Continuing Healthcare At Beckett House

Based on record review, policy review, and interview, the facility failed to ensure a psychotropic medication had a 14 day stop date. This affected one resident (#14) of five residents reviewed for unnecessary medication. The census was 77. Findings include: Review of Resident #14's medical record revealed a 05/28/21 admission with diagnoses including Alzheimer's disease, adjustment disorder with mixed anxiety and depression, dementia, hypertension, hypothyroidism, difficulty in walking, osteoarthritis, insomnia, pain in right knee, lumbago with sciatica, muscle wasting and atrophy, and abnormalities of gait and mobility. Review of the 05/07/25 quarterly Minimum Data Set (MDS) Assessment revealed the resident was severely impaired for daily decision making with disorganized thinking, that comes and goes, changes in severity. Physician orders included Compound: Ativan (Lorazepam) Gel Apply to skin topically two times a day for target behaviors: agitation, anxiety milligram (mg) per milliliter (ml), apply 0.5 ml to inner wrist and apply to wrist topically every 12 hours as needed 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 observation, record review, and interview, the facility failed to clean a dependent resident's eyeglasses. This affected one resident (#23) of four residents reviewed for activities of daily living. The census was 77. Findings include: Review of Resident #23's medical record revealed a 09/30/21 admission and a 02/10/24 readmission. Diagnoses include type 2 diabetes, chronic obstructive pulmonary disease, peripheral vascular angioplasty with implants and grafts, Alzheimer's disease, weakness, cognitive communication deficit, abnormality of gait and mobility, muscle wasting and atrophy, dementia, vitamin D deficiency, osteoarthritis of left knee, neuromuscular dysfunction of bladder, hypertension, anemia, benign prostatic hyperplasia, transient ischemic attack and cerebral infarction without residual deficits, cardiomegaly, moderate protein calorie malnutrition, atherosclerotic heart disease, congestive heart failure, gastroesophageal heart disease, anxiety disorder, depressive disorder, hyperlipidemia, retention of urine, overactive bladder and history of pulmonary embolism,…

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

Based on record review and interview, the facility pharmacist failed to identify a psychotropic medication needed a 14 day stop date. This affected one resident (#14) of five residents reviewed for unnecessary medication. The census was 77. Findings include: Review of Resident #14's medical record revealed a 05/28/21 admission with diagnoses including Alzheimer's disease, adjustment disorder with mixed anxiety and depression, dementia, hypertension, hypothyroidism, difficulty in walking, osteoarthritis, insomnia, pain in right knee, lumbago with sciatica, muscle wasting and atrophy, and abnormalities of gait and mobility. Review of the 05/07/25 quarterly Minimum Data Set Assessment revealed the resident was severely impaired for daily decision making with disorganized thinking, that comes and goes, changes in severity. Physician orders included Compound: Ativan (Lorazepam) Gel Apply to skin topically two times a day for target behaviors: agitation, anxiety milligram (mg) per milliliter (ml), apply 0.5 ml to inner wrist and apply to wrist topically every 12 hours as needed for target…

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 accurate documentation in the medical record. This affected one resident (#12) of one resident reviewed for edema. The census was 77. Findings included: Review of Resident #12's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included hemiparesis and hemiplegia, cerebral infarction, peripheral insufficiency, congestive heart failure, chronic ischemic heart disease, aphasia, high blood pressure, major depression, and anxiety. Review of the quarterly minimum data set assessment dated [DATE] revealed his cognition was moderately impaired. He required set up or clean up assistance for eating, oral hygiene, dependent for toileting, substantial/maximal assistance for bath/showering, personal hygiene and turning and repositioning. The resident was occasionally incontinent of urine and always continent of bowel. Review of the physician orders revealed an order dated 03/18/25 to apply compression…

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 of medication administration, and staff interview , the facility failed to ensure proper hand washing was completed during medication administration. This affected two residents (#50 and #57) of six residents observed for medication administration. Findings include: On 06/11/25 observation between 7:07 A.M. and 7:15 A.M. revealed Licensed Practical Nurse (LPN) #136 put on gloves and prepared medication for Resident #57, removed her gloves and put on new gloves without washing her hands and went in to the Resident #57's room and administered the medication, then removed her gloves and used hand sanitizer. LPN #136 then again put on new gloves, prepared medication for Resident #50, changed her gloves and went into the resident's room to administer medications. On 06/11/25 at 7:18 A.M. interview with LPN #136 verified she had not washed her hands between glove changes.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and interview, the facility failed to maintain a clean and safe living environment for residents. This affected one (#40) of three residents sampled and two additional residents (#6 and #67) identified during environmental tour. The facility census was 78. Findings include: 1. Medical record review revealed Resident #40 was admitted on [DATE] with diagnoses including myocardial infarction and cerebral infarction. Observation on 12/16/24 at 8:10 A.M. revealed Resident #40 was independently ambulating in his room. Resident #40's bathroom revealed a missing floor tile approximately 10 inch in length by four inches in width at the entrance of Resident #40's shower. Interview with Resident #40 at the time of the observation stated he showers in his room and the tile had been broken since he moved in. 2. Observation on 12/16/24 at 11:20 A.M. of the 500-hall central bath revealed two opened bags of soiled linens, including a towel protruding out of the top of the bag resting…

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, medical record review, and policy review, the facility failed to provide adequate incontinence care. This affected one (Resident #36) of four residents sampled for activities of daily living. The facility census was 78. Findings include: Medical record review revealed Resident #36 was admitted on [DATE] with diagnoses including displaced right femur fracture, diabetes mellitus and unspecified dementia. Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #36 was severely impaired for daily decision-making and was dependent on staff for toileting and personal hygiene. Observation on 12/16/24 between 10:46 A.M. and 11:13 A.M. revealed Certified Nurse Assistant (CNA) #100 was pushing a hoyer mechanical lift down the hall towards Resident #36's room. CNA #100 entered the room where CNA #101 was waiting to assist with incontinence care. CNA #100 stated her supplies were ready and motioned to the night stand next to the bed. There was a towel with two…

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, interviews, and interviews, the facility failed to ensure the windows were kept in good repair. This had the potential to affect all residents residing in the facility. The census was 67. Findings included: Observation of the 200 Hall sunroom on 06/13/24 at 6:00 A.M. revealed the windows were streaked and dirty, on both sides of the glass. On the outside of the windows, build up of grass and debris were present. Three screens were torn. Observation of the 300 Hall sunroom on 06/13/24 at 6:04 A.M. revealed windows were cloudy and streaked, had dirt and debris on them. One window had a crack and one window was shattered with shards of glass missing and duct tape around the edges in attempt to hold the window together. Another window had a torn screen. Observation of the 400 Hall sunroom on 06/13/24 at 6:08 A.M. revealed windows were dirty and streaked with dirt and cobwebs on the outside of the windows. There were four torn screens. Observation of the 500 Hall sunroom on 06/13/24 at 6:11 A.M. revealed windows were dirty and streaked with two cracked windows and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, review of glucometer manufacturer information, policy review, and interview, the facility failed to ensure ensure glucometers used for multiple residents were cleaned/disinfected between resident use. This affected four residents (Residents #1, #4, #21, and #36) observed during medication administration. The facility identified 17 residents (Residents #1, #4, #21, #25, #28, #33, #34, #35, #36, #46, #50, #56, #61, #63, #64, #65, and #67) who had blood glucose levels monitored using facility glucometers. Findings include: 1. On 06/13/24 at 7:40 A.M., Registered Nurse (RN) #100 entered Resident #21's room to administer medication and monitor Resident #21's blood glucose level. RN #100 carried a basket with a glucometer, alcohol wipes, glucometer strips and lancets into Resident #21's room and placed the basket on the table without a barrier. Resident #21's blood glucose was monitored using the facility's glucometer. After using the glucometer it was placed back into the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents received showers per their preferences. This affected two (Resident #31 and #34) of six residents reviewed for activities of daily living. The facility census was 67. Findings include: 1. Record review revealed Resident #31 admitted to the facility on [DATE] with diagnoses including paraplegia, neuromuscular dysfunction of bladder, hyperlipidemia, congestive heart failure, and need for assistance with personal care. Review of a minimum data set (MDS) quarterly assessment completed on 03/14/24 revealed Resident #31's cognition remained intact and it was very important for him to choose between a tub bath, shower, bed bath or sponge bath. Review of a shower preference sheet completed on 05/01/24 revealed Resident #31 prefers showers but is okay with bed baths. Review of shower sheets revealed Resident #31 received showers on Tuesday and Friday nights. Resident #31 received a bed bath on 05/10/24, 05/14/24, 05/17/24, 05/21/24, 05/24/24,…

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

Based on observation, interviews, and policy review the facility failed to maintain residents' personal living space in a comfortable, homelike manner. This affected two residents (Resident #4 and #62) of three residents interviewed for a homelike environment. The census was 67. Findings include: Interview on 06/12/24 at 1:34 P.M. with Ombudsman #100 revealed residents had been complaining since 02/29/24 that they wanted the windows cleaned but the windows haven't been cleaned and residents were also unhappy with the broken screens for the windows. Continuous interviews and observations with Maintenance Director (MD) on 06/13/24 at 8:26 A.M. revealed a company came in to give window estimates which would cost a fortune and since they were already renovating other things, no windows had been ordered yet. The MD stated he does have new screens for the building but has not had a chance to put them in yet. Interview on 06/13/24 at 8:35 A.M. with the Administrator revealed he was aware of some of the windows being in disrepair but the facility just spent a million dollars on a renovation…

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 interview, the facility failed to store and prepare food under sanitary conditions. This had the potential to affect 56 of 57 residents who received food from the facility. The facility census was 57. Findings included: Observations on 03/18/24 from 7:03 P.M. to 7:18 P.M. during an initial tour of the kitchen revealed: one opened bag a macaroni noodles and one opened bag of bow tie pasta that were not dated, a Tupperware container of vanilla wafers that were not dated, two quarts of pears that were not dated, and a bag of shredded cheddar cheese was not dated. Additionally, the sanitizer water was tested, and the test strip did not change to the appropriate color. All findings were confirmed by Dietary Manager #128 and Regional Director of Operations #109 at the time of the observation. Observation of tray line for lunch on 03/20/24 revealed the following: -12:16 P.M. Dietary [NAME] (DC) #160 touched his ear then continued to plate noodles. -12:19 P.M. DM #128 coughed into his elbow, did not wash hands, then at 12:21 P.M. grabbed soup out of the steamer to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were properly assessed for restraints. This affected one resident (#27) of two residents reviewed for restraints. The facility census was 57. Findings include: Record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease without angina, atrial fibrillation, dementia with behaviors, psychosis, anxiety disorder, major depression, and aphasia. Review of orders revealed no order for body pillows to bilateral bed or restraints. Review of a quarterly minimum data set (MDS) completed on 03/09/24 revealed Resident #27 did not have restraints. Review of assessments revealed no device assessment had been completed related to bilateral body pillows. Review of a care plan dated 03/19/24 revealed Resident #27 had an alteration in musculoskeletal status related to right wrist fracture with an intervention that included bilateral body pillows for comfort per 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 medical record review, observation, and interviews the facility failed to ensure assessments were accurate. This affected two residents (#21 and #26) of six reviewed for dental and one resident (#49) of two reviewed for discharges. The facility census was 57. Findings included: 1. Record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, atrial fibrillation, hypertension, hypothyroidism, gastro-esophageal reflux disease without esophagitis, anemia, benign paroxysmal vertigo, qualitative platelet defects. Review of the admission assessment dated [DATE] revealed the resident did not have her own teeth and had partial upper and lower dentures. Review of Resident #21's admission Minimal Data Set (MDS) dated [DATE] revealed the resident had no loose or broken full or partial dentures and was edentulous. The resident's brief interview for mental status (BIMS) score was 15 out of 15 (cognition intact). Review of Resident #21's dental note from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Record review revealed Resident #58 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, depression, bipolar, post-traumatic stress disorder. Review of Resident #58's current plan of care revealed no evidence Resident #58 had a plan of care for anxiety disorder, depression, bipolar, post-traumatic stress disorder, behaviors, or refusal of care (showers). Observation on 03/18/24 at 8:00 P.M., revealed strong odors coming from Resident #58's room. Observation and interview on 03/19/24 at 9:30 A.M. with Resident #58, revealed Resident #58 had strong odors coming from his body. The resident voiced no concern regarding receiving assistance with activity of daily living care. The resident reported he needed to apologize to the two aides working last night because he read their body language wrong. The resident reported to the surveyor if he asked someone not to come in his room he means it. Interview on 03/21/24 at 9:46 A.M., with Regional Clinical Support (RCS) #199 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure Residents #15, #26, and #46 had quarterly care conferences in conjunction with minimum data sets and failed to revise care plans for Residents #21. This affected four residents (#15, #21, #26, and #46). The facility census was 57. Findings included: 1. Record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, anemia, and anxiety disorder. Review of minimum data set (MDS) list revealed Resident #15 had a quarterly MDS completed on 01/24/24. Review of assessments revealed Resident #15 had care conference meetings on 01/20/23, 05/02/23, 06/27/23, 09/29/23, and 03/05/24. There was no documentation of a care conference being completed between 09/29/23 and 03/05/24. Interview on 03/19/24 at 10:02 A.M. with Resident #15 revealed she had never been to a care conference. Interview on 03/20/24 at 3:25 P.M. with Social Worker Designee (SWD) #144 revealed care conference are offered…

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 no medical record review, observation, and interview the facility failed to ensure residents who were dependent on staff received assistance with activities of daily living (ADL). This affected three residents (Resident #27, #37, and #165) of four reviewed for ADL. Findings included: 1. Record review revealed Resident #165 was admitted to the facility on [DATE] with diagnoses including bronchitis, hypothyroidism, anemia, Parkinsonism, depression, gastro-esophageal reflux, and Alzheimer's. Review of Resident #165's general note dated 03/12/24 revealed the resident had all her own teeth. Review of Resident #165's functional abilities and goals dated 03/16/24 revealed the resident required some assistance (partial assistance from another to complete activities) for self-care needs. The resident was setup or clean-up assistance with oral hygiene. Review of Resident #165 oral/dental plan of care dated 03/13/24 revealed the resident had her own natural teeth. The intervention included coordinate arrangements 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, hospital record review, observation, and interview the facility failed to ensure wounds were properly identified as healed. This affected one resident (#23) of two residents reviewed for skin conditions. Facility census was 57. Findings include: Review of the medical record revealed Resident #23 was admitted on [DATE] with diagnoses that included type 2 diabetes, Alzheimer's disease, and moderate protein-calorie malnutrition. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #23 had cognitive impairment and no skin concerns. A skin grid non-pressure form dated 01/10/24 at 11:53 A.M. revealed Resident #23 had a diabetic ulcer to the right foot planter surface below the fifth toe discovered on 01/10/24. The diabetic ulcer measured five centimeters (cm) long and two cm wide. The wound bed was covered with slough (yellow/white necrotic tissue). An order was received to paint the wound with betadine. A skin grid non-pressure form dated 02/07/24 at 10:45 A.M. reveled Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide Resident #15 with an optometry consult. This affected one resident (#15) of two residents reviewed for optometry services. The facility census was 57. Findings included: Record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, anemia, and anxiety disorder. Review of a quarterly Minimum Data Set, dated [DATE] revealed Resident #15 had moderately impaired vision. Review of care plan dated 02/02/24 revealed Resident #15 had moderately impaired vision and interventions included to arrange a consultation with eye care practitioner as required. Record review revealed no evidence of a visual consult consent form being completed for Resident #15. Review of 360Care vision lists from 03/06/23, 06/22/23, 08/02/23, and 09/28/23 revealed Resident #15 was not seen by the eye doctor. Interview on 03/19/24 at 10:06 A.M. with Resident #15 revealed she has a hard time seeing things far away and 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 medical record review, observation, interviews, and policy review the facility failed to ensure pressure relieving intervention were in-place. This affected one resident (#21) of three residents reviewed for pressure ulcers. The facility census was 57. Finding included: Record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, atrial fibrillation, hