Country Club Retirement Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, self-reported incident (SRI) review, facility policy review, and interviews, the facility failed to thoroughly investigate allegations of abuse for Residents #4 and #17. This affected two residents (#4 and #17) out of two residents reviewed for abuse. This had the potential to affect all 60 residents. The facility census was 60. Findings include: 1. Review of the medical record revealed Resident #4 was admitted on [DATE] with diagnoses including dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had a Brief Interview Mental Status (BIMS) score of one out of 15 which indicated severe cognitive impairment. Resident #4 was dependent on staff for toileting. Review of SRI #246175 dated 04/09/24 revealed on 04/09/24 at approximately 7:20 P.M. State Tested Nursing Assistant (STNA) #5 notified the Director of Nursing (DON) that STNA #102 slapped 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, facility policy review, Hospice agreement review, and interview the facility failed to follow the bowel policy for Residents #22 and #39. This affected two residents (#22 and #39) out of five residents reviewed for unnecessary medications. The facility also failed to ensure Hospice communication was onsite for Resident #9. This affected one resident (#9) out of one resident reviewed for Hospice. The facility census was 60. Findings include: 1. Review of the medical record revealed Resident #22 was admitted on [DATE] with diagnoses including dementia, mood disorder, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22's Brief Interview Mental Status (BIMS) score was 11 of 15, which indicated cognitive impairment. Resident #22 was always continent of bowel. Review of the bowel documentation in the electronic medical record revealed Resident #22 did not have a bowel movement on 05/06/24, 05/07/24, 05/08/24, 05/09/24, 05/10/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy review, and interview the facility failed to comprehensively assess and provide adequate interventions and treatment for Resident #31. Resident #31 developed a stage III (full-thickness loss of skin, in which adipose (fat) is visible in the ulcer. Slough and/or eschar may be visible) pressure ulcer and stage II (partial-thickness skin loss involving the epidermis and dermis) pressure ulcer to buttocks. This affected one resident (#31) out of one resident reviewed for pressure ulcers. The facility census was 60. Findings include: Review of the medical record revealed Resident #31 was admitted on [DATE] and expired on [DATE] with diagnoses including type II diabetes, convulsions, history of traumatic brain injury, Parkinson's disease, and chronic kidney disease. Review of the plan of care dated [DATE] revealed Resident #31 had open areas to the right toe, an abrasion to the left lower leg, and areas to the right and left buttock. Interventions dated [DATE] and…

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 offer an alternative meal choice or nutritional shake for Resident #42 when less than 50% of the meal was consumed. This affected one resident (#42) of the two residents reviewed for nutritional support. The facility census was 60. Findings include: Review of the medical record for Resident #42 revealed an admission date of 11/02/22. Diagnoses included dementia, muscle weakness, and venous insufficiency. Review of Resident #42's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of seven of 15, indicating severely impaired cognition for daily decision-making abilities. Resident #42 was noted to require supervision or touching assistance by staff for eating and was noted to be 66 inches tall and weighed 146 pounds with a noted weight loss. Review of Resident #42's orders revealed a diet order for a regular diet with regular textured food and thin consistency liquids. 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 medical record review, staff interview, and facility policy review, the facility failed to ensure dialysis communication forms were completed post dialysis treatment and returned to the facility for Resident #267. This affected one resident (#267) of one resident reviewed for dialysis treatment. The facility census was 60. Findings include: Review of the medical record for Resident # 267 revealed an admission date of 04/27/24. Diagnoses included acute kidney failure, dependence on renal dialysis, and hypertension. Review of Resident #267's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating intact cognition for daily decision-making abilities. Review of the plan of care dated 05/06/24 revealed Resident #267 required dialysis related to renal failure. Interventions included encouraging the resident to attend scheduled dialysis appointments, monitoring labs, monitoring for peripheral edema, depression, infection, renal…

