagnoses; acute kidney failure, ataxic gait, muscle wasting and atrophy, essential hypertension, lower back pain, generalized anxiety disorder and cocaine abuse. Review of Resident #84's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident's cognition and mood were marked as not assessed. Resident #84 was reported as independent with toileting and required supervision with bed mobility, transfer, dressing, eating and personal hygiene. Review of Resident #84's Brief Interview for Mental Statues (BIMS) dated 01/15/19 revealed the resident was cognitively intact. Interview with MDS Coordinator #84 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, interview and policy review the facility failed to ensure residents had care plans developed and implemented for smoking, falls, activities, psychotropic medications, and range of motion. This affected five Resident's (#13, #43, #55, #58 and #84) of 27 residents reviewed for care planning. The facility census was 101. Findings include: 1. Record review revealed Resident #84 was admitted to the facility on [DATE] with the following diagnoses; acute kidney failure, ataxic gait, muscle wasting and atrophy, essential hypertension, lower back pain, generalized anxiety disorder and cocaine abuse. Review of Resident #84's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident's cognition was not assessed. Resident #84 was reported to be independent with toileting and required supervision with bed mobility, transfer, dressing, eating and personal hygiene. Review of Resident #84's record revealed the resident signed the smoking policy upon admission 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, and interview the facility failed to ensure a resident's care plan was revised. The facility also failed to provide residents with the ability to participate in the implementation and development of their care plans. This affected five (#5, #6, #19, #67 and #76) of 27 residents reviewed for care planning. The facility census was 101. Findings include: 1. Record review revealed Resident #67 was admitted to the facility on [DATE] with the following diagnoses; other symbolic dysfunctions, unspecified abnormalities of gait and mobility, muscle weakness, type two diabetes mellitus without complications, polyarthritis, mood disorder, anxiety disorder, major depressive disorder, hypertension, and intracranial injury without loss of consciousness. Review of Resident #67's annual Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required supervision with bed mobility, transfers, dressing, eating, personal hygiene. Resident #67 was independent with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and resident and staff interview, the facility failed to ensure activities were provided for a resident who was deaf , failed to ensure residents were assessed and that the activities met the residents interests. This affected four (#5, #19, #55 and #58) of seven reviewed for activities. The census was 101. Findings include: 1. Medical record review for Resident #19 revealed admission date of 09/22/17. Medical diagnoses included atrial fibrillation, heart failure, and deaf nonspeaking. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #19 was cognitively intact. Functional status was independent for bed mobility, transfers, eating and toilet use. she was always continent for bowel and bladder. Interview with Resident #19 on 01/14/19 at 8:47 A.M. revealed she was able to communicate by reading lips. She indicated she doesn't participate in activities because she does not know what everyone was saying. She stated she very rarely received an…

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 review of the Resident Assessment Instrument (RAI) the facility failed to identify and complete a significant change assessment. This affected two Residents (#21 and #25) of 27 reviewed for resident assessments. The facility census was 101. Findings include: 1. Record review for Resident #25 revealed an original admission date of 01/11/18. The resident was sent to the hospital on [DATE] due to a fractured hip from a fall. The resident was readmitted on [DATE]. Diagnosis included fracture of right hip, pain in left knee, contracture of left hip, diabetes mellitus, muscle weakness, heart disease, major depressive disorder, psychosis, Alzheimer's disease, and anxiety. Review of significant change assessment Minimum Data Set (MDS) dated [DATE] revealed Resident #25 had moderately impaired cognition. The MDS did not indicate a fall with major injury even thought the resident had a fall on 08/08/18 that resulted in a fractured hip. The resident had a weight of 148 pounds.…

