Arbors At Milford

Based on observation, staff interview, and policy review, the facility failed to store and prepare foods in a manner to prevent spoilage and contamination. This had the potential to affect all 62 residents who received food from the facility kitchen. The facility identified 10 (#1, #5, #23, #29, #59, #65, #121, #123, #124, and #321) who received no food from the kitchen. The facility census was 72. Findings include: 1. Observation of the kitchen on 03/10/25 between 7:12 A.M. and 9:30 A.M., with Food Service Director (FSD) #157 revealed two packages of pie crusts undated and unlabeled in the dry food storage area. There were two packages of English muffins and six packages of rolls that were not dated. Observation of a garbage can located by the primary preparation station and a garbage can in the dishwashing room revealed neither garbage can had lids on them. Further observation of the kitchen revealed four ceiling air ventilator covers had black spots around the ventilators and a black substance built up on them. Interview with FSD #157 verified the two packages of pie crusts were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure a resident's advance directive was fully completed and dated by the physician. This affected one (#65) of three residents reviewed for advanced directives. The facility census was 72. Findings include: Medical record review revealed Resident #65 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, end stage renal disease, cutaneous abscess of the abdominal wall, renal dialysis, essential primary hypertension, heart failure, dysphagia, and hyperlipidemia. Review of the Minimum Data Set (MDS) assessment, dated 02/04/25, revealed Resident #65 had impaired cognition. Resident #65 was dependent on staff for medication administration, eating, dressing, bathing, and personal hygiene. Review of the undated form titled, DNR Comfort Care, revealed Resident #65 was indicated to have a DNR Comfort Care (DNRCC) advanced directive selected; however, there was no selection made under the section 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 observation, resident and staff interview, medical record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and review of a government website, the facility failed to accurately code the status of a non-invasive mechanical ventilation on Minimum Data Set (MDS) assessments. This affected one (#60) of four residents reviewed for ventilators. The facility census was 72. Findings include: Medical record review for Resident #60 revealed she was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure with hypoxia, pulmonary hypertension, congestive heart failure, asthma, essential primary hypertension, chronic kidney disease, anemia, dysphagia, and diabetes mellitus. Review of the MDS assessment, dated 02/18/25, for Resident #60 revealed she was cognitively intact. Resident #60 was dependent on staff for medication administration, toilet use, and lower body dressing. Resident #60 required maximum assistance from staff with showers.…

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 Preadmission Screening and Resident Review (PASRR) was accurately completed. This affected one (#25) of two residents reviewed for PASRR. The facility census was 72. Findings Include: Medical record review for Resident #25 revealed she was admitted to the facility on [DATE] with hospice services. Diagnoses included morbid obesity, acute and chronic respiratory failure, obstructive sleep apnea, hypothyroidism, bipolar disorder, diabetes mellitus, peripheral vascular disease, anxiety disorder, major depressive disorder, and alcohol dependence. Review of the Minimum Data Set (MDS) assessment for Resident #25, dated 02/15/25, revealed the resident was cognitively intact. Resident #25 was dependent on staff for medication administration, toilet use, bathing, lower body dressing, sit to lying position, chair to bed transfer, and tub transfer. Resident #25 required moderate assistance from staff with oral…

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, resident and staff interviews, medical record review, and policy review, the facility failed to develop care plans for dental care for residents with dental concerns. This affected one (#49) of three residents reviewed for dental care. The facility census was 72. Findings Include: Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. Diagnoses included end stage renal disease with dependence on renal dialysis, combined congestive heart failure, and oropharyngeal dysphagia. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #49 had no natural teeth and was not assessed as having loose fitting dentures. Review of the care plan dated 02/24/24 revealed Resident #49 had no care plan for dental care. During an interview on 03/10/25 at 1:01 P.M. Resident #49 stated his dentures did not fit due to recent gradual…

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 medical record review, the facility failed to ensure fall interventions were implemented as care planned. This affected one (#55) of five residents reviewed for falls. The facility census was 72. Findings Include: Review of the medical record revealed Resident #55 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, epilepsy, type II diabetes, major depressive disorder, and stage III chronic kidney disease. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Review of care plan dated 04/29/24 revealed Resident # 55 was at risk for falls related to generalized weakness, poor balance, decreased strength and endurance, and need for assistance with activities of daily living (ADLs). Interventions included to encourage to rest in the afternoon, encourage to lay in the center of the bed,…