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, pharmacy recommendation review, and staff interview, the facility to address pharmacy recommendations in a timely manner for Residents #22 and #32. This affected two residents (#22 and #32) of five residents reviewed for pharmacy recommendations. The facility census was 60. Findings include: 1. Review of the medical record for Resident #32 revealed an admission date of 12/12/23. Diagnoses included anxiety, heart disease, and fracture of the left arm. Review of Resident #32's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 of 15, indicating intact cognition for daily decision-making abilities. Resident #32 was noted to receive antianxiety medication daily. Review of the plan of care dated 11/09/23 revealed Resident #32 had the potential for feelings of sadness, emptiness, anxiety, depression. Interventions included discussing feelings, encouraging loved ones to visit, providing one-on-one care, emotional…

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 closed record review, review of resident fund statements, review of withdrawal transaction report, review of check, review of receipts, policy review and interview the facility failed to ensure accounting principles were followed for resident funds. This affected one (Resident #68) of one resident reviewed for misappropriation. Findings included: Closed record review revealed Resident #68 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including anxiety, bipolar, and cerebral infarction. The resident's primary insurance was Medicaid and secondary was Medicare part B. Review of Resident #68's resident fund statement dated 07/01/23 to 09/29/23 revealed on 08/15/23 $2,500.00 was debited for spend down. Review of Resident #68's withdrawal transaction report dated 11/22/23 revealed $2,500.00 was withdrawn from Resident #68's account. Review of check #002225 dated 11/22/23 revealed a check was made out to the Administrator for the amount of$2,500.00. The memo…

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 closed record review, review of the self-reported incident (SRI), review of the police report, policy review, and interview the facility failed to ensure resident's money was not misappropriated. This affected one (Resident #68) of one review for misappropriation. Findings included: Closed record review revealed Resident #68 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including anxiety, bipolar, and cerebral infarction. The resident's primary insurance was Medicaid and secondary was Medicare part B. Review of Resident #68's resident fund statement dated 07/01/23 to 09/29/23 revealed on 08/15/23 $2500.00 was debited for spend down. Review of Resident #68's withdrawal transaction report dated 11/22/23 revealed $2,500.00 was withdrawn from Resident #68's account. Review of check #002225 dated 11/22/23 revealed a check was made out to the Administrator for $2,500.00. The memo indicated cash for resident spend down. Review of a Walmart receipt dated 11/27/23…

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 closed record review, review of the self-reported incident (SRI), review of the police report, policy review, and interview the facility failed to thoroughly investigate misappropriated funds. This affected one (Resident #68) of one review for misappropriation. Findings included: Closed record review revealed Resident #68 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including anxiety, bipolar, and cerebral infarction. The resident primary insurance was Medicaid and secondary was Medicare part B. Review of Resident #68's resident fund statement dated 07/01/23 to 09/29/23 revealed on 08/15/23 $2500.00 was debited for spend down. Review of Resident #68's withdrawal transaction report dated 11/22/23 revealed $2,500.00 was withdrawal from Resident #68's account. Review of check #002225 dated 11/22/23 revealed a check was made out to the Administrator for $2,500.00. The memo indicated cash for resident spend down. Review of a Walmart receipt dated 11/27/23…

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

Based on observation, record review, staff interviews, resident interviews, review of SANI-CLOTH instructions, and policy review the facility failed to ensure the glucometer used to complete finger stick blood sugar (FSBS) testing was cleansed properly. This had the potential to affect three residents (#70, #90, and #100) who utilized the same glucometer. In addition, the facility failed to ensure ice used for ice pass was free of contamination. This had the potential to affect all 63 residing in the facility. Findings Include: 1. Observation of Licensed Practical Nurse (LPN) # 240 on 11/07/23 at 7:38 A.M. performing a FSBS test on Resident #90, revealed the LPN took the glucometer, test strip container, lancet and alcohol prep pad into the resident's room and laid the items directly on the blanket on top of the resident's bed. The nurse completed hand hygiene and donned gloves. The nurse told the resident she was going to check his sugar and preceded to get a test strip out of the test strip container, pick up the glucometer from the bed, place the test strip in the glucometer,…

