Country Court

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, resident interviews and policy review the facility failed to provide showers per resident preference. This affected six of six residents (Resident #19, #21, #26, #30, #43, and #47) reviewed for showers. The census was 53. Findings Include: 1. Review of the medical record for Resident #47 revealed an admission date of 05/23/24. Diagnosis included chronic obstructive pulmonary disease, hemiplegia and hemiparesis affecting the right dominant side and diabetes. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was cognitively intact and under the area of preferences Resident #47 indicated it is very important to choose between a tub bath, shower, bed bath or sponge bath. The resident's cognition, according to subsequent MDS Assessments, has remained intact. Review of the care plan dated 06/07/24 revealed Resident #47 required assistance for bathing related to physical limitation and weakness. Interventions included bathing (required)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, interviews, and facility policy review the facility failed to ensure fall/safety measures were in place for a high fall risk resident. This deficient practice affected one resident (Resident #19) of four residents reviewed for accidents and hazards. The facility census was 53. Findings Include: Review of Resident #19's medical record revealed admission date 12/28/23 with diagnoses including but not limited to Parkinson's Disease, hemiplegia on the left side, anxiety, depression and history of stroke. Review of Resident #19's annual Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact with a Brief Interview Mental Status (BIMS) score of 15 out of a possible 15 dated 01/04/25. Resident #19 required assistance from staff to complete activities of daily living (ADL) tasks including transfers, bathing/showering and personal hygiene tasks related to left side weakness and hemiplegia. Review of Section J - Health Conditions revealed two or more…

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, interview, and facility policy review the facility failed to implement indwelling urinary catheter care orders. This deficient practice affected one resident (Resident #21) of two residents reviewed for urinary catheter care. The facility census was 53. Findings Include: Review of Resident #21's medical record revealed admission date 05/26/23 with diagnoses including but not limited to end stage renal disease, obstructive uropathy, and high blood pressure. Review of Resident #21's urinary catheter care plan dated 06/02/23 revealed Resident #21 had a suprapubic indwelling urinary catheter with interventions including catheter care every shift. Review of Resident #21's signed physician orders revealed an order dated 01/01/25 to change #20 french/10 milliliter (ML) Supraprubic catheter with plug every day shift every 29 days for maintenance, last changed on 12/01/24 and an order dated 02/14/25 to flush the catheter every day shift until clear discharge for sediment. There were no…

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, interview and facility policy review the facility failed to obtain urinary testing prior to administration of an antibiotic medication for a possible urinary tract infection and failed to complete criteria for the use of an antibiotic medication. This deficient practice affected one resident (Resident #21) of two residents reviewed for antibiotic medication use. The census was 53. Findings Include: Review of Resident #21's medical record revealed admission date 05/26/23 with diagnoses including but not limited to end stage renal disease, obstructive uropathy, and high blood pressure. Resident #19 had moderately impaired cognition with a BIMS score of 10 out of possible 15 dated 01/20/25. Resident #21 required assistance with completion of ADL tasks including transfers, bathing/showering, personal hygiene, and had an indwelling urinary catheter. Review of Resident #21's signed physician orders dated 02/01/25 to 02/19/25 revealed an order dated 02/13/25 for antibiotic medication Amoxicillin oral tablet 500 milligram (MG) give one tablet by mouth three…

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

Based on record review, staff interview, and policy review the facility failed to ensure Resident #9 and Resident #17, received education regarding the benefits and potential side effects of the the influenza vaccination. This affected two residents (Resident #9 and #17) of five residents reviewed for vaccinations. The facility census was 52. Findings include: 1. Review of the medical record of Resident #9 revealed an admission date of 02/02/23. Diagnoses included unspecified dementia, schizophrenia, and peripheral vascular disease. Review of Resident #9's Immunization Audit Report revealed the resident refused the influenza vaccine on 02/17/23 and education was not provided. The report did not show evidence the resident was offered the vaccine in 2024 or 2025. 2. Review of the medical record for Resident #17 revealed an admission date of 12/01/24. Diagnoses included peripheral vascular disease, diabetes mellitus, and anxiety disorder. Review of Resident #17's Immunization Audit Report revealed the resident was never offered the influenza vaccine in 2024 or 2025. Interview 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 observation, record review, and interview the facility failed to ensure pressure relieving interventions, including a low air loss mattress was in place for Resident #3 as ordered to promote healing the resident's pressure ulcer. This affected one resident (#3) of three residents reviewed for pressure ulcers. The facility census was 48. Findings include: Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, delusional disorders, type 2 diabetes, anxiety disorder, malignant neoplasm of left breast, and protein-calorie malnutrition. Review of a wound consult note dated 06/12/23 revealed Resident #3 had an in-house acquired Stage III (full-thickness loss of skin, in which adipose (fat) is visible in the ulcer. Slough and/or eschar may be visible) pressure wound to coccyx that measured 3.4 centimeters (cm) long by 0.8 cm wide with 0.6 cm depth. Review of a nurse's note dated 07/28/23 at 5:05 P.M. revealed Resident #3…