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 physician interview, the facility failed to ensure a resident was assessed timely by the physician after admission. This affected one (#25) of three residents reviewed for physician visits. The facility census was 72. Findings Include: Medical record review for Resident #25 revealed she was admitted to the facility on [DATE] with hospice services. Diagnoses included morbid obesity, acute and chronic respiratory failure, obstructive sleep apnea, hypothyroidism, bipolar disorder, diabetes mellitus, peripheral vascular disease, anxiety disorder, major depressive disorder, and alcohol dependence. Resident #25 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) assessment for Resident #25, dated 02/15/25, revealed Resident #25 was cognitively intact. Resident #25 was dependent on staff for medication administration, toilet use, bathing, lower body dressing, sit to lying position, chair to bed…

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, medical record review, and policy review, the facility failed to ensure proper personal protective equipment was worn while providing care and services for a resident on enhanced barrier precautions, failed to perform adequate hand hygiene between resident contact, and failed to ensure blood-contaminated materials were properly disposed of. This affected one (#47) of five residents reviewed for enhanced barrier precautions, one (#324) of two residents reviewed for laboratory services, one (#37) of one residents reviewed for blood glucose monitoring. The facility census was 72. Findings include: 1. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE]. Diagnoses included type II diabetes, end stage renal disease with dependence on renal dialysis, morbid obesity, and generalized anxiety disorder. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was cognitively intact, had no behaviors, did 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to maintain a safe and clean environment. This affected three (#12, #14, and #46) of 12 residents reviewed for environment. The facility census was 72. Findings include: 1. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE] with diagnoses of atrial fibrillation, congestive heart failure, hypertension, diabetes mellitus type II, and dementia. Observation on 03/10/24 at 10:15 A.M. revealed Resident #46's room had an area of the wall located below heating ventilation and air conditioning (HVAC) unit that was unpainted drywall was stained with a black substance. 2. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses of cerebrovascular accident with right (dominant) side hemiplegia and hemiparesis, chronic obstructive pulmonary disease, diabetes mellitus type II, morbid obesity, alcoholic cirrhosis, and congestive heart failure. Observation…

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, review of the guidance from Centers for Disease Control and Prevention (CDC). staff interviews, and review of the facility policy, the facility failed to implement recommended infection control practices to prevent the spread of COVID-19 and failed to perform appropriate hand hygiene and sterile practices during a resident's wound treatment. This affected (#2, #9, #14, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #33, #34, #35, #36, #37, #38, #40, #42, #43, #44, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, and #73). The facility census was 76. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date 03/02/24. Diagnoses included COVID-19 on 03/05/24, acute diastolic heart failure, pulmonary fibrosis, nonrheumatic mitral valve insufficiency, Alzheimer's disease, and dementia. Resident #14 was transferred to the local hospital on [DATE]. Review of the medical record for Resident #2 revealed an admission…

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, resident and staff interview, and review of the facility policy, the facility failed to ensure a resident was treated with respect and dignity. This affected one (Resident #1) of three residents reviewed for dignity and respect. The facility census was 76. Findings include: Review of the medical record for Resident #1 revealed an admission date 02/19/24. Diagnoses included chronic pulmonary disease, morbid obesity, cognitive communication deficit, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact. Resident #1 was dependent with maximum assistance from staff for transferring, ambulating by wheelchair with staff, upper and lower body dressing, and personal hygiene. Interview on 03/06/24 at 2:00 P.M. with Resident #1 stated the staff were nasty and did not respect her or provide appropriate care and privacy. Observation on 03/07/24 from 11:00 A.M. through 11:19 A.M. revealed Resident #1 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interviews, observations, and review of the facility policy, the facility failed to provide activities to the residents. This affected two (#73 and #74) of five residents reviewed for activities. The facility census was 76. Findings include: 1. Review of the medical record for Resident #73 revealed an admission date 02/14/23. Diagnoses included pressure ulcer, paraplegia, chronic obstructive pulmonary disease, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 was cognitively intact. Resident #73 was dependent on staff for bed mobility and transfers. Resident #73 used a wheelchair with staff at the facility to get to room or activities. Review of the plan of care dated 03/01/24 revealed Resident #73 had risks for altered activity patterns or pursuits related to her current medical condition. Interventions included to allow resident to make choices or decisions about their preferred activity pursuits, encourage to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and policy review, the facility failed to ensure a resident was transferred safely using a mechanical lift with two-person assistance as specified in the care plan. This affected one (#26) of three residents reviewed for accident hazards. The facility identified 26 residents that utilize mechanical lifts for transfers. The facility census was 72. Findings include: Review of the Resident #26's medical record revealed an admission date of 02/09/24, with diagnoses including: generalized idiopathic epilepsy and epileptic syndromes, dependence on renal dialysis, end stage renal disease, dependence on wheelchair, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder. Review of Resident #26's admission change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be cognitively intact and Resident #26 was independent with eating. Resident #26 also required set up assistance with oral hygiene, personal hygiene,…