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 accurately code an injectable medication on the Minimum Data Set (MDS). This affected one Resident (#72) of five reviewed for unnecessary medications. The facility census was 101. Findings include: Record review for Resident #72 revealed an admission date of 12/19/18 with diagnosis including fracture of left hip, muscle weakness, communication deficit, chronic obstructive pulmonary disease, stroke, hypertension and seizures. Review of the MDS dated [DATE] revealed the residents cognition was not assessed. The resident required extensive assist for bed mobility, dressing, toileting and personal hygiene with staff support. The number of medications the resident received as injections in the last seven days was coded as zero. Review of physician orders for the month of December 2018 revealed an order for Enoxaparin injectable (brand name anti clotting medication) 30 milligrams (mg)/0.3 milliliters (ml) administer 0.3 ml (30 mg) subcutaneously (injection)…

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 accurately complete a baseline plan of care within 48 hours of admission. This affected two Residents (#21 and #72) of 27 reviewed for baseline plan of care. The facility census was 101. Findings include: 1. Record review for Resident #72 revealed an admission date of 12/19/18 with diagnosis including fracture of left hip, muscle weakness, communication deficit, chronic obstructive pulmonary disease, stroke, hypertension and seizures. Review of Minimum Data Set (MDS) dated [DATE] revealed the resident's cognition was was not assessed. The resident required extensive assist for bed mobility, dressing, toileting and personal hygiene with staff support. Review of baseline plan of care revealed the medical record was silent for this document. Interview with Registered Nurse (RN) #27 on 01/15/19 at 12:19 P.M. revealed she was unable to locate the baseline plan of care. Interview with the Corporate RN #300 on 01/16/19 at 1:30 P.M., revealed the base line plan…

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, family and staff interview and policy review the facility failed to ensure restorative therapy was provided to residents. This affected one (#55) of one resident reviewed for rehabilitation and restorative care. The facility identified 23 residents who received rehabilitative services. The census was 101. Findings include: Medical record review for Resident #55 revealed an admission date of 11/16/18. Medical diagnoses included traumatic brain injury. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was rarely or never understood. He was totally dependent for bed mobility, transfers, eating and toileting. Further review of the MDS revealed there were functional limitations in range of motion (ROM) for the upper and lower extremities impairment for both sides. Review of Physical Therapy (PT) discharge notes dated 12/17/18 for Resident #55 revealed to provide bilateral extremities ROM while in bed. Review of Occupational Therapy (OT) discharge notes…

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 and the facility failed to ensure a pressure reducing device was monitored and had the correct settings. his affected one Resident (#25) of six reviewed for pressure. The facility identified two residents who utilized alternating pressure mattress. The facility census was 101. Findings include: Record review revealed Resident #25 was admitted on [DATE]. The resident was sent to the hospital on [DATE] due to a fractured hip. The resident was readmitted on [DATE]. Diagnoses included fracture of the right hip, pain in the left knee, contracture of the left hip, diabetes mellitus, muscle weakness, heart disease, major depressive disorder, psychosis, Alzheimer's disease, and anxiety. Review of physician orders for the month of January 2019 revealed an order for an air mattress with concave side to the bed at all times to help define bed boundaries. This order had a start date of 10/04/18. Review of the plan of care for actual impaired skin integrity with an initiation…

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 ensure a resident with a history of weight loss and who was pocketing food received a speech evaluation. This affected one Resident (#27) of one reviewed for nutritional status. The facility census was 101. Findings include: Medical record review for Resident #27 revealed an admission date of 05/07/15 with diagnosis of mood disorders, hearing loss, dementia without behaviors, abnormal heart beats with pacemaker placement, arthritis, muscle weakness, mental disorder, depressive disorder, anemia, hypertension, and chronic kidney disease. Review of the most recent quarterly assessment dated [DATE] revealed the resident was not assessed for cognition. The resident required extensive assist with eating and had weight loss in the last month or six month. The resident had no identified dental or chewing problems. Review of the plan of care with an initiation date of 08/10/18 and revision on 09/25/18, 10/02/18, and 01/04/19 revealed an identified…