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 and interview the facility failed to ensure Resident #50's medical record was maintained in a complete and accurate manner related to wounds and wound care. This affected one resident (#50) of four sampled residents. The census was 49. Findings include: Review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included diabetes, atrial fibrillation, high blood pressure, peripheral vascular disease, end stage renal disease with hemodialysis and lower extremity wounds. The resident was discharged to the hospital on [DATE] and did not return to the facility. Resident #50 had vascular/diabetic wounds, identified on admission to multiple areas of his lower extremities/feet. The resident was noted to receive wound services from an outside provider (wound clinic). Further review revealed the facility had no comprehensive documentation from the wound clinic maintained as part of the resident's medical record to ensure a continuity 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 observations, staff interview, and facility policy review, the facility failed to properly date opened food items in the refrigerator, freezer, and dry storage areas. The facility also failed to use proper hand hygiene during lunch meal service. The deficient practices had the potential to affect all 51 residents who resided in the facility as there were not any residents who were on a nothing by mouth (NPO) diet. Findings Include: 1. During the initial tour on 12/12/22 from 10:30 A.M. to 10:39 A.M. with Dietary Manager #134, the following items were observed not properly dated: In the refrigerator: A bag of garnish lettuce, opened and not dated A bag of leaf lettuce, opened and not dated A bag of green peppers, not dated A bag of red peppers, not dated A large plastic uncovered bin of onions, not dated Interview on 12/12/22 at 10:34 A.M. with Dietary Manager #134 confirmed the above findings. In the freezer: A bag of Key [NAME] Blend frozen vegetables, opened with a tie twisted around the bag, 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 observation and staff interview the facility failed to maintain a safe and comfortable environment. This affected all the residents in the facility. The facility census was 51. Findings included: 1. Observations during the initial tour on 12/12/22 from 9:00 A.M. to 9:25 A.M. revealed; a. The carpet was torn by the 100 hall nurses station. b. The wallpaper was torn above the head of the bed in room [ROOM NUMBER]. c. A large area of the wallpaper was torn off the wall under the window. d. The paint was peeling in the corner of the ceiling and was hanging down. e. the wallpaper was torn in hallway by room [ROOM NUMBER]. f. The carpet had numerous large stains in the hallway between the Director of Nursing and Social Service offices, stains in the carpet by room [ROOM NUMBER], stains in the carpet by rooms [ROOM NUMBERS], between rooms 121 and 123, between rooms [ROOM NUMBERS], at double doors outside of room [ROOM NUMBER], outside room [ROOM NUMBER], outside room [ROOM NUMBER], between rooms [ROOM…

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 4. Review of Resident #31's record revealed an admission date of 03/15/22. Diagnoses included heart failure, congestive heart failure, and hypertension. Review of Resident #31's December 2022 physician orders, revealed an order, dated 03/16/22, for Digoxin 125 micrograms daily for hypertension. Review of Resident #31's pharmacy recommendation, dated 06/09/22, revealed a recommendation for a Digoxin level to be done. Continued reviewed revealed that the physician accepted and agreed to obtaining the level. Review of Resident #31's lab work revealed she had no evidence of a Digoxin level ever being obtained. Interview on 12/15/22 at 1:12 P.M. the Director of Nursing revealed Resident #31's Digoxin level was never obtained. She confirmed the order was missed. 2. Review of the medical record for Resident #4 revealed an admission date on 03/05/2004. Medical diagnoses included schizoaffective disorder-Bipolar type, major depressive disorder, catatonic schizophrenia, drug induced movement disorder, and Chronic…