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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of video camera footage, review of the ventilator manual, family and staff interview, and review of the facility policy, the facility failed to timely respond to a resident's ventilator alarm. This affected one (Resident #34) of three residents reviewed for ventilators. The facility identified five residents who were on a ventilator. The facility census was 76. Findings include: Review of the medical record for Resident #34 revealed an admission date 02/06/24. Diagnoses included acute and chronic respiratory failure with hypercapnia, acute pulmonary insufficiency, and dependence on respirator (ventilator). Review of the Minimum Data Set (MDS) assessment date 02/13/24 revealed Resident #34 was cognitively intact. Resident #34 was dependent on staff for personal care dependent on a ventilator. Review of the plan of care dated 02/06/24 revealed Resident…

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

Based on medical record review, review of video footage, family and staff interview, and review of the facility policy, the facility failed to provide timely assessment and pressure to a resident's dialysis access site that was actively bleeding. This affected one (Resident #34) of three residents reviewed for dialysis. The facility census was 69. Findings include: Review of the medical record for Resident #34 revealed an admission date 02/06/24. Diagnoses included end stage renal disease and acute pulmonary insufficiency. Review of the Minimum Data Set (MDS) assessment date 02/13/24 revealed Resident #34 was cognitively intact. Resident #34 was dependent on staff for transfers, personal care, toileting, upper and lower dressing, and bathing. Review of the plan of care dated 02/07/24 revealed Resident #34 was at risk of abnormal bleeding or hemorrhage related to anticoagulant therapy, recent surgery, and medication. Interventions included avoiding activities that could result in injury, observe for and report to physician of bleeding, blood tinged or frank blood in urine, blood in…

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

Based on observation, interview and policy review the facility failed to maintain a sanitary kitchen and acceptable food storge practices. This had the potential to affect 72 out of 72 residents who received food from the kitchen. The facility census was 78. Findings include: Tour of kitchen on 05/02/22 at 8:50 A.M. revealed there were no towels at the employee hand washing sink and there was a 12 inch by six inch hole in the wall behind the hand washing sink. There was thawing wrapped meat in a pan of water. The reach in refrigerator and freezer had no temperature log completed after the date of 04/28/22 and had no inside thermometers. There were approximately 10 to 15 containers of covered food bowls without labels and dates. The dry storage shelving and pan storage shelves in the tray line contained debris of dried food. Two trash containers, on carts, had dried food debris on the wheels and up the sides of the trash containers. The walk-in refrigerator and the walk in freezer had no inside thermometer, and a last date of 04/30/22 of logged temperatures on the outside door. 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 observation, record review, review of personnel files, staff interview, and policy review the facility failed to ensure the facility implemented contact precautions for a resident with methicillin resistant staphylococcus aureus (MRSA). This affected one resident (#42) out of two residents reviewed for transmission based precautions. The facility identified 12 residents that were assisted by respiratory therapists. In addition, the facility failed to implement their tuberculosis control plan and ensure all newly hired employees were tested for tuberculosis. This had the potential to affect all 78 residents who resided in the facility. The facility census was 78. Findings include: 1. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure, dependence on respirator ventilator status, tracheostomy status, type two diabetes mellitus, major depressive disorder, aphonia, other dysphagia, weakness, and atopic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and policy review, the facility failed to provide timely feeding assistance to a dependent resident. This affected one (Resident #5) of three residents reviewed for feeding assistance. The facility identified nine residents that required assistance with feeding. The facility also failed to ensure residents were provided with routine showers and/or bathing. This affected four (Residents #5, #33, #53, and #63) of five residents reviewed for hygiene. The facility census was 78. Findings include: 1a. Review of the medical record of Resident #5 revealed an admission date of 12/19/16. Diagnoses included respiratory failure, dysphagia following unspecified cerebrovascular disease, alcoholic cirrhosis of liver with ascites, heart failure, end-stage renal disease, dementia with behavioral disturbance, unspecified psychosis, essential hypertension, hypothyroidism, anxiety disorder, feeding difficulties, and major depressive disorder. Review of the quarterly Minimum Data Set…