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 residents who were receiving psychotropic medications were assessed for non pharmaceutical interventions prior to receiving the medications and also failed to ensure gradual dose reductions were attempted for the use of psychotropic medications. This affected three (#30, #33, and #88) of three residents reviewed for unnecessary medications. The facility census was 101. Finds include: 1. Review of Resident #88's medical record revealed an admission date of 10/14/15. Diagnosis included hypertension, diabetes, schizophrenia, coronary artery disease anxiety disorder, chronic gout, major depressive disorder, insomnia, renal impairment, diverticulitis, acquired coagulation factor deficiency, and heart failure. Review of a Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #88 was cognitively intact and was supervision only for all activities of daily living. The MDS indicated no symptoms of depression. Review of a care plan…

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 observations and staff interview, the facility failed to ensure expired medications and laboratory supplies were discarded appropriately and medications were secure and inaccessible to unauthorized staff. This affected two of two medication carts and an undetermined number of residents who utilize the medications and supplies from the storage rooms. The facility census was 101. Findings include: 1. Observations of the nurses station storage area on the South unit on 01/15/19 at 10:49 A.M., revealed five intravenous solution bags labeled 0.45% Normal Saline with an expiration date of 12/13/18 an two select silicone cure catheter for suction with expiration dates of 08/08/18 were being stored in this area during the survey. All other injectable medications and medical supplies being stored was not expired. Interview with Regional Support Registered Nurse #310, immediately following the observation on 01/15/19 at 10:49 A.M., verified there were expired injectable's, food items and medical supplies stored in the nurses stations supply areas. She further stated the drugs should…

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 laboratory tests were completed as ordered by the physician. This affected one (#33) of five residents reviewed for laboratory services. The facility census was 101. Findings include: Record review for Resident #33 revealed an admission date of 10/31/10. Diagnoses included stroke, hemiplegia, muscle wasting, difficulty with speaking, anemia, dementia with behaviors, high cholesterol, insomnia, muscle weakness, overactive bladder, allergies, hearing loss, anxiety and major depressive disorder. Review of the physician orders for Resident #33, revealed laboratory orders with a start date of 09/28/16, for a Basic Metabolic Profile (BMP) every three months; a Complete Blood Count (broad screening to test for anemia and infections), Magnesium ( test for abnormal levels) and Renal Panel (kidney function) every four months with a start date of 01/25/17; a Hepatic Panel (liver functions) every six months with a start date of 10/11/16; a HgBA1C ( average sugar levels in blood over two to three months) every six months…

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, staff interview and review of facility policy, the facility failed to ensure medical records were complete, accurate and protected. This affected three (#5, #35 and #20) 27 of residents reviewed during the investigation portion of the survey. The facility census was 101. Findings include: 1. Review of Resident #20's medical record revealed an admission date of 04/09/15. Diagnosis included kidney failure anxiety disorder, major depressive disorder, bipolar disorder, paranoid schizophrenia, and hypertension. Review of a Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #20 was cognitively intact and required extensive assist of one for activities of daily living. Review of the skin risk assessment dated [DATE], indicated the resident was at risk for skin disturbance. Review of a care plan with a revised date of 01/03/19, revealed an intervention of treatments as ordered. Review of a Certified Nurse Practitioner (CNP) note dated 01/02/19, revealed a diagnosis…

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 interview, record review and review of the facility policy, the facility failed to implement their smoking policy in regards to supervising residents with smoking and smoking materials. This affected one (#84) of one resident reviewed for smoking. The facility census was 101. Findings include: 1. Record review revealed Resident #84 was admitted to the facility on [DATE]. Diagnoses included acute kidney failure, ataxic gait, muscle wasting and atrophy, essential hypertension, lower back pain, generalized anxiety disorder and cocaine abuse. Review of Resident #84's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognition was not assessed. Resident #84 was reported to be independent with toileting and required supervision with bed mobility, transfer, dressing, eating and personal hygiene. Further review of Resident #84's record revealed the resident signed the smoking policy on 12/21/18. Review of Resident #84's smoking assessment dated [DATE],…

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.