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, review of resident diets, review of the menu and dietary spreadsheet, and facility policy review, the facility failed to follow the pre-planned menu and provide pureed bread to five residents (Residents #1, #16, #28, #33, and #154) who received a pureed diet. The deficient practice affected all five residents (Residents #1, #16, #28, #33, and #154) who received a pureed diet. The facility census was 51. Findings Include: Review of the list of resident diets provided by the facility revealed there were five residents who received a pureed diet, Residents #1, #16, #28, #33, and #154. Review of the pre-planned lunch menu dated 12/14/22 revealed country fried steak, garlic mashed potatoes, sunshine carrots, choice of roll, cinnamon maple apple cake, country gravy, margarine, and coffee or tea was to be served to residents. Review of the dietary spreadsheet dated 12/14/22 revealed for a pureed diet the following should be served: #8 scoop of pureed country fried steak, #8 scoop of garlic mashed potatoes, #10 scoop of pureed sunshine carrots, 2/3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, resident interview, and facility policy and procedure review, the facility failed to ensure call lights were in working order. This affected one Resident (#103) out of four residents reviewed for accidents, and had the potential to affect 27 residents (#1, #3, #4, #7, #8, #9, #10, #11, #14, #16, #18, #20, #21, #28, #31, #32, #33, #35, #37, #38, #41, #45, #103, #153, #154, #204, #301) who utilized the station #3 shower room. The census was 51. Findings Include: Review of the medical record for Resident #103 revealed an admission date of 11/22/22 and a discharge date of 12/13/22 with the diagnoses of encounter for orthopedic aftercare, osteomyelitis right ankle and foot, atrial fibrillation, dementia, peripheral autonomic neuropathy, gait abnormalities, muscle weakness, need for assist with personal care, arthritis, low back pain, benign prostatic hyperplasia and cataracts. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] 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 medical record review, observation and staff interview the facility failed to ensure Resident #42 had her call light within reach. This affected one resident (Resident #42) of five reviewed for accidents. Findings included: Review of the medical record revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included dementia, generalized anxiety disorder, peripheral vascular disease, congestive heart failure, obsessive compulsive disorder, hypothyroidism, major depressive disorder, and osteoarthritis. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #42 had severely impaired cognition. Observation on 12/12/22 at 9:15 A.M. and 10:05 A.M. revealed the call light for Resident #42 was clipped to the privacy curtain in the middle of the room out of her reach. Interview on 12/12/22 at 10:06 A.M. with the Director of Nursing verified Resident #42 could not reach her call light. This deficiency represents non-compliance investigated under Complaint Number…