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 there was enough staff to respond to call lights, provide timely incontinence care, provide assistance with meals and provide treatments. This affected 11 (Residents #45, #34, #42, #33, #24, #68, #10, #64, #26, #5, #63, ) of 25 residents reviewed for staffing. The census was 78. Findings included: 1. During interview on 05/02/22 and 05/03/22, Residents #45, #34, #42, and #24 stated the response time for call lights was long. 2. During observation on 05/03/22 at 7:44 A.M., the call lights for Residents #10, #64 and #68 were on. During observation on 05/03/22 at 8:03 A.M., an unidentified State Tested Nursing Assistant (STNA) said there was no STNA assigned to these resident's hall. She did not stop to answer any of the three call lights. AT 8:13 A.M., Unit Manager UM) #328 came down the hall but did not answer any of the three call lights. Resident #38's call light. Resident #10's call light was answered at 8:21 A.M. Resident #64'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 medical record review, review of pharmacy recommendations, staff interview and policy review, the facility failed to ensure pharmacy recommendations were timely addressed by the physician and timely implemented pharmacy recommendations agreed by the physician. This affected four (Residents #5, #31, #45, and #52) of five residents reviewed for unnecessary medications. The facility census was 78. Findings include: 1. Review of the medical record revealed Resident #45 admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure, with hypoxia, dependence on respirator ventilation status, chronic obstructive pulmonary disease, muscle weakness, major depressive disorder, anxiety disorder, insomnia, post traumatic stress disorder, and neuromuscular dysfunction of bladder. Review of Resident #45's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, toilet…

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, interview and policy review, the facility failed to answer call lights in a timely manner. This affected seven (Residents #10, #24, #34, #42, #45, #64, and #68) of 25 residents reviewed for call lights. The census was 78. Findings include: 1. During interview on 05/02/22 and 05/03/22, Residents #45, #34, #42, and #24 stated the response time for call lights was long. 2. During observation on 05/03/22 at 7:44 A.M., the call lights for Residents #10, #64 and #68 were on. During observation on 05/03/22 at 8:03 A.M., an unidentified State Tested Nursing Assistant (STNA) said there was no STNA assigned to these resident's hall. She did not stop to answer any of the three call lights. AT 8:13 A.M., Unit Manager UM) #328 came down the hall but did not answer any of the three call lights. Resident #38's call light. Resident #10's call light was answered at 8:21 A.M. Resident #64's light was answered at 8:23 A.M. and Resident #68's light was finally answered at 8:30 A.M. During interview on 05/03/22 at 8:34 A.M., Resident #68 stated it can take up to 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 and interview, the facility failed to complete accurate comprehensive and quarterly assessments. This affected two (Residents #46 and #60) of 28 residents reviewed for accuracy of assessments. The facility census was 78. Findings include: 1. Review of the medical record for Resident #46 revealed the resident was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus with Diabetic Neuropathy, and Osteoarthritis. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment and requires extensive assistance with all Activities of Daily Living (ADL). The MDS indicated Resident #46 was receiving hospice services. During an interview on 05/04/22 at 9:09 A.M., Resident #46's assigned nurse, Registered Nurse (RN) # 334 revealed the resident does not receive hospice services. During an interview on 05/04/22 at 9:18 A.M., the MDS nurse, RN #400, revealed resident #46…

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 routine care conferences were completed. This affected three (Residents #33, #51, and #53) of three residents reviewed for care conferences. The facility census was 78. Findings include: 1. Review of the medical record revealed Resident #51 admitted to the facility on [DATE]. Diagnoses included undisclosed fracture of cervical vertebra, type II diabetes, and chronic diastolic heart failure. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #51 had moderately impaired cognition, no behaviors, did not refuse care, and did not wander. Review of the medical record revealed Resident #51 had documentation for care conferences on 06/25/21 attended by speech therapy, the social worker, the dietitian, the nursing staff and the healthcare Power of Attorney/daughter, and on 05/03/22 attended by the nursing staff, the social worker, and two daughters. Interview on 05/04/22 at 1:02 P.M., the Social Worker…

