Laurels Of Mt Vernon The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and staff interview, revealed the facility failed to ensure accuracy of assessments. This affected one (Resident #47) of two residents reviewed for dental assessments. The census was 89. Findings include: Review of Resident #47 revealed they were admitted on [DATE]. Diagnoses included alcoholic cirrhosis of the liver, alcohol dependence with alcohol induced persisting dementia, acute kidney failure, viral hepatitis C, severe protein calorie malnutrition, and anxiety. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed his cognition was not intact, was independent with eating, turning and reposition, required supervision or touching assistance with oral hygiene, toileting, bathing/showering, dressing and personal hygiene, with no obvious or likely cavity or broken natural teeth. Observation on 02/03/25 at 3:49 P.M. revealed his lower teeth were broken and missing with decay of teeth. Interview on 02/05/25 at 2:04 P.M. with Director of Nursing…

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 develop a comprehensive care plan for Resident #47's dental needs. This affected one (Resident #47) of two residents reviewed for dental care. Findings include: Review of Resident #47 revealed they were admitted on [DATE]. Diagnoses included alcoholic cirrhosis of the liver, alcohol dependence with alcohol induced persisting dementia, acute kidney failure, viral hepatitis C, severe protein calorie malnutrition, and anxiety. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed his cognition was not intact, was independent with eating, turning and reposition, required supervision or touching assistance with oral hygiene, toileting, bathing/showering, dressing and personal hygiene, with no obvious or likely cavity or broken natural teeth. Review of Resident #47's medical record revealed no evidence the facility developed a comprehensive care plan for dental care. Observation on 02/03/25 at 3:49 P.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, observation and staff interview, the facility failed to ensure pressure reduction interventions were in place at all times for Resident #53. This affected one resident (Resident #53) of three residents reviewed for pressure ulcer prevention. Findings include: Review of the medical record for Resident #53 revealed an admission date of 01/07/25 with diagnoses including but not limited to injury of left Achilles tendon, muscle wasting, and bradycardia. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #53 had moderately impaired cognition, required dependent for activities of daily living (ADLs) and had a surgical wound. Review of the care plan dated 01/08/25 revealed Resident #53 was at risk for impaired skin integrity. Interventions included but not limited to encourage to float heels while in bed and assist as needed. Review of the physician's orders for February 2025 revealed an order for heel elevation boots to bilateral feet while…

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 interview the facility failed to ensure fall interventions were in place for Resident #60. This affected one resident (Resident #60) of one reviewed for falls. The facility census was 89. Findings include: Review of the medical record for Resident #60 revealed an admission date of 10/21/23 with diagnoses including end stage renal disease, obstructive uropathy, chronic kidney disease stage four, osteoarthritis, major depressive disorder and paroxysmal atrial fibrillation. Review of Resident #60 dated 10/26/23 revealed Resident #60 was at risk for fall related injury and falls related to muscle weakness with limited mobility and end stage renal disease (ERSD), psychoactive medication use antidepressant for depression, antianxiety for anxiety. Interventions included activities to access for in-room activities and preferences, encourage the resident to wear appropriate footwear, call light within reach, commonly used items within reach, move closer to nurses' station…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, interview, and facility policy review the facility failed to ensure proper storage of Resident #8 and Resident #78 respiratory equipment, and failed to implement an order for a breathing improvement device for Resident #286. This affected three residents (Resident #8, Resident #78, and Resident #286) out of four residents reviewed for respiratory care. The facility census was 89. Findings Include: 1. Review of the medical record for Resident #8 revealed an admission date 11/30/18 and re-admission date 12/03/24 with the following diagnoses including but not limited to acute respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), sleep apnea, and type two diabetes mellites. Resident #8 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of nine out of a possible 15. Resident #8 required assistance for completion of Activities of Daily Living (ADLs) tasks including medication administration and the use of a wheelchair for mobility.…