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, resident interview, staff interview, and facility policy and procedure review, the facility failed to honor residents shower preferences. This affected three residents (#22, #38, and #103) of six residents reviewed for activities of daily living. The facility census was 51. Findings Include: 1. Review of the medical record for Resident #103 revealed an admission date of 11/22/22 and a discharge date of 12/13/22 with the diagnoses of encounter for orthopedic aftercare, osteomyelitis right ankle and foot, atrial fibrillation, dementia, peripheral autonomic neuropathy, gait abnormalities, muscle weakness, need for assist with personal care, arthritis, low back pain, benign prostatic hyperplasia and cataracts. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #103 required extensive two staff assistance for transfers and bed mobility and extensive one staff assistance for toileting, personal hygiene, dressing, and bathing. Review of the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, review of the Self-Reported Incident (SRI), resident interview and staff interview the facility failed to ensure misappropriation of funds did not occur for Resident #13. This affected one resident (Resident #13) of two reviewed for misappropriation of property. Findings included: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE]. Diagnoses included osteomyelitis, diabetes, diabetic foot ulcer to the left foot, chronic kidney disease, atherosclerotic heart disease, gout, hyperlipidemia, hypothyroidism, obstructive sleep apnea, and benign prostatic hyperplasia. Review of the SRI report dated 08/31/22 revealed Resident #13 reported to a staff member he had money missing from his room. The staff member informed the Administrator who began an investigation. The Administrator spoke with Resident #13 who stated it was $200.00 in a bank envelope and it was last seen the week prior. Resident #13 indicated his wallet had went through 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, review of the facility's investigation, staff interview, and facility policy review, the facility failed to report an allegation of verbal abuse for one resident (Resident #102). This affected one (Resident #102) of two residents reviewed for abuse/misappropriation. The facility census was 51. Findings Include: Review of the closed medical record for former Resident #102 revealed an admission date on 04/05/22 and a discharge date on 04/08/22. Medical diagnoses included paroxysmal atrial fibrillation, type II diabetes mellitus, and weakness. Review of the admission assessment dated [DATE] revealed Resident #102 was alert to person, place, and time and was verbally appropriate. Review of the Five-Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #102 required limited assistance from one staff to complete Activities of Daily Living. The resident's cognition was not assessed at the time of the MDS assessment. Review of progress notes dated from 04/01/22 to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility Self-Reported Incident (SRI), policy review, resident interview and staff interviews the facility failed to thoroughly investigate allegation of misappropriation for Resident #13 and verbal abuse for Resident #102. This affected two residents (Resident #13 and #102) of 17 reviewed for abuse. Findings included: 1. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE]. Diagnoses included osteomyelitis, diabetes, diabetic foot ulcer to the left foot, chronic kidney disease, atherosclerotic heart disease, gout, hyperlipidemia, hypothyroidism, obstructive sleep apnea, and benign prostatic hyperplasia. Review of the SRI report dated 08/31/22 revealed Resident #13 reported to a staff member he had money missing from his room. The staff member informed the Administrator who began an investigation. The Administrator spoke with Resident #13 who stated it was $200.00 in a bank envelope and it was last seen the week prior. Resident #13…

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, review of Pre-admission Screening and Resident Reviews (PASARRs), and facility policy review, the facility failed to update PASARR screenings when two residents (Resident #31 and #34) had additional mental health diagnoses added. This affected two (Residents #31 and #34) of two residents reviewed for PASARR screenings. The facility census was 51. Findings Include: 1. Review of the medical record for Resident #34 revealed an admission date on 02/25/19. Medical diagnoses included unspecified dementia with agitation (10/01/22), Major Depressive Disorder-recurrent (02/25/19), delusional disorders (08/21/19), anxiety disorder (03/29/20), hallucinations (08/21/19), and cognitive communication deficit (02/25/19). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #34 had impaired cognition and scored ten out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The resident scored two out of 27 on the PHQ-9 assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide quarterly care conferences for Resident#17 and failed to invite Resident #5 to her care conference. This affected two (#5 and #17) of two residents reviewed for care conferences. The facility census was 51. Findings include: 1. Review of Resident #17's medical record revealed an admission date 03/25/20. Diagnoses included paraplegia, multiple sclerosis, and trigeminal neuralgia. Review of Resident #17's Minimum Data Set 3.0, dated 10/14/22, revealed the resident had intact cogitation. Interview on 12/12/22 at 10:02 A.M. Resident #17 revealed he did not recall ever being invited to a care conference meeting. Review of a yearly look back of care conferences from 12/2021 through 12/2022 revealed the resident had only had one care conference on 08/30/22. Interview on 12/14/22 at 12:54 P.M. with Licensed Practical Nurse (LPN) #105 who is in charge of setting up care conferences revealed the resident has only had one care conference this year which…