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. Record review revealed Resident #31 was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, cerebrovascular disease, anxiety disorder, diabetes, and weight loss. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition. Review of physician orders revealed Resident #31 had a new physician order dated 04/20/22 for hospice services. Review of the medical record revealed no hospice provider documentation, including the hospice plan of care and hospice progress notes. Review of the Plan of Care dated 04/20/22, revealed Resident #31 was identified to receive hospice services. The interventions included to coordinate facility care with the hospice provider. Review of Licensed Social Worker (LSW) #348's progress notes dated 04/25/22 and review of Care Conference dated 04/25/22 revealed LSW #348, the physician, Resident #31's Power of Attorney and a facility nurse attended the care conference. During interview…

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 policy review, the facility failed to ensure incontinence care was provided to residents. This affected two (Residents #33 and #26) of two residents reviewed for incontinent care. The facility identified there were 46 residents who were incontinent. The census was 78. Findings include: 1. Record review revealed Resident #33 was admitted on [DATE]. Medical diagnoses included diabetes, fibromyalgia, depression, pain, hypertension, dementia without behavioral disturbances. Review of care plan, dated 06/23/21, for Resident #33 revealed she needed activities of daily living (ADL) assistance related to hip replacement. her interventions were to check and change every two hours, change briefs and provide incontinence care. Review of quarterly MDS assessment, dated 04/27/22, revealed Resident #33 was cognitively intact. She required extensive assistance for bed mobility, transfers, and toilet use. She was frequently incontinent of bladder and always incontinent of bowel. Review 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 observation, interviews, and record reviews the facility failed to ensure physician orders were accurate and implemented. This affected two (Residents #5 and #60) of 28 residents reviewed for accuracy of physician orders. The facility census was 78. Findings include: 1. Review of the medical record for Resident #60 revealed a readmission date of 01/22/22 with diagnoses including end stage renal disease, dependence on renal dialysis, type two diabetes mellitus with diabetic chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/01/22, revealed the resident had no cognitive impairment and required limited assistance with Activities of Daily Living (ADL). The MDS indicated the resident had one stage two pressure ulcer and the treatments included a pressure reducing device for her bed. Review of Resident #60's May 2022 physician orders revealed an order for a low loss air mattress, dated 12/29/21 and an order dated 04/29/22 to cleanse buttocks with peri wash, pat dry,…

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

Based on medical record review, observation, staff interview and policy review the facility failed to ensure insulin was administered without error. This affected one (Resident #31) of three residents observed for medication administration. The facility census was 78. Findings included Review of the medical record review for Resident #31 revealed an admission date of 10/17/19. Diagnoses included diabetes. Review of the physician orders dated 09/15/21 revealed Novolog Solution 100 unit milliliters (ml) (Insulin Aspart) to inject five units subcutaneously before meals related to diabetes. Observation of the medication administration on 05/04/22 at 12:10 P.M. revealed Licensed Practical Nurse (LPN) #345 pulled out the Novolog pen and placed a needle on the end of the pen and dialed up five units of the insulin and administered the insulin to Resident #31. Interview with LPN #345 on 05/04/22 at 12:15 P.M. revealed she was not aware she was supposed to expel two units from the insulin pen to ensure the pen was working correctly. She she verified she had not expelled two units of insulin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff and resident interview and policy review, the facility failed to ensure a resident received routine dental services. This affected one (Resident #45) of three residents reviewed for dental services. The facility census was 78. Findings include: Review of the medical record revealed Resident #45 was admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure, with hypoxia, dependence on respirator ventilation status, chronic obstructive pulmonary disease, muscle weakness, major depressive disorder, anxiety disorder, insomnia, post traumatic stress disorder, and neuromuscular dysfunction of bladder. Review of Resident #45's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #45 was not reported to have a broken or loosely fitting full or partial denture. Review of 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 record review, observation, interview and policy review, the facility failed to ensure the menu was followed and provide the correct puree diet food portion. This affected one (Resident #31) of three residents who received a physician ordered puree diet. The facility census was 78. Findings include: Review of the medical record revealed Resident #31 was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, cerebrovascular disease, anxiety disorder, diabetes, and weight loss. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition. Review of the physician orders dated May 2022 revealed Resident #31 had a puree consistency diet order. Observation on 05/04/22 at 11:55 A.M. during lunch tray line, revealed Resident #31 received three ounces of meat instead of the menu planned four ounces of meat. The portion of puree bread was an approximate served from an incorrect sized scoop. Interview on 05/04/22 at 12:00…

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.