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 ensure non-pharmacological pain interventions were implemented for one resident. This affected one resident (Resident #237) out of two residents reviewed for pain management. The facility census was 89. Findings Include: A review of Resident #237's medical record revealed admission date of 01/15/23 with the following diagnoses including but not limited to acute kidney failure, pulmonary emboli (clot), alcohol abuse, bipolar disorder, and weakness. Resident #237 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 14 out of a possible 15 dated 01/22/25. Resident #237 required assistance from staff to complete Activities of Daily Living (ADL) tasks including transfers and personal hygiene tasks. Resident #237 was non-ambulatory and used a wheelchair for mobility. A review of Resident #237's physician orders revealed an order dated 01/22/25 with a revision date of 02/04/25 for pain medication Oxycodone HCL oral tablet 10 milligrams (MG) give one tablet by mouth every four…

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 and interview the facility failed to ensure laboratory testing was completed for residents. This affected one resident (Resident #237) out of five residents reviewed for use of unnecessary medications. The facility census was 89. Findings Include: A review of Resident #237's medical record revealed admission date of 01/15/23 with the following diagnoses including but not limited to bacteremia, acute kidney failure, pulmonary emboli (clot), alcohol abuse, bipolar disorder, and weakness. Resident #237 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 14 out of a possible 15 dated 01/22/25. Resident #237 required assistance from staff to complete Activities of Daily Living (ADL) tasks including transfers and personal hygiene tasks. Resident #237 was non-ambulatory and used a wheelchair for mobility. A review of Resident #237's physician's history and physical progress note dated 01/21/25 authored by the facility's medical director revealed laboratory tests requested for Complete Blood Count (CBC) and Basic Metabolic Panel (BMP)…

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, revealed the facility failed to ensure routine dental services were in place for Resident #47. This affected one (Resident #47) of two residents reviewed for dental care. The census was 89. Findings include: Review of Resident #47 revealed they were admitted on [DATE]. Diagnoses included alcoholic cirrhosis of the liver, alcohol dependence with alcohol induced persisting dementia, acute kidney failure, viral hepatitis C, severe protein calorie malnutrition, and anxiety. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed his cognition was not intact, was independent with eating, turning and reposition, required supervision or touching assistance with oral hygiene, toileting, bathing/showering, dressing and personal hygiene, with no obvious or likely cavity or broken natural teeth. Observation on 02/03/25 at 3:49 P.M. revealed his lower teeth were broken and missing with decay of teeth. Interview on 02/05/25 at 2:04 P.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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a facility investigation, review of the facility abuse policy, and interview, the facility failed to protect from abuse Resident #87, who exhibited severe cognitive impairment (with a Brief Interview for Mental Status score of two) and had the diagnoses of unspecified dementia and cognitive communication deficit. This resulted in verbal and physical abuse occurring on 04/12/24 at 7:28 P.M. by Licensed Practical Nurse (LPN) #655 when Resident #87 was yelled at and forcibly placed back into the wheelchair. This affected one resident (#87) of six residents reviewed for dementia care. The facility census was 83. Findings Include: Review of the medical record for Resident #87 revealed an admission date of 04/04/24 with the diagnoses including unspecified dementia, cognitive communication deficit, depression, anxiety, and difficulty in walking. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to ensure medications were dated and disposed of according to industry standards. This had the potential to affect all 85 residents residing at the facility. The facility census was 88. Findings include: 1. Observation on [DATE] at 7:40 A.M. revealed during medication room review of the facility's second medication room refrigerator and opened multi-use vial of Aplisol Tuberculin solution without the date it was opened. The vial of Aplisol Tuberculin solution had been delivered from the pharmacy on [DATE] and had an expiration date of 09/2024. Interview on [DATE] at 7:55 A.M. with Licensed Practical Nurse (LPN) #212 confirmed the opened multi-use vial of Aplisol Tuberculin solution did not have the date it was opened, and the vial was delivered to the facility from the pharmacy on [DATE]. Review of the manufacturer's information sheet for Aplisol Tuberculin solution revealed, Vials in use more than 30 days should be discarded due to possible…