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 manufacturer instruction review the facility failed to administer insulin via an insulin pen according to the manufacturer's guidelines. This affected one resident (#100) of one resident observed for insulin injection. The facility census was 63. Findings include: Review of Resident #100's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including type two diabetes, atrial fibrillation, and noncompliance with medical treatment. Review of Resident #100's physician orders revealed the resident an order dated 11/04/23 for Novolin N flex pen inject 30 units twice daily and finger stick blood sugar (FSBS) testing as needed dated 09/28/23. Review of Resident #100's November 2023, medication administration record (MAR) revealed the resident routinely received his Novolin N injection and had not required as needed FSBS testing during the month. Observation of Licensed Practical Nurse (LPN) #240 providing medication 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 interviews, and resident interviews the facility failed to ensure residents received diet items as ordered. This affected two residents (#10 and #30) of three residents reviewed for therapeutic diets. The facility census was 63. Findings include: 1. Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease and type two diabetes with neuropathy. Resident #10's diet was reduced concentrated sweets diet. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact and required limited assistance with personal hygiene but was independent with all other activities of daily living. Observation of Resident #10's breakfast meal tray on 11/07/23 at 8:35 A.M. revealed the tray contained the following food items: two slices of toast, mandarin oranges, yogurt, sausage gravy, and a biscuit. Review of Resident #10's meal…

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 interviews, and facility policy review the facility failed to ensure safe and proper storge of food items in the dry storage, refrigerator, and freezer. This had the potential to affect all residents, as all residents receive food from the kitchen. The facility also failed to ensure proper handwashing by staff while passing meal trays to resident rooms. This affected five residents (#7, #34, #50, #59, and #120) observed to be affected during the tray passing observation. The facility census was 70. Findings include: 1. Observation and interview on 04/17/23 at 6:50 P.M. with Kitchen Staff #71 confirmed the following findings of food storage: Refrigerator Cups of milk were covered and undated. A water pitcher was left uncovered. Freezer An opened bag of French fries was found updated. A second bag of French fries was left open to air and undated. An opened bag of tater tots was found undated. Observation and interview on 04/17/23 at 9:10 P.M. with Dietary Manager #16 confirmed the following findings of food storage: Refrigerator A pie did not have a label…

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 interviews, resident interviews, record review, and facility policy review the facility failed to maintain a clean and sanitary environment. This affected two residents (#35 and #56) and had the potential to affect 17 additional residents (#4, #10, #16, #21, #22, #23, #25, #28, #37, #40, #49, #51, #52, #53, #55, #58, and #221) in the affected hallway. The facility census was 70. Findings include: 1. Review of the medical record for Resident #35 revealed an admission date of 12/21/22. Diagnoses included scapula fracture, lack of coordination, chronic pulmonary disease, edema, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively intact and required no assistance with toileting. Observation on 04/17/23 at 8:20 P.M. revealed Resident #35 had a dirty toilet with diarrhea splattered on the seat and bowl. Resident #35 also had a pile of dirty linens on the floor that he reported were there from having an accident in his 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 2. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including displaced fracture of the right femur, atrial fibrillation, benign prostatic hyperplasia, diabetes, hyperlipidemia, Stage IV sacral pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling), hypothyroidism, and hypertension. Review of the five-day MDS assessment dated [DATE] revealed Resident #54 had intact cognition and a Stage IV pressure ulcer present upon admission. Review of the April 2023 physician's orders revealed Resident #54 had an order dated 04/20/23 for a sacrum wound negative pressure wound vacuum therapy continuously at 125 millimeters of mercury (mmHg) with white foam and black foam. It was to be changed three times weekly on Tuesday, Thursday, and Sunday. Observation on 04/20/23 at 12:00 P.M. revealed Licensed Practical Nurse (LPN) # 20 and LPN #48 provided wound…

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 failed to ensure the advance directives and plan of care were accurate in the medical record for Resident #18. This affected one resident (#18) of 24 medical records reviewed. The facility census was 70. Findings include: Review of Resident #18's medical record revealed she was admitted to the facility on [DATE] with diagnoses including diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), Stage III chronic kidney disease, atrial fibrillation, depression, and high blood pressure. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 required limited assistance of one staff member for bed mobility, transfers, dressing, and toilet use and supervision with set-up help only for personal hygiene. Review of the Physician Orders for 04/23 revealed Resident #18 had a code status of Do Not Resuscitate-Comfort Care (DNR-CC). Further documentation in the medical record revealed a Full Code form…

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 with staff, and review of the facility policy the facility failed to provide resident privacy for Residents #54 and #271 when staff failed to knock before entering the room. This affected two residents (#54 and #271) of two reviewed for privacy. The facility census was 70. Findings included: 1. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including displaced fracture of the right femur, atrial fibrillation, benign prostatic hyperplasia, diabetes, hyperlipidemia, Stage IV sacral pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle. Slough may be present on some parts of the wound bed. Often includes undermining and tunneling.), hypothyroidism, and hypertension. Observation on 02/20/23 at 12:16 P.M. Hospitality Aide #25 opened the door and walked into the room of Resident #54 with his lunch tray without knocking while the nurses were performing his wound care. She apologized and went right back…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and review of the Department of Medicaid informational slide presentation titled PASRR - What Nursing Facility Needs to Know the facility failed to update Preadmission Screening and Resident Review (PASRR) with new mental illness diagnoses. This deficient practice affected three residents (#5, #43, and #33) out of three residents reviewed for PASRR requirements. The facility census was 70. Findings include: 1. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with admitting diagnoses of unspecified dementia and anxiety disorder. Review of Resident #5's medical record revealed medical diagnoses were updated on 05/22/19 with unspecified psychosis diagnoses and updated again on 01/01/22 with unspecified depression diagnoses. Review of Resident #5's initial PASRR dated 05/01/15 revealed in section D for medical diagnoses, anxiety was marked for mental illness. Review of Resident #5's medical record revealed no updated PASRR reflecting…

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 #18 had a care plan developed for the use of oxygen. This affected one resident (#18) of 23 residents reviewed for care plans. The facility census was 70. Findings include: Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), Stage III chronic kidney disease, atrial fibrillation, depression, and high blood pressure. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 required limited assistance of one staff member for bed mobility, transfers, dressing, and toilet use and supervision with set-up help only for personal hygiene. Review of the physician's order dated 08/17/22 revealed an order for oxygen at two liters per minute via nasal cannula continuous. Review of the medical record revealed no documented evidence of a care plan for the use of oxygen.…

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 interviews the facility failed to ensure neurological checks were completed for Resident #56 after a fall with a head injury. This affected one resident (#56) of five residents reviewed for falls. The facility census was 70. Findings include: Review of the medical record for Resident #56 revealed an admission date of 11/18/22. Diagnoses included wedge compression fracture, muscle weakness, cognitive communication deficit and heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 was cognitively intact and required no assistance with bed mobility or transferring. Review of the fall investigation dated 02/10/23 revealed another resident had wandered into Resident #56's room, and Resident #56 began escorting the other resident out of her room. Staff observed this and assisted the other resident in leaving. Resident #56 reached back to her wheelchair and fell. Resident #56 was observed to have a skin tear to her right elbow and a bump 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 observation, resident and staff interviews, record review, and facility policy review the facility failed to ensure fall interventions were implemented for two residents (#42 and #56) and failed to initiate a new fall prevention intervention for Resident #56 after a fall. This affected two residents (#42 and #56) of five residents reviewed for falls. The facility census was 70. Findings include: 1. Review of the medical record for the Resident #42 revealed an admission date of 02/16/23 with diagnoses including Parkinson's disease, and weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was cognitively intact and required extensive assistance of two staff members for transfers and bed mobility. Review of the baseline care plan dated 02/16/23 revealed Resident was at risk for falls due to having recent falls within the previous year with an intervention to keep the call light within reach. Review of the progress notes dated 03/06/23 revealed Resident #42 was found…

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, review of the continuous positive airway pressure (CPAP) cleaning instructions, and facility policy review the facility failed to ensure respiratory equipment was dated and maintained in a clean and sanitary manner for Residents #18, #29, and #36. This affected three residents (#18, #29 and #36) of 13 residents who received oxygen/respiratory therapy. The facility census was 70. Findings include: 1. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), Stage III chronic kidney disease, atrial fibrillation, depression, and hypertension. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 required limited assistance of one staff member for bed mobility, transfers, dressing, and toilet use and supervision with set-up help only for personal hygiene. Observation on 04/18/23 at 9:05 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 medical record review, staff interview, and review of the facility policy the facility failed to ensure laboratory tests ordered by the physician were completed. This affected one resident (#19) of five residents reviewed for unnecessary medications. The facility census was 70. Findings include: Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including dementia, chronic obstructive pulmonary disease (COPD), diabetes, depression, and insomnia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19's cognition is moderately impaired. She required extensive assistance from one staff member for bed mobility, dressing, toilet use, and personal hygiene and extensive assistance with two or more staff for transfers. Review of the physician's orders revealed an order for a complete blood count (CBC) every month. Review of the completed laboratory results revealed the CBC was not completed for July 2022. On 04/20/23…

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 timely dental services for Resident #18. This affected one resident (#18) of two residents reviewed for dental services. The facility census was 70. Findings include: Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), Stage III chronic kidney disease, atrial fibrillation, depression, and hypertension. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 required limited assistance of one staff member for bed mobility, transfers, dressing, and toilet use and supervision with set up help only for personal hygiene. Observation on 04/18/23 10:15 A.M. revealed Resident #18 had lower teeth missing teeth. Resident #18 stated, I need them to be taken care of. Review of the plan of care dated 02/23/22 revealed Resident #18 was at risk for 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, interviews, and record reviews the facility failed to provide Residents #14 and #21 all items on the specified diet menu. This affected two residents (#14 and #21) of two residents reviewed for pureed diets. The facility census was 70. Findings include: 1. Review of the medical record for Resident #21 revealed an admission date of 09/17/20 with diagnoses including Alzheimer's disease and weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively impaired and required set up assistance for eating. Review of the plan of care dated 03/29/23 revealed Resident #21 was at risk for altered nutrition related to Alzheimer's disease. Interventions included providing diet as ordered, encouraging intake, and providing supplements as ordered. Review of the physician's orders dated 02/07/23 revealed orders for a regular diet with pureed texture and thin liquids. 2. Review of the medical record for the Resident #14 revealed an admission date of 04/16/20…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, review of recipe instructions, and review of the facility policy the facility failed to make pureed food according to the recipe to ensure high nutritional value. This affected two residents (#14 and #21) of two residents who were on a pureed diet. The facility census was 70. Finding include 1. Review of the medical record for Resident #21 revealed an admission date of 09/17/20 with diagnoses including Alzheimer's disease and weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively impaired and required set up assistance for eating. Review of the plan of care dated 03/29/23 revealed Resident #21 was at risk for altered nutrition related to Alzheimer's disease. Interventions included providing diet as ordered, encouraging intake, and providing supplements as ordered. Review of the physician's orders dated 02/07/23 revealed orders for a regular diet with pureed texture and thin liquids. 2. Review of the medical…

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 a facility investigation and staff interview the facility failed to provide the necessary services to prevent Resident #4 from ingesting liquid cleaning solution used for perineal care. This affected one resident (#4) of six residents reviewed for accidents. Findings include: Review of the medical record for Resident #4 revealed an admission date of 04/06/19 with diagnoses including Alzheimer's disease, anxiety, anemia, depression, and cognitive communication deficit. Review of the Minimum Data Set (MDS) 3.0 assessment, with an assessment reference date of 02/03/21 revealed the resident had a Brief Interview of Mental Status (BIMS) of 01 indicating severe cognitive impairment. The assessment revealed the resident required extensive assistance from one staff for bed mobility, toilet use and personal hygiene, extensive assistance from one staff for transfers and limited assistance from one staff for locomotion on the unit via wheelchair. The assessment revealed the resident had no behaviors. Review of a nursing progress note, dated 02/02/21 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of Centers for Disease Control and Prevention (CDC) guidance, review of facility policy and staff interview the facility failed to maintain adequate infection control practices during incontinence care for Resident #46 and during personal care for Resident #21 to prevent the spread of infection. This affected one resident (#46) of one resident observed for incontinence care and one resident (#21) of three residents reviewed for isolation precautions. Findings include: 1. Review of the medical record for Resident #46 revealed an admission date of 3/07/19 with diagnoses including Parkinson's disease, muscle weakness, benign prostatic hyperplasia (BPH), abnormal posture, and urine retention. Review of the plan of care, dated 03/14/19 revealed the resident was incontinent of bladder related to impaired mobility and diagnoses of BPH and urine retention with interventions to assist to the bathroom per resident request and toileting program, encourage fluids, assist 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.