Otterbein New Albany

Based on observation and staff interview, the facility failed to prepare, distribute and serve food following proper infection control. This had the potential to affect the 12 of 12 residents residing in House 6690. The census was 56. Findings include: On 05/12/25 observations in the kitchen between 11:50 A.M. and 12:16 P.M. revealed Certified Nurse Aide (CNA) #100 washed her hands, put her hair up in a hair net, then put on gloves, gathered baked beans and hot dogs, removed her gloves and put on new gloves without washing her hands. CNA #100 opened the hot dogs and placed them in a pan of water and puts on the stove. She removed her gloves and put on new gloves without washing her hands and opened the baked beans and placed them in a pan. CNA #100 then removed her gloves and washed her hands. At 12:12 P.M. CNA #100 again put on a hair net and then gloves without washing her hands, added brown sugar to the baked beans using her gloves, removed her gloves and her hair net and walked down the hall without washing her hands. At 12:16 P.M. observation revealed CNA #151 washed her hands…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and facility policy and procedure review, the facility failed to follow physician orders for obtaining weekly weights to monitor weight gain related to congestive heart failure. This affected one resident (#29) of five resident record reviews. The census was 56. Findings included: Review of Resident #29's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, diabetes, atrial fibrillation, left above knee amputation, morbid obesity, non pressure ulcer of the left leg, lymphedema, chronic kidney disease and absence of right toes. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed her cognition was intact. She was independent with eating, required set up or clean up assistance with oral hygiene, substantial/maximal assistance with toileting, partial/moderate assistance for bathing/showering, and personal hygiene and supervision/touching assistance for turning and repositioning. She 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, medical record review, staff interview, review of facility menu, and review of a dietary initiative, the facility failed to follow the menus and recipes for meals. This had the potential to affect all residents with the exception of Resident #8 who the facility identified as not eating anything my mouth. The facility census was 52. Findings include: 1. Review of the menu for 08/13/24 revealed residents were to receive tuna salad on croissant (one each), half a cup of mixed vegetables, five to eight crackers and cheese, one orange push pop, and milk. Observation in House #400 on 08/13/24 of the lunch meal at 11:17 A.M. revealed State Tested Nurse Aide (STNA) #172 preparing tuna salad while not using any measuring utensils. Interview on 08/13/24 at 11:29 A.M. with STNA #172 revealed lunch would be tuna salad, crackers, cheese, and mixed vegetables. Observation on 08/13/24 at 12:05 P.M. revealed STNA #172 preparing resident meals. The meals included a small bowl of fruit, four to five slices…

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 review of food storage temperature logs, and staff interview, the facility failed food was stored in a safe and sanitary manner. This had the potential to affect all 51 residents receiving food from the facility. The facility identified Resident #8 as eating nothing by mouth. The census was 52. Findings include: 1. Observation on 08/12/24 from 9:06 A.M. to 9:49 A.M., in House #300, revealed food debris was noted in both the pantry refrigerator and the kitchen refrigerator. Observation of the refrigerator in the pantry revealed it felt warm and the sensor connected to it read 72 degrees Fahrenheit (F). State Tested Nurse Aide (STNA) #126 pointed out the internal temperatures which indicated the refrigerator was 54 degrees F and the freezer was 24 degrees F. The refrigerator contained milk, eggs, cheese, coleslaw, and pasta salad. The freezer contained frozen vegetables, chicken, lasagnas, ground turkey, and pierogies, and these foods were starting to soften. Interview with STNA #126 at the time of the observation revealed the refrigerator was connected to a…

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 review, the facility failed to develop a comprehensive plan of care to address resident needs and conditions as required. This affected four (#13, #26, #35, and #42) of 25 sampled residents reviewed. The facility census was 52. Findings Include: 1. Review of the medical record for Resident #13 revealed an initial admission date of 05/05/22 with the latest readmission of 08/8/24. Diagnoses including but not limited to acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), Parkinson's disease, restlessness and agitation, anxiety disorder, major depressive disorder, seizures, hypertension, hyperlipidemia, insomnia, dementia, and atrial fibrillation. Review of Resident #13's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors, however had wandering behaviors. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and resident and staff interview, the facility failed to change and date oxygen tubing and supplies as ordered and failed to store respiratory equipment in a safe and sanitary manner. This affected four (#13, #42, #154, and #155) of seven residents reviewed for respiratory care. The census was 52. Findings Include: 1. Review of the medical record for Resident #154 revealed initial admission date 05/28/24 and re-admission date 08/01/24. Diagnoses included chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and other diseases of the bronchus. Resident #154 had intact cognition and required limited assist from staff for activities of daily living (ADLs) tasks and medication administration. Review of the respiratory care plan for Resident #154 dated 05/31/24 revealed oxygen used as ordered and breathing treatments as ordered. Review of the physician orders for Resident #154 revealed an order dated 08/02/24 to change oxygen tubing weekly every night…

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 infection control during a dressing change, failed to implement enhanced barrier precautions, and failed to maintain sanitary placement of a urinary catheter bag. This affected seven (#8, #11, #25, #102, #103, #154, and #155) of eight residents reviewed for infection control practices. The facility census was 52. Findings Include: 1. Review of the medical record for Resident #8 revealed an admission date of 10/04/21 with the diagnoses including Down syndrome, obstructive sleep apnea, chronic respiratory failure, asthma, and stage four pressure injury to right buttock. Resident #8 was dependent for all care, personal hygiene needs, and administration of medications and treatments. Resident #8 had impaired cognition and required a wheelchair for mobility. Review of the physician orders for Resident #8 revealed an order dated 07/04/24 for a right ischial wound with instructions to change wound vacuum three times a week…

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, medical record review, staff interview, and facility policy review, the facility failed to provide residents with a dignified dining experience. This affected one (#46) of two residents reviewed for dignity. The facility census was 52. Findings include: Review of the medical record revealed Resident #46 was admitted to facility on 06/08/24 with diagnoses that included cerebral infarction, arteriovenous malformation of cerebral vessels, and chronic motor or vocal tic disorder. Review of a Minimum Data Set (MDS) assessment on 06/13/24 revealed Resident #46 needed substantial to maximal assistance with eating. Observation on 08/14/24 at 9:01 A.M. revealed State Tested Nurse Aide (STNA) #196 was standing while feeding Resident #46 his breakfast meal in his bed. Interview with STNA #196 on 08/14/24 at 9:01 A.M. confirmed STNA #196 was standing while feeding Resident #46. STNA #196 stated that on some occasions, Resident #46 had asked her to sit down while feeding him. Review of a facility document for senior lifestyle neighborhood standards for dining, approved…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, medical record review, and review of invoices, the facility failed to ensure residents had a means to contact staff members of needs and services that were individualized to the resident's needs. This affected one (#102) of one resident reviewed for call lights. The facility census was 52. Findings include: Review of the medical record for Resident #102 revealed an admission date of 07/19/24 with diagnoses including quadriplegia, type two diabetes mellitus, depression, atherosclerosis of other arteries, osteoarthritis, spinal stenosis, paroxysmal atrial fibrillation, and neuromuscular dysfunction of the bladder. Review of Resident #102's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #102 had moderately impaired cognition. Interview on 08/12/24 at 11:55 A.M. with Resident #102 revealed she was quadriplegic but could move her head. She reported the facility had not provided a call light for her to use and because of this she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, and medical record review, the facility failed to ensure residents were provided the right to chose their eating utensils to promote a homelike dining experience. This affected one (#21) of one residents reviewed for choices. The facility census was 52. Findings Include: Review of the medical record for Resident #21 revealed an initial admission date of 07/31/23 with the diagnoses including but not limited to dementia, colostomy, diabetes mellitus, hypertension, obstructive reflux uropathy, morbid obesity, malignant neoplasm of colon, and osteoarthritis. Review of Resident #21's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of Resident #21's current plan of care revealed no care plan indicating the resident was not able to have a table knife at meals. Review of Resident #21's monthly physician orders for August 2024 identified orders dated 06/10/24 for the resident to receive a…

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 resident funds account review, medical record review, and staff interview, the facility failed to ensure residents were assisted with spending down their resident trust accounts once the balance reached $200 less than the Medicaid allowable limit. This deficient practice affected one resident (#43) of four residents reviewed for personal funds. The facility census was 52. Findings Include: Review of the medical record for Resident #43 revealed an admission date 08/18/23 with a diagnosis of Alzheimer's disease with late unset. Resident #43 had dual payer sources consisting of Medicaid and a commercial insurance. Review of Resident #43's document for resident fund management authorization and agreement to handle resident funds form dated 9/01/23, revealed the resident's account type was marked as non-transferable account which included no automatic transfer of deposits to pay for care cost. The form was signed by Resident #43's Power of Attorney (POA). Review of Resident #43's account statement dated 01/02/24 to 08/02/24 revealed several debits and credits on the account…

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, review of maintenance logs, and staff interview, the facility failed to maintain a safe and homelike environment. This affected two (#31 and #36) of nine residents reviewed for environment. The facility census was 52. Findings include: 1. Review of the medical record revealed Resident #36 was admitted on [DATE] with diagnoses that included autistic disorder, heart failure, epilepsy, lack of coordination, insomnia, and anxiety. Observation on 08/13/24 at 3:41 P.M., 08/14/24 at 4:32 P.M., and 08/19/24 at 1:09 P.M. revealed Resident #36's room wall had paint chips missing from the wall in an area measuring seven inches long by eight inches wide, and the window frame next to Resident #36's bed had chipped wood along the bottom sill, exposing jagged sharp wood splinters. Interview with State Tested Nurse Aide (STNA) #77 on 08/15/24 at 2:57 P.M. confirmed that the bottom window sill next to Resident #36's bed was jagged and sharp. STNA #77 stated if there are maintenance…