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 ensure the use of a lap buddy was assessed to be the least restrictive device for Resident #42 and failed to identify the device as a physical restraint once the resident could no longer independently remove the device on command. This affected one resident (#42) of one resident reviewed for physical restraints. The facility census was 88. Findings include: Review of Resident #42's medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including Huntington's Disease, anxiety disorder, major depression, traumatic brain injury, and insomnia. Review of Resident #42 fall history revealed Resident #42 fell while she was pushing the empty wheelchair on 10/10/22. Following the incident, the facility fall committee implemented the use of a lap buddy (a cushion which fits into to the armrests of a wheelchair and lays across a resident's upper thighs while sitting in a wheelchair) as a fall…

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 medications were administered as ordered to treat medical conditions of Resident #59 and/or medications were administered as needed/ordered based on the resident's hemodialysis schedule. This affected one resident (#59) of six residents reviewed for unnecessary medication use. The facility census was 88. Findings include: Review of the medical record for Resident #59 revealed an admission date of 07/03/23 with diagnoses including end stage renal disease with dependence on renal dialysis, type two diabetes mellitus, chronic viral hepatitis C, unspecified protein-calorie malnutrition, and hemiplegia and hemiparesis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 had intact cognition. She was on a therapeutic diet. She was on dialysis. Review of the physician order dated 10/10/23 revealed Resident #59 had dialysis at DaVita every Tuesday, Thursday, and Saturday. a. Review of the physician order dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and facility policy review the facility failed to implement fall interventions for Resident #17. This affected one resident (#17) of two residents reviewed for fall interventions. The facility census was 88. Findings include: Review of Resident #17's medical record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including stroke, diabetes mellites type two, sleep apnea, depression, anxiety, and breast cancer. Review of Resident #17 fall investigation dated 03/03/23 revealed Resident #17 slid out of bed and was on the floor beside the bed. Resident #17 had no injuries. Review of Resident #17's fall care plan revised on 03/03/23 revealed the intervention for the fall out of bed was to place a perimeter mattress on Resident #17's bed. Review of Resident #17's physician orders revealed a signed order dated 03/29/23 for a perimeter mattress to bed at all times, check every shift. Review of the Minimum Data Set (MDS) assessment dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to provide timely care and interventions for Resident #183 related to a urinary tract infection (UTI). The facility also failed to provide proper oversight, assessment, and follow up of urinary catheters for Resident #60 and Resident #334. This affected one resident (#183) of four residents reviewed for UTI and two residents (#60 and #334) of two residents reviewed for urinary catheters. The facility census was 88. Findings include: 1. Resident #183 was admitted to the facility on [DATE] with diagnoses including displaced intertrochanteric fracture of right femur, type II diabetes, hypertension, insomnia, muscle weakness, difficulty walking, cognitive communication deficit, hypothyroidism, atrial fibrillation, chronic obstructive pulmonary disease, enterocolitis, chronic kidney disease (stage III), depression, heart failure, hyperlipidemia, edema, and anxiety disorder. Review of the 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 record review, interview, and facility policy review the facility failed to ensure weekly weights were obtained for Resident #46 who had significant weight loss. This affected one resident (#46) of two residents reviewed for nutrition. The facility census was 88. Findings include: Review of the medical record for Resident #46 revealed an admission date of 10/13/22 with diagnoses including Parkinson's disease, dementia, chronic obstructive pulmonary disease, type two diabetes, heart failure, depression, and dysphagia. Review of the plan of care dated 10/18/22 revealed Resident #46 was at nutritional or dehydration risk related to diagnoses, and as of 09/23/23 a significant weight gain or loss in one and three months. Interventions included administering medications as ordered, encouraging choices within ordered diet, observing for signs of dehydration, obtaining labs as ordered, obtaining weight, regular diet, supplements as ordered, and referring to dietitian as needed. Review of the quarterly Minimum…

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 respiratory equipment was stored in a clean environment. This affected one resident (#17) of one resident reviewed for respiratory care. The facility census was 88. Findings include: Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including stroke, diabetes mellites type II, sleep apnea, depression, anxiety, and breast cancer. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had impaired cognition and required extensive assistance from staff for completion of activities of daily living (ADL) tasks including bed mobility and transfers. Review of Resident #17's physician's orders revealed a signed physician order dated 10/09/23 for Budesonide inhalation suspension (steroid) 0.5 milligram (mg) per milliliter (ml) to be administered 2.0 ml via nebulizer machine every twelve hours for respiratory care. Review of Resident #17's medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to complete pre and post dialysis assessments for Resident #59. This affected one resident (#59) of one resident reviewed for dialysis. The facility census was 88. Findings include: Review of the medical record for Resident #59 revealed an admission date of 07/03/23 with diagnoses including end stage renal disease with dependence on renal dialysis, type II diabetes mellitus, chronic viral hepatitis C, unspecified protein-calorie malnutrition, and hemiplegia and hemiparesis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 had intact cognition. She was on a therapeutic diet. She was on dialysis. Review of the plan of care dated 09/20/23 revealed Resident #59 was at risk for complications related to dialysis due to end stage renal disease. Interventions included administering medications as ordered, not using shunted arm for blood pressure, checking bruit and thrill every shift, utilizing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to comprehensively assess/provide written description of pain and provide evidence of non-pharmacological interventions prior to administering as needed pain medications for Resident #60. This affected one resident (#60) of five residents reviewed for unnecessary medications. The facility census was 88. Findings include: Review of the medical record for Resident #60 revealed an admission date of 08/20/21 with diagnoses including other muscle spasm, type II diabetes mellitus, lymphedema, generalized anxiety disorder, major depressive disorder, post-traumatic stress disorder, bipolar disorder, and hypertension. Review of the plan of care dated 08/23/21 revealed Resident #60 was at risk for pain related to diagnoses, muscle spasms, and back pain. Interventions included administering medications as ordered, anticipating the residents need for pain relief, evaluating the effectiveness of pain interventions, observing for probable cause…

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 have proper justification for the use of psychotropic medication for Resident #75. This affected one resident (#75) of six residents reviewed for unnecessary medications. The facility census was 88. Findings include: Resident #75 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, degenerative disease of nervous system, amnesia, aphasia, hyperlipidemia, cognitive communication deficit, major depressive disorder, insomnia, hypertension, anxiety disorder, and constipation. Review of Resident #75's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive impairment. Review of Resident #75's current physician orders revealed she was prescribed Depakote (anticonvulsant used to treat bipolar disorder) 125 milligrams (mg) twice daily for dementia without behavioral disturbance, psychotic disturbance, mood…

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 maintain a safe, homelike environment. This affected two residents (#17 and #21) of 88 residents residing in the facility. Findings include: 1. Review of the medical record revealed Resident #21 was re-admitted to the facility on [DATE] with the diagnoses including obesity, bipolar disorder, major depression, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had intact cognition and required extensive assistance from staff to complete activities of daily living (ADL) tasks including bed mobility and transfers. Observation on 10/16/23 at 9:25 A.M. revealed Resident #21's half of the room was nearest the window. Resident #21 uses a large bariatric bed which was in the far corner of the room beneath the light fixture. Immediately to the left side of Resident #21's bed was a wall with multiple patched areas. The wall was blue in color, and the patched areas were white in color with rough edges…

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 interviews, record reviews, and document reviews, the facility failed to maintain sufficient levels of nursing staff to ensure resident care needs and preferences were met. This had the potential to affect all 86 residents that resided in the facility. Findings include: 1. Review of the medical record for Resident #34 revealed an admission date of 03/20/21 and the diagnoses of anxiety, high blood pressure, schizophrenia, insomnia, and depression. Review of the Minimum Data Set (MDS) Assessment, dated 07/12/21, revealed the resident had intact cognition and required extensive assistance of two staff for bed mobility, transfers, and toilet use, extensive assistance of one staff for personal hygiene, and limited assistance of one staff for locomotion via wheelchair. Review of the care plan dated 03/24/21 revealed the resident had an ADL self care performance deficit and required assistance with ADL's and mobility related to activity intolerance, fatigue, weakness, impaired balance, pain, shortness 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, observation, resident interview, staff interview, and facility policy and procedure, the facility failed to complete showers per resident preference and complete nail care as needed. This affected five (#34, #35, #43, #76, and #80) out of five residents reviewed for activities of daily living (ADL's). Findings Include: 1. Review of the medical record for Resident #34 revealed an admission date of 03/20/21 and the diagnoses of anxiety, high blood pressure, schizophrenia, insomnia, and depression. Review of the Minimum Data Set (MDS) Assessment, dated 07/12/21, revealed the resident had intact cognition and required extensive assistance of two staff for bed mobility, transfers, and toilet use, extensive assistance of one staff for personal hygiene, and limited assistance of one staff for locomotion via wheelchair. Review of the care plan dated 03/24/21 revealed the resident had an ADL self care performance deficit and required assistance with ADL's and mobility related to activity…

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 resident record review, staff interview, and facility policy review, the facility failed to complete updated Pre-admission Screening and Resident Reviews (PASRR) which included all mental health diagnoses. This affected two residents (Resident #43 and Resident #44) out of two reviewed for PASRR screenings. Findings Include: 1. Review of Resident #43's medical record revealed an admission date of 11/14/12 with medical diagnoses including other osteoporosis without current pathological fracture. On 07/13/17, additional medical diagnoses were added including major depressive disorder, bipolar disorder, delusional disorders, and other schizoaffective disorders. On 01/05/18, the resident was diagnosed with metabolic encephalopathy. Review of the PASRR screening dated 12/04/12 revealed only mood disorder was included on the review. No other medical diagnoses were included on the PASRR screening. Interview on 09/14/21 at 04:56 PM with Social Services (SS) #511 confirmed Resident #43's most recent PASRR was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility policy, the facility failed to properly assess Resident #35 after a fall. In addition, the facility failed to ensure Resident #291 safely smoked based on the individualized smoking assessment. This affected two residents (Resident #35 and Resident #291) of five residents reviewed for accidents. Findings include: 1. Record review for Resident #35 revealed an admission date of 07/13/21 with diagnoses including adult failure to thrive, difficulty in walking and muscle weakness. Diagnosis dated 09/08/21 included fracture of unspecified part of neck of left femur subsequent encounter for closed fracture with routine healing. Record review of Resident #35's fall assessment, dated 07/14/21, revealed the resident was at risk for fall related injury and falls related to weakness and history of falling. Review of Resident #35's care plan, dated 07/14/21, revealed the resident was at risk for fall related injury and falls related to history 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 and staff interview, the facility failed to complete monthly pharmacy recommendations. This affected three residents (#34, #47 and #69) out of six residents reviewed for unnecessary medications. Findings Include: 1. Review of the medical record for Resident #34 revealed an admission date of 03/20/21 and the diagnoses of anxiety, high blood pressure, schizophrenia, insomnia, and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was intact, and required extensive assistance of two staff for bed mobility, transfers, and toilet use, and limited assistance of one staff for locomotion via wheelchair. Review of Resident #34's physician orders revealed orders for Trazodone 50 milligrams (mg) at night for insomnia, Latuda 20 mg for schizophrenia, Buspirone 10 mg twice daily, Eliquis 2.5 mg twice daily for blood clot prevention, and Alprazolam 1 mg three times daily for anxiety. Review of the care plan, dated 03/26/21, revealed the…

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