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 record review the facility failed to assist Resident #38 and Resident #154 with nail care. This affected two (#38, #154) of two residents reviewed for nail care. The facility census was 51. Findings include: Review of Resident #38's medical record revealed an admission date of 01/29/20. Diagnoses included seizure disorder, COPD, asthma, obesity, and difficulty in walking. Review of Resident #38's quarterly Minimum Data Set (MDS) 3.0, dated 9/16/22, revealed the resident was cognitively intact, and required one person physical assistance for bathing and set up help for personal hygiene. Observation on 12/12/22 at 12:26 P.M. revealed Resident #38 was noted to have long, dirty, jagged finger nails. Interview at this time with Resident #38 revealed no one has cut them (finger nails) in awhile, but he would like them cut. Interview on 12/13/22 at 9:57 A.M. with the Director of Nursing (DON) verified the resident had long, dirty, jagged nails that needed cut. 2. Review of Resident #154's medical record revealed an admission date of 12/06/22. Diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview and facility policy and procedure, the facility failed to ensure pressure ulcer interventions were in place. This affected one resident (#37) out of one resident reviewed for pressure. The facility identified one resident (#37) with pressure ulcers. The census was 51. Findings Include: Review of the medical record for Resident #37 revealed an admission date of 04/10/19 and the diagnoses of paraplegia, colostomy, protein calorie malnutrition, diabetes type two, spinal stenosis, and reflex neuropathic bladder. Review of the Braden pressure ulcer risk assessment dated [DATE], revealed Resident #37 was at low risk for developing a pressure ulcer. Review of the care plan dated 04/22/19 and updated 11/23/22 revealed Resident #37 had a history of wounds with multiple dates and stages of differing wounds. Interventions included encourage 80 to 100% of diet, float heels off bed, low air loss mattress to bed, encourage turning and repositioning at two hour…

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 record review the facility failed to ensure Resident #35's splinting program was initiated per therapy recommendations. This affected one (#35) of two residents reviewed for therapy recommendations. The facility census was 51. Findings include: Review of Resident #35's medical record revealed an admission date of 09/24/19. Diagnoses included Alzheimer's Disease, chronic pain syndrome, and osteoarthritis. Various observations from 12/12/22 through 12/14/22 revealed Resident #35 had a paper indicating a splinting program protocol sheet on her wall but the resident was not wearing any splints during this time. Her bilateral hands were noted to be contracted during the observations. Review of Resident #35's quarterly Mimium Data Set 3.0, dated 09/07/22, revealed she had impaired cognition and needed total dependence of one person with physical assist for personal hygiene. Review of Resident #35's Occupational Therapy Discharge Summery, dated 05/20/22, revealed the resident and staff will demonstrate 100 percent carry over of contracture management…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, resident interview, family interview, and facility policy and procedure review, the facility failed to ensure residents were not left unattended while unresponsive, resulting in a fall for Resident #103, and failed to thoroughly investigate a fall for Resident #38. This affected two residents (#38 and #103) out of four Residents reviewed for accidents. The census was 51. Findings Include: 1. Review of the medical record for Resident #103 revealed an admission date of 11/22/22 and a discharge date of 12/13/22 with the diagnoses of encounter for orthopedic aftercare, osteomyelitis right ankle and foot, atrial fibrillation, dementia, peripheral autonomic neuropathy, gait abnormalities, muscle weakness, need for assist with personal care, arthritis, low back pain, benign prostatic hyperplasia and cataracts. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #103 required extensive two staff assistance for transfers…

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, review of the medical record and staff interview the facility failed to ensure Resident #42 received her nutritional supplements as ordered. This affected one resident (Resident #42) of four revealed for nutrition. Findings included: Review of the medical record revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included dementia, generalized anxiety disorder, peripheral vascular disease, congestive heart failure, obsessive compulsive disorder, hypothyroidism, major depressive disorder, and osteoarthritis. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #42 had severely impaired cognition and required extensive assistance of one staff member for eating. She did not have a weight loss. Review of the December 2022 physician orders revealed Resident #42 had an order for a magic cup twice daily with lunch and dinner dated 11/10/22. Observation on 12/13/22 at 5:05 P.M. revealed Personal Care Attendant (PCA)#135 gave Resident #42 her meal 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to put in place an end date for Resident #31's as needed anxiety medication, and failed to implement a recommendation to reduce an antidepressant for Residents #4 and #34. This affected three out of six residents reviewed for unnecessary medications (Resident #4, #31, and #34). The facility census was 51. Findings include: 1. Review of Resident #31's record revealed an admission date of 03/15/22. Diagnoses included bipolar disorder, major depressive disorder, and anxiety disorder. Additionally a new diagnosis of hallucinations was added on 03/20/22. Review of Resident #31's December 2022 physician orders revealed an order dated 03/16/22 for Hydroxyzine 25 milligrams (mg) by mouth as needed for anxiety four times daily. The order did not identify a duration for the medication. Review of Resident #31's pharmacy recommendation, dated 04/15/22, revealed a recommendation to add a stop date to the resident's Hydroxyzine 25 mg four times a day. The Physician…

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, policy review, and staff interview the facility failed to ensure Resident #5 was offered a pneumonia vaccine. This affected one resident (Resident #5) out of five reviewed for immunizations. Findings include: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, major depressive disorder, neuromuscular dysfunction of the bladder, obstructive sleep apnea, anxiety disorder, anemia, asthma, cramps and spasms. Further review of the medical record revealed no evidence the resident was offered or received the pneumonia vaccine. Review of the history and physical dated 04/03/15 revealed Resident #5 was not up to date on her immunization and did not want any vaccines. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #5 had intact cognition and was offered the pneumonia vaccine and refused. On 12/14/22 at 2:41 P.M. interview with Director of Nursing verified she could not find any…

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 review of the medical record, resident interviews and staff interviews the facility failed to ensure Resident #153, Resident #201, and Resident #204 received COVID-19 vaccine education. This affected three residents (Resident #153, #201 and #204) of five reviewed for COVID-19 vaccinations. Findings included: 1. Review of the medical record revealed Resident #201 was admitted to the facility on [DATE]. Diagnoses included cellulitis, acute metabolic acidosis, heart failure, diabetes, atrial fibrillation, thyrotoxicois, glaucoma, osteoarthritis, and hypertension. There was no Minimum Data Set (MDS) information available, she had refused the COVID-19 vaccination and there was no documentation COVID-19 vaccination education was given. On 12/14/22 at 10:03 A.M. interview with Resident #201 revealed she had not been given education on the COVID-19 vaccine from the facility. On 12/14/22 at 9:27 A.M. interview with the Director of Nursing (DON) verified the facility did not have documentation they had given…

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

Based on observation, staff interview and policy and procedure review the facility failed to follow infection control guidelines in regards to cleaning a glucometer. This had the potential to affect four residents (Residents #21, #42, #67 and #273) who were ordered to have blood sugar checks by fingerstick on Station II. The facility census was 68. Findings include: On 12/18/19 at 3:57 P.M. observation of a finger stick blood sugar (FSBS) for Resident #273 revealed Licensed Practical nurse (LPN) #245 obtained the FSBS using a glucometer. She then went to the medicine cart, placed a barrier on top of the cart and placed the glucometer on it. Using a sani cloth germicidal wipe, she wiped the glucometer for four seconds and left it on the barrier to dry, reporting it had to dry for five minutes. Review of the manufacturers guidelines on the container revealed it was to remain visibly wet for four minutes. On 12/19/19 at 8:53 A.M. LPN #245 verified she did not follow the facility policy or the manufacturer guidelines of cleaning the glucometer. Four residents (Residents #21, #42, #67…

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 follow physician orders in regards to notification of weight gain. This affected one (Resident #67) of three residents reviewed for hospitalization. The census was 68. Findings include: Resident #67 was admitted to the facility with diagnoses including congestive heart failure, diabetes and stage IV kidney disease. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed her cognition was intact, and she required extensive assistance of two or more staff members for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the plan of care revised 08/23/19 revealed Resident #67 was to be weighed daily and to notify the physician if three pounds were gained in one day or five ponds gained in one week. Review of the resident's recorded weights revealed on 08/20/19 she weighed 176.2 pounds and on 08/21/19 she weighed 179.4 pounds a gain of 3.2 pounds. On 09/26/19 she weighed 177 pounds and 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.

Based on record review and staff interview, the facility failed to provide an estimated cost for services for one (Resident #56) who was discharged from Medicare part A services and remained in the facility. The deficient practice affected one (Resident #56) of three residents reviewed for Beneficiary Notices. The facility census was 68. Findings include: Review of the Beneficiary Notices for Resident #56 revealed the resident was discharged from Medicare part A services on 09/20/19 and remained in the facility. Review of the Advanced Beneficiary Notice of Non-Coverage (ABN) for Resident #56 showed the notice did not include an estimated cost of services following discharge from Medicare part A services. Interview with the Office Manager on 12/17/19 at 4:34 P.M. confirmed the ABN did not include any estimated costs for continued services. The Office Manager stated the training she received did not accurately inform her of how to complete the form. The Office Manager stated she thought only the estimated cost of the resident's room and board needed to be included on the notice.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, staff interview and policy review, the facility failed to provide an accurate smoking assessment with smoking materials secured safely for one (Resident #25) of one resident reviewed for safe smoking. The facility census was 68. Findings include: Resident #25 was admitted on [DATE] with diagnoses including dementia, major depression, anxiety and heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a four out of 15 on the Brief Interview for Mental Status (BIMS) assessment which was considered severely impaired cognition. Review of the smoking assessment dated [DATE] completed by Registered Nurse (RN) #127 revealed Resident #25 had cognitive loss, could light his own cigarettes, smoked two to five cigarettes daily, and the staff did not store his lighter and cigarettes. He was safe to smoke unsupervised outside in the enclosed shelter. Interview on 12/17/19 at 5:30 P.M. with Licensed Practical Nurse (LPN) #204…

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 care plans included all components of care in regards to respiratory care and urinary tract infections. This affected two (Residents #15 and #16) of 19 residents whose care plans were reviewed. The facility census was 68. Findings include: 1. Resident #15 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia, depression and anxiety. Review of a five day minimum data set (MDS) assessment dated [DATE] revealed his cognition was severely impaired, he required extensive assistance of one staff member for bed mobility, toileting and personal hygiene and total assistance of two or more staff members for transferring. Review of the physicians orders revealed an order dated 09/24/19 for BiPap (a device that assists with breathing) at home setting at bedtime. Review of the care plan revealed it failed to include information related to use of BiPap at bedtime. This was verified during interview on 12/18/19…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and staff interview, the facility failed to maintain accurate care plans related to alarms and the use of pain medications. This affected two (Resident #15 and Resident #1) of 19 residents reviewed for care plans. The facility census was 68. Findings include: 1. Resident #15's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia, depression and anxiety. Review of a five day minimum data set (MDS) assessment dated [DATE] revealed his cognition was severely impaired, he required extensive assistance of one staff member for bed mobility, toileting and personal hygiene and total assistance of two or more staff members for transferring. Review of the plan of care dated 11/19/19 revealed the resident was to have a mobility monitor on when in bed. Observations of Resident #15 from 12/16/19 to 12/18/19 revealed he had no mobility monitor in place while he was in bed. On 12/18/19 at 10:55 A.M. interview 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 observation, record review and staff interview the facility failed to ensure residents received necessary assistance with activities of daily living. This affected two (Resident #9 and #15) of two residents review for activities of daily living. The facility census was 68. Findings include: 1. Resident #9 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, chronic kidney disease, respiratory failure and chronic obstructive pulmonary disease. Review of the annual minimum data set (MDS) dated [DATE] revealed his cognition was intact and he required extensive assistance of one person with bed mobility, transfers, dressing, toileting and personal hygiene. Observation on 12/16/19 at 12:18 P.M. revealed his clothes were soiled with a brown substance and a dried white substance and he had unkempt facial hair. On 12/17/19 at 7:55 A.M. Resident #9 was wearing the same soiled clothing and was still unshaven. At 1:15 P.M. observation revealed the same stained clothes and he remained…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to follow physician orders in regards to obtaining daily weights. This affected one (Resident #67) of three residents reviewed for hospitalization. The facility census was 68. Findings include: Resident #67 was admitted to the facility with diagnoses including congestive heart failure, diabetes and stage IV kidney disease. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed her cognition was intact. Review of physicians orders revealed an order dated 07/30/19 to obtain weights daily and to notify the physician if three pounds were gained in one day or five pounds gained in one week. Review of Resident #67's recorded weights revealed no evidence weights were obtained on 07/31/19, 08/01/19, 08/04/19, 08/07/19, 08/14/19, 8/16/19, 08/17/19, 08/18/19, 08/23/19, 08/30/19, 09/01/19, 09/05/19, 09/14/19, 09/15/19, 09/18/19, 09/19/19, 09/20/19, 09/28/19, 10/01/19, 10/04/19, 10/05/19, 10/09/19, 10/11/19, 10/12/19, 10/17/19, 10/19/19,…

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, staff interview and policy review the facility failed ensure smoking materials were safely secured for one (Resident #25) of one resident reviewed for safe smoking. The affected one (Resident #25) and had the potential to affect two additional residents (#36 and #7). The facility census was 68. Findings include: 1. Clinical record review revealed Resident #25 was admitted on [DATE] with diagnoses including dementia, major depression, anxiety and heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a four out of 15 on the Brief Interview for Mental Status (BIMS) assessment which was considered severely impaired impaired cognition. Review of the smoking assessment dated [DATE] completed by Registered Nurse (RN) #127 revealed Resident #25 had cognitive loss, could light his own cigarettes, smoked two to five cigarettes daily, and the staff did not store his lighter and cigarettes. He was safe to smoke unsupervised, outside 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview and policy review the facility failed to provide physician ordered respiratory care for Resident #7. This affected one of two residents reviewed for respiratory care. The facility census was 68. Findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety and heart disease. Review of a physician's order dated 04/01/18 revealed the resident was to use oxygen (O2) at three liters per minute (LPM) as needed to keep her O2 saturation at 90 percent per checks by pulse oximeter (a device when attached to the finger determines O2 saturation). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. Review of the Medication Administration Record (MAR) from 10/01/19 to present revealed no evidence the resident's O2 saturation levels were monitored. Review of documentation under the vitals tab revealed the resident's oxygen level was 90 percent on 10/07/19 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 staff interview and record review, the facility failed to stop administering blood pressure medication prior to dialysis at the dialysis center's request. This affected one (Resident #49) of one resident reviewed for dialysis treatment. The facility census was 68. Findings include: Review of Resident #49's medical record revealed an admission date of 07/18/19 with the following medical diagnoses: aneurysm of artery of upper extremity, other complication of vascular dialysis catheter, aneurysm of artery of lower extremity, diabetes mellitus with diabetic chronic kidney disease, end stage renal disease, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, chronic obstructive pulmonary disease (COPD), muscle weakness, essential primary hypertension (high blood pressure), dependency on renal dialysis (a process for purification of the blood) major depressive disorder, generalized anxiety disorder, and peripheral vascular disease. Review of Resident #49's physician orders…

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 the pharmacy identified perimeters for opioid medications. This affected one (Resident #15) of five residents reviewed for unnecessary medications. The census was 68. Findings include: Review of Resident #15's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia, depression and anxiety. Further review revealed a five day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed his cognition was severely impaired, he required extensive assistance of one staff members for bed mobility, toileting and personal hygiene and total assistance of two or more staff members for transferring. Review of the physicians orders revealed orders on 09/24/19 for Tramadol HCL (opioid pain medication) 50 milligrams (mg) every six hours as needed for pain and Tramadol HCL 50 mg two tabs as needed every six hours for pain and on 11/15/19 Oxycodone Immediate (opioid pain medication) 5 mg…

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 non-pharmacological interventions were attempted and blood pressures monitored prior to administration of medications. This affected one (Resident #15) of five residents reviewed for unnecessary medications. The census was 68. Findings include: Review of Resident #15's medical record revealed he was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia, depression and anxiety. Further review revealed a five day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed his cognition was severely impaired, he required extensive assistance of one staff members for bed mobility, toileting and personal hygiene and total assistance of two or more staff members for transferring. Review of the physicians orders revealed orders on 09/24/19 Tramadol HCL 50 milligrams (mg) every six hours as needed for pain and Tramadol HCL 50 mg two tablets as needed every six hours for pain and on 11/15/19 Oxycodone Immediate 5…

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 interviews and policy review, the facility failed to support the use of psychoactive medications for two (Residents #41 and #45) of five residents reviewed for unnecessary medications. The census was 68. Findings include: 1. Clinical record review revealed Resident # 41 was admitted on [DATE] with diagnosis including bipolar disorder. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition. The resident had a physician's order dated 05/01/19 for a psychoactive medication (Risperidone), antipsychotic, at 1.0 milligram (mg) daily which was decreased to 0.5 mg on 12/17/19. Review of the resident's behavior intervention documentation in the Medication Administration Record (MAR) since 11/01/19 revealed there was nothing specific about what behaviors were monitored or evidence the resident was having any behaviors to support the use of the psychoactive medication. Review of the resident's progress notes since…

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.