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 review, the facility failed to insure residents were free from physical restraints. This deficient practice affected one (#31) of one residents reviewed for physical restraints. The facility census was 52. Findings Include: Review of Resident #31's medical record revealed an admission date of 11/14/21 with diagnoses including dementia, anxiety, osteoarthritis, major depressive disorder, and history of falls. Resident #31 required assistance from staff for transfers and activities of daily living (ADLs) tasks and used a wheelchair for mobility. Resident #31 had impaired cognition and could be redirected during times of agitation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had delusions, was always incontinent of urine and bowel, and was at risk for skin impairment. Resident #31 had a Brief Interview of Mental Status (BIMS) score of zero out of 15 reflecting severely impaired cognition. Review…

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 Pre-admission Screening and Resident Review (PASARR) evaluations were updated upon determination or newly evident or possible serious mental disorders. This affected one (#4) of one reviewed for PASARR. The facility census was 52. Findings Include: Review of the medical record for Resident #4 revealed an initial admission date of 11/16/17 with the latest readmission of 02/26/24, and with the diagnoses including but not limited to bipolar disorder, morbid obesity, hypertension, dementia with anxiety, peripheral vascular disease, polyarthritis, cataracts, alcohol dependence with alcohol induced dementia, generalized muscle weakness, difficulty in walking, mixed incontinence, hyperlipidemia, low back pain, sensorineural hearing loss, osteoarthritis, dermatitis, and insomnia. A diagnoses of anxiety disorder was added on 04/24/23. Review of Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, medical record review, and facility policy review, the facility failed to thoroughly assess residents for activity preferences, provide activities of resident interest, and failed to ensure activities were completed as planned. This affected three (#6, #42, and #103) of five residents reviewed for activities. The facility census was 52. Findings include: 1. Review of the medical record for Resident #103 revealed an admission date of 07/19/24 with diagnoses including quadriplegia, type two diabetes mellitus, depression, atherosclerosis of other arteries, osteoarthritis, spinal stenosis, paroxysmal atrial fibrillation, and neuromuscular dysfunction of the bladder. Review of Resident #103's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #103 had moderately impaired cognition. Review of Resident #103's plan of care revealed activities and activities preferences were not addressed. Review of Resident #103's activity screening…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and medical record review, the facility failed to adequate assess and provide treatments for non-pressure skin injuries, and facility to provide treatment as ordered to prevent edema. This affected three (#13, #42, and #102) of 25 medical records reviewed for care. The facility census was 52. Findings include: 1. Review of the medical record for Resident #102 revealed an admission date of 07/23/24 with diagnoses including adult failure to thrive, hypertensive heart disease with heart failure, acute respiratory failure with hypoxia, and restlessness and agitation. Review of Resident #102's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition. Resident #102 had an indwelling catheter. Review of Resident #102's progress note dated 08/03/24 revealed Resident #102 obtained a skin tear following her daughter transferring her. The nurse assessed the area and identified a small skin tear to the left shin measuring 2.0 centimeters…

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 and staff interview, medical record review, and review of a facility policy, the facility failed to ensure pressure ulcers were timely assessed and and monitored and failed to ensure treatments were administered as ordered. This affected one (#103) of six residents reviewed for pressure ulcers. The facility census was 52. Findings include: Review of the medical record for Resident #103 revealed an admission date of 07/19/24 with diagnoses including quadriplegia, type two diabetes mellitus, depression, atherosclerosis of other arteries, osteoarthritis, spinal stenosis, paroxysmal atrial fibrillation, and neuromuscular dysfunction of the bladder. Review of Resident #103's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #103 had moderately impaired cognition. The resident had one unstageable pressure ulcer (obscured full-thickness skin and tissue loss) and one stage four pressure ulcer (full-thickness skin and tissue loss). Review of Resident #103's admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to implement an effective intervention to reduce fall risk and determine effectiveness following a fall. This affected one (#4) of six residents reviewed for accidents. The facility census was 52. Findings Include: Review of the medical record for Resident #4 revealed an initial admission date of 11/16/17 with the latest readmission of 02/26/24. Diagnoses including but not limited to bipolar disorder, morbid obesity, hypertension, dementia with anxiety, peripheral vascular disease, polyarthritis, anxiety disorder, cataracts, alcohol dependence with alcohol induced dementia, generalized muscle weakness, difficulty in walking, mixed incontinence, hyperlipidemia, low back pain, sensorineural hearing loss, osteoarthritis, dermatitis and insomnia. Review of the plan of care dated 05/25/18 revealed Resident #4 was at risk for falls related to history of falls. Interventions included anticipate and meet needs, assist…

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 comprehensively assess a Resident #42's bowel and bladder function and implement interventions and/or a program to restore function and prevent further decline in bowel and bladder function. Additionally, the facility failed to ensure Resident #11 and #102, with urinary catheters received appropriate and timely care of the catheter as ordered. This affected three (#11, #42, and #102) of six residents reviewed for bowel and bladder status and urinary catheters. The facility census was 52. Findings include: 1. Review of Resident #42's medical record revealed an initial admission date of 11/21/23 with the latest readmission of 02/16/24. Diagnoses including but not limited to Parkinson's disease, vascular dementia, abnormalities of gait and mobility, hypercholesterolemia, major depressive disorder, obstructive sleep apnea, benign neoplasm of peripheral nerves and autonomic nervous system, spinal stenosis, cervical disc disorder, adult failure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, medical record review, and facility policy review, the facility failed to obtain resident weighs as ordered, failed to thoroughly assess Resident #103's nutritional status and contributing factors to nutritional deficits, and failed to provided double portioned food items as ordered to prevent malnutrition/weight loss. Additionally, the facility failed to ensure supplements were provided to Resident #20 as ordered and failed to re-weigh the resident following a significant change to the resident's weight per (facility) policy. This affected two (#20 and #103) of six residents reviewed for nutrition. The facility census was 52. Findings include: 1. Review of the medical record for Resident #103 revealed an admission date of 07/19/24 with diagnoses including quadriplegia, type two diabetes mellitus, depression, atherosclerosis of other arteries, osteoarthritis, spinal stenosis, paroxysmal atrial fibrillation, and neuromuscular dysfunction of the bladder. Review…

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 timely address pharmacy recommendations. This affected two (#5 and #26) of five residents reviewed for unnecessary medications. The facility census was 52. Findings include: 1. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses that included dementia without behavior disturbance, severe protein calorie malnutrition, chronic obstructive pulmonary disease, depression, and adult failure to thrive. Review of Resident #5's medication regimen review (MRR) by the pharmacist on 02/08/24 noted the resident had been using the antidepressant Remeron 7.5 milligrams mg for approximately six months without an attempted gradual dose reduction (GDR) or documented contraindication to a GDR. The request was made to the physician to consider a trial medication discontinuation. The physician responded on 05/03/24 indicating the physician disagreed, and a GDR was contraindicated. An interview on 08/14/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to residents were appropriately monitored as ordered when administered medications. This affected two (#102 and #103) of five residents reviewed for unnecessary medications. The facility census was 52. Findings include: 1. Review of the medical record for Resident #103 revealed an admission date of 07/19/24 with diagnoses including quadriplegia, type two diabetes mellitus, depression, atherosclerosis of other arteries, osteoarthritis, spinal stenosis, paroxysmal atrial fibrillation, and neuromuscular dysfunction of the bladder. Review of Resident #103's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #103 had moderately impaired cognition. Review of Resident #103's plan of care dated 08/08/24 revealed Resident #103 had diabetes mellitus. Interventions included checking all of the body for breaks in skin, checking blood sugar as ordered, dietary consultation for nutritional regimen, discussing nutritional…

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 residents were free from significant medication errors. This affected one (#26) of five residents reviewed for unnecessary medications and one (#6) of one residents reviewed for pain management. The facility census was 52. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 07/27/22 with diagnoses including sepsis, cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type two diabetes mellitus, major depressive disorder, peripheral vascular disease, muscle weakness, and hypothyroidism. Review of Resident #26's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 had intact cognition. Review of Resident #26's physician order dated 12/03/22 revealed an order for the blood pressure medication losartan potassium 25 mg one tablet by mouth one time a day for hypertension to be held for blood pressure less…

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, medical record review, and resident and staff interview, the facility failed to secure and store medications appropriately. This affected two (#25 and #44) of five residents observed during medication administration. The facility census was 52. Findings Include: 1. Review of the medical record for Resident #25 revealed admission date 08/06/24 with diagnoses including stomach cancer, adult failure to thrive, esophagus cancer, dysphalgia, and high blood pressure. Resident #25 required assistance from staff for activities of daily living (ADLs) tasks, medication administration, and personal hygiene care. Observation on 08/15/24 at 8:15 A.M., during medication administration for Resident #25, revealed several containers of opened medications sitting on the bedside table in the room including Flonase nasal spray 50 micrograms (mcg) dispensed from the pharmacy on 07/25/24 with expiration date 03/27, two bottles of Ofloxacin ear drops 0.3 percent (%) with one bottle's expiration date as 01/26 and the second bottle's expiration date as 03/25 (there was no open 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 review of the medical record, staff interview, and review of a facility policy, the facility failed to timely obtain laboratory values as ordered. This affected two (#13 and #39) of five residents reviewed for urinary tract infections (UTI). The facility census was 52. Findings include: 1. Review of the medical record for Resident #13 revealed an initial admission date of 05/05/22 and readmission date of 08/08/24 with diagnoses including acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, Parkinson's disease without dyskinesia, anxiety disorder, major depressive disorder, dementia, hemiplegia affecting left nondominant side, dysphagia, peripheral vascular disease, and epilepsy. Review of Resident #13's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had a severe cognitive impairment. Review of Resident #13's progress note dated 08/10/24 at 2:36 P.M. revealed the nurse informed Family Nurse Practitioner (FNP) #313 of the resident's unusual behavior…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to report results of laboratory results in a timely manner. This affected two (#13 and #20) of 25 residents reviewed for laboratory values. The census was 52. Findings include: 1. Review of the medical record revealed Resident #20 was admitted to facility on 05/22/23 with diagnoses that included traumatic subdural hematoma, Parkinson's disease, heart failure, hemiplegia, hemiparesis, depressive disorder, and seizures. Review of Resident #20's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 01, indicative of severe impairment for daily decision making. Resident #20 received a substantial to maximal level of assistance with eating and had lost a significant amount of weight as of 07/02/24. Review of the nutrition progress note on 07/18/24 revealed Resident #20 lost a significant amount of weight, but that was now stabilized, with a weight range 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.

Based on observation and resident and staff interview, the facility failed to ensure appetizing food was served to the resident. This affected one (#39) of 11 resident residing in House #300. The facility census was 52. Findings include: Interview on 08/12/24 at 9:49 A.M. with Resident #39 revealed the facility's green beans always tasted awful, like they had come straight from the can. Observation in House #300 on 08/14/24 a 12:47 P.M. revealed State Tested Nurse Aide (STNA) #126 was finishing preparing lunch. The residents were served soup, berries, a soft pretzel, green beans, and juice. After all meals were served at 1:39 P.M., a sample test tray was consumed. The green beans were noted to have no flavor and were rubbery. Interview on 08/14/24 at 1:39 P.M. with STNA #126 revealed the green beans had been warmed up from a can, and she only added a sprinkle of salt to the green beans because not everybody in the building liked pepper.

Based on observation, medical record review, review of menus, staff interview, and review of a dietary initiative, the facility failed to ensure residents were served food items as ordered to meet their needs. This affected two (#33 and #102) of seven residents on a soft and bite sized diet. The facility census was 52. Findings include: Review of the medical record for Resident #33 revealed an admission date of 04/02/24 with diagnoses including paranoid schizophrenia, centrilobular emphysema, auditory and visual hallucinations, and hyperlipidemia. Review of Resident #33's physician order dated 06/27/24 revealed an order for a regular diet with a soft and bite sized texture. Review of the medical record for Resident #102 revealed an admission date of 07/23/24 with diagnoses including adult failure to thrive, hypertensive heart disease with heart failure, acute respiratory failure with hypoxia, and restlessness and agitation. Review of Resident #102's physician order dated 07/23/24 revealed an order for a regular diet with a soft and bite sized texture. Review of the lunch menu for…

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

Based on medical record review and staff interview, the facility failed to maintain a complete and accurate medical record. This affected two (#4 and #13) of 25 sampled residents. The facility census was 52. Findings Include: 1. Review of the medical record for Resident #4 revealed an initial admission date of 11/16/17 with the latest readmission of 02/26/24. Diagnoses included bipolar disorder, morbid obesity, hypertension, dementia with anxiety, peripheral vascular disease, polyarthritis, generalized muscle weakness, and difficulty in walking. Review of the fall investigation form dated 04/01/24 at 3:00 A.M. revealed Resident #4 was found in her doorway sitting on the floor. The resident reported she was walking and fell. Review of Resident #4's medical record revealed the fall occurrence on 04/01/24 at 3:00 A.M. was not documented in the resident's medical record. On 08/19/24 at 10:18 A.M., interview with Regional Nurse #350 verified the 04/01/24 fall was not documented in Resident #4's medical record. 2. Review of the medical record for Resident #13 revealed an initial admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure residents receiving antibiotics were properly assessed prior to implementation of antibiotic therapy and antibiotics appropriately prescribed. This affected three (#4, #11, and #39) of five residents reviewed for urinary tract infections (UTI). The facility census was 52. Findings include: Review of the medical record for Resident #11 revealed an admission date of 12/05/23 with diagnoses including ulcerative colitis, hypertension, type two diabetes mellitus, neuromuscular dysfunction of the bladder, dysuria, and chronic pain. Review of Resident #11's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition. Resident #11 had an indwelling catheter. Review of Resident #11's plan of care dated 12/06/23 revealed Resident #11 had an indwelling catheter related to neurogenic bladder. Removal was clinically contraindicated per the physician and the resident 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 interview, record review and facility policy review, the facility failed to report and investigate an injury of unknown origin. This affected one (Resident #17) of one resident reviewed for injury of unknown origin. The facility census was 56. Findings include: Review of the medical record for Resident #17 revealed an admission date of 07/01/23 with diagnoses including unspecified severe protein calorie malnutrition, acute kidney failure, dementia, anxiety, depression, osteoporosis, repeated falls, and dislocated left shoulder. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #17 had significant cognitive impairment with physical behaviors towards others. Resident #17 required extensive assistance of two persons for bed mobility, transfers and toileting. Resident #17 had no falls documented on the assessment. Review of the nursing progress notes for Resident #17 dated 09/08/23 at 11:30 A.M. revealed the State Tested Nursing Assistant (STNA) reported to the nurse that Resident #17 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 medical record review, staff interview, and facility policy review, the facility failed to appropriately monitor all residents who had significant weight decline. This affected one (Resident #60) of three residents reviewed for nutrition. Census was 53. Findings Include: Review of the medical record revealed Resident #60 was admitted to the facility on [DATE]. Her diagnoses were degenerative disease of nervous system, congestive heart failure, cerebellar ataxia, hyperlipidemia, diabetes mellitus, anemia, osteoarthritis, polyneuropathy, primary open-angle glaucoma, bursitis, anxiety disorder, overactive bladder, major depressive disorder, shoulder lesion, non-toxic goiter, dementia, thyrotoxicosis, weakness, acquired absence of left breast and nipple, transient cerebral ischemic attack, respiratory failure, and hypokalemia. Review of her Minimum Data Set (MDS) assessment, dated 05/15/23, revealed she was cognitively intact. Review of Resident #60's weights, dated February 2023 to August 2023, 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.

Based on staff interview, observations, medical record review, and facility policy review, the facility failed to implement infection control practices to prevent the potential spread of illness, related to hand hygiene, glove use, personal protective equipment, and tuberculosis screening. This had the potential to affect all 12 residents in House Two (Resident #7, #8, #10, #15, #21, #26, #34, #41, #43, #44, #49, and #103), four residents (Resident #5, #17, #36, and #52) of four residents reviewed for infection control, with the potential to affect all 56 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 04/09/22 with diagnoses including congestive heart failure (CHF), type 2 diabetes (DM2), acute myocardial infarction (MI), atrial fibrillation (a-fib), hypertension (HTN), hyperlipidemia (HLD), and acute and chronic respiratory failure with hypoxia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 04/16/22, revealed the resident had impaired cognition with a Brief Interview 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.

Based on staff interview, observations, medical record review, and facility policy review, the facility failed to ensure resident call lights/pendants were within reach. This affected five residents (Resident #4, #24, #17, #52, and #203) of five reviewed for accomodation of needs. Findings include: 1. Review of the medical record for Resident #17 revealed an admission date of 10/24/17 with diagnoses including fracture of the right tibia shaft, protein-calorie malnutrition, Alzheimer's disease, osteoarthritis, lumbar region intervertebral disc degeneration, dementia, need for assistance with personal care, unsteadiness on her feet, mood disorder, and muscle weakness. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 04/26/22, revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of zero out of 15 (severe cognitive impairment). The resident required extensive to total assistance of one to two staff members for all Activities of daily Living (ADL's) including eating. Review of the plan of care dated 07/19/22 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.

Based on staff interview and facility policy review, the facility failed ensure newly hired employees had a criminal background check prior to beginning to work in the facility. This had the potential to affect all 56 residents residing in the facility. Findings include: Review of personnel files with Human Resource #265 on 07/21/22 at approximately 3:00 P.M. revealed Maintenance #238 was hired on 06/09/22, Assistant Director of Nursing (ADON) #239 was hired on 07/14/21, Temporary Nurse Aide (TNA) #235 was hired on 05/05/22, and TPN #256 was hired on 03/25/22. He also confirmed the facility did not have documented evidence a criminal back ground check was completed for those identified employees. Interview on 07/21/22 at approximately 3:11 P.M. with Director of Nursing revealed if the personnel files did not contain the criminal background checks, the facility was not able to provide evidence the checks were completed. Review of the facility policy titled,Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated 12/06/16, revealed the policy of the facility 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.

Based on staff interview, resident interview, observations, and facility policy review, the facility failed to sufficiently staff house three to meet the needs of residents. This affected all 12 residents (Resident #4, #5, #6, #9, #17, #24, #30, #36, #38, #52, #203, and #204) of 12 residents residing in House Three. Findings include: Review of the facility assessment revised 01/01/22 revealed the general staffing plan to ensure the facility had sufficient staff to meet the needs of the residents at any given time, consider if and how the degree of fluctuation in the census, and acuity levels impact staffing needs. The staffing plan included one director of nursing (DON), one assistant director of nursing (ADON), one minimum data set (MDS) nurse, who were all full time on days, two floor nurses on days and on nights, 10 elder assistants (EA) on days and evenings and five EA's on nightshift, a business office Manger (BOM), quality of life coordinator full time on days, housing coordinator full time on days, maintenance full time on days, a coach full time on days, and a guide full…

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, resident interview, staff interviews, and facility meal schedule review, the facility failed to provide an adequate number of dietary staff to ensure food was delivered/served in a palatable and appetizing manner. This had the potential to affect 12 (Residents #4, #5, #6, #9, #17 #24, #30, #36, #38, #52, #203, and #204) of 35 residents observed for meal service. Findings Include: Observations on 07/20/22 from 11:45 A.M. to 12:55 P.M., revealed Elder Assistant (EA) #301 was only staff preparing and cooking all the food items for residents in the 300 house. During the food preparation and cooking period, no residents were being served food, because she was responsible for continuing to cook all the resident food and prepare side dishes, including beginning stages of cutting a watermelon. At 12:25 P.M., Dietitian #300 stepped in and assisted EA #301 with cutting the watermelon so she could finish preparing and cooking the hamburgers, baked beans and french fries. At 11:55 A.M., 12:24 P.M., and 12:46 P.M., Resident #301 told staff that was walking around her that…

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, resident interview, staff interviews, and facility policy review, the facility failed to serve food at a safe and appetizing temperature. This had to the potential to affect 12 (Residents #4, #5, #6, #9, #17 #24, #30, #36, #38, #52, #203, and #204) of 35 residents observed as being served meals. Findings Include: Observations on 07/20/22, starting at 11:45 A.M., revealed Elder Assistant (EA) #301 started to cook lunch, which included hamburgers, baked beans, and french fries. At 12:12 P.M., the first seven hamburgers were completed and the cooking temperatures were between 172 and 187 degrees Fahrenheit. The hamburgers were placed on a dinner plate and put into the microwave. At 12:34 P.M., seven more hamburgers were cooked, with cooking temperatures being between 164 and 180 degrees. They were placed on top of the already cooked hamburgers that were on the dinner plate. All of them were then covered with aluminum foil and placed on the kitchen counter. At 12:43 P.M., the french fries were taken out of the oven and placed on the stove and kitchen counter; 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 observations, staff interview, and facility policy review, the facility failed to properly store and date foods and failed to use appropriate hand hygiene while serving a lunch meal. The deficient practices had the potential to affect all 24 residents who resided in the 200 and 300 houses (Residents #4, 6, 7, 8, 9, 10, 15, 17, 21, 24, 26, 30, 34, 36, 38, 41, 43, 44, 49, 52, 103, 203, 204, and 312) and nine residents (Residents #45, 46, 153, 154, 155, 156, 157, 158, and 159) who resided in 500 house. One resident (Resident #39) in 500 house was on a nothing by mouth (NPO) diet. Findings Include: Observation of Elder Assistant (EA) #249 on 07/18/22 from 12:06 P.M. to 12:14 P.M. serving lunch in the 500 house showed EA #249 wearing gloves. The EA opened the plastic bag of submarine buns with her gloved hands, reached into the bag, and grabbed a bun from the bag. The EA placed the bun on a plate with her gloved hands. The EA was then observed touching the handle on the pot holding the meatballs and marinara sauce and the serving spoon. The EA picked up the plate with the…

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

Based on staff interview, observations, medical record review, and facility policy review, the facility failed to store an indwelling catheter bag and provide incontinence care in a dignified manner per facility policy for Resident #5. This affected one resident (Resident #5) of one resident reviewed for urinary catheters. Findings include: Review of the medical record for Resident #5 revealed an admission date of 04/09/22 with diagnoses including neuromuscular dysfunction of the bladder. Review of the physician orders for July revealed an order dated 04/15/22 to change the residents urinary catheter (16 french (fr) with a 30 ml balloon) as needed for a neurogenic bladder, to change the urinary catheter bag, tubing, and graduate weekly and to provide urinary catheter care each shift. Further review of the orders revealed orders dated 07/01/22 for 30-60 milliliter (ml) irrigation of the residents catheter with normal saline as needed for patency and for the residents catheter to be changed as needed for obstruction. Review of the comprehensive Minimum Data Set (MDS) assessment, 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 record review, staff interviews, and policy review, the facility failed to notify the physician of a change in condition for Resident #46. The deficient practice affected one resident (Resident #46) of one reviewed for change of condition. The facility census was 58. Findings Include: Review of the medical record for Resident #46 revealed an original admission date on 04/15/22. The resident was hospitalized on [DATE] and had a readmission date on 06/20/22. Medical diagnoses included benign neoplasm of cerebral meninges, non-traumatic subarachnoid hemorrhage, encephalopathy, sepsis (06/20/22), Type II Diabetes Mellitus, personal history of irradiation, other seizures, and unspecified symptoms involving cognitive functions and awareness. Review of the nurse's notes in May 2022 revealed on 05/22/22 at 6:35 P.M., Resident #46 was noted with right side facial swelling and upon palpitation it was hard and warm. Lungs were not clear and sounded congested. Vital signs were: blood pressure 162/95, pulse 104,…

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, review of minimum data set (MDS) assessments, staff interview, and facility policy review, the facility failed to ensure MDS assessments were completed accurately for two residents (Residents #2 and #55). The deficient practice affected two (Residents #2 and #55) of two residents reviewed for accurate assessments. Findings Include: 1. Review of the medical record for Resident #2 revealed an admission date on 01/15/22 with medical diagnoses including dementia without behavioral disturbance, type II diabetes mellitus with hyperglycemia, major depressive disorder, and anxiety disorder. Review of the the physician orders for July 2022 revealed Resident #2 had orders for Seroquel (an antipsychotic) 50 milligrams (mg) daily dated 02/10/22 and Seroquel 100 mg daily at night dated 02/09/22. Review of the Medication Administration Record (MAR) for May, June, and July 2022 revealed Resident #2 was administered Seroquel twice daily as ordered. Review of the quarterly Minimum Data Set (MDS) 3.0…

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

Based on observations, medical record review, resident interviews, staff interviews, facility policy review, and resident council minutes review, the facility failed to offer activities to meet the residents needs and preferences. This affected one resident (Resident #5) of three residents reviewed for activities. The census was 56. Findings Include: Review of the medical record for Resident #5 revealed an admission date of 04/09/22 with diagnoses including congestive heart failure (CHF) and acute and chronic respiratory failure with hypoxia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 04/16/22, revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of nine out of 15 (moderate cognitive impairment). The resident required extensive to total assistance of two or more staff for all Activities of daily Living (ADL's). Review of the physician orders for July revealed an order dated 04/09/22 for permission for the resident to participate in on and off campus activities. Review of the plan of care dated 04/09/22 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, record review, and facility policy review, the facility failed to monitor bruising on Resident #46's bilateral legs. The deficient practice affected one resident (Resident #46) of one resident reviewed for bruising/skin. Findings Include: Review of the medical record for Resident #46 revealed an original admission date on 04/15/22 and readmission date on 06/20/22 with medical diagnoses including benign neoplasm of cerebral meninges, non-traumatic subarachnoid hemorrhage, encephalopathy, sepsis, type II diabetes mellitus, personal history of irradiation, other seizures, and unspecified symptoms involving cognitive functions and awareness. Review of the readmission skin assessment dated [DATE] revealed Resident #46 did not have any bruising on her legs noted on the assessment. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 was rarely or never understood. Per the staff assessment, the resident had severely impaired cognition.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, record review, and facility policy review, the facility failed to timely investigate a fall with major injury and failed to complete neurochecks per facility protocol for Resident #2. The deficient practice affected one resident (Resident #2) of two residents reviewed for accidents. Findings Include: Review of the medical record for Resident #2 revealed an admission date on 01/15/22. Medical diagnoses included dementia without behavioral disturbance, type II diabetes mellitus with hyperglycemia, major depressive disorder, anxiety disorder, and shortness of breath (SOB). Review of the fall risk assessments dated 01/15/22, 03/31/22, and 06/24/22 revealed the resident was at risk for falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 was rarely or never understood. Per staff assessment, Resident #2 had severely impaired cognition. Resident #2 required extensive assistance from one staff for most Activities of Daily Living…

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 staff interview, resident interview, observations, medical record review, facility policy review, the facility failed to ensure Resident #4 and Resident #17 received nutritional supplements as ordered. This affected two Residents (#4 and #17) of two residents reviewed for nutrition. Findings include: 1. Review of the medical record for Resident #4 revealed an initial admission date of 08/18/15 and a re-entry date of 03/23/20 with diagnoses including anemia and heart failure. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/01/22, revealed the resident was rarely/never understood, had long and short-term memory problems, and was moderately cognitively impaired. The resident required extensive assistance of two or more staff for all Activities of daily Living (ADL's). Review of the plan of care dated 07/07/22 revealed the resident had congestive heart failure with a risk for breathing issues, edema, and weight fluctuations. Interventions included monitoring cardiac status, check breath sounds, and monitor/document labored breathing and/or the use 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.

Based on staff interview, resident interview, observations, medical record review, facility policy review, the facility failed to ensure oxygen (O2) was administered, stored, labeled, and dated properly. This affected three residents (Resident #4, #5, and #52) of three residents reviewed for respiratory care. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 04/09/22 with diagnoses including congestive heart failure (CHF) and acute and chronic respiratory failure with hypoxia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 04/16/22, revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of nine out of 15 (moderate cognitive impairment). The resident required extensive to total assistance of two or more staff for all Activities of daily Living (ADL's). Further review of the MDS revealed the resident received oxygen therapy. Review of the plan of care dated 04/09/22 revealed Resident #5 had alteration in her respiratory status related to acute/chronic respiratory failure.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to timely and adequately review pharmacy recommendations. This affected one (Resident #48) of five residents reviewed for unnecessary medications. Findings Include: Resident #48 was admitted to the facility on [DATE] with diagnoses including pain in left knee, muscle weakness, difficulty in walking, type II diabetes, hypertension, lymphedema, anxiety disorder, Alzheimer's disease, major depressive disorder, dementia, and cognitive communication deficit. Review of Resident #48's Minimum Data Set (MDS) assessment, dated 07/01/22, revealed she had a significant cognitive impairment. Review of Resident #48 medical records revealed a pharmacy recommendation made on 09/07/21 to review Duloxetine 60 milligrams (mg) for a gradual dose reduction (GDR). Physician disagreed with the recommendation with the justification of follows psych. It was signed by the physician on 09/09/21. Facility psychiatrist made a progress note…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to provide proper justification for the use of psychotropic medications. This affected two residents (Resident #2, and Resident #48) of five residents reviewed for unnecessary medications. The census was 56. Findings Include: 1. Resident #48 was admitted to the facility on [DATE]. Her diagnoses were pain in left knee, muscle weakness, difficulty in walking, type II diabetes, hypertension, lymphedema, anxiety disorder, Alzheimer's disease, major depressive disorder, dementia, and cognitive communication deficit. Review of her Minimum Data Set (MDS) assessment, dated 07/01/22, revealed she had a significant cognitive impairment. Review of Resident #48 medical records revealed a physician order for Zyprexa (antipsychotic medication) 2.5 milligrams (mg). The justification documented for this medication was dementia with psychosis. Review of Resident #48 diagnoses list and medical record, revealed she did not have a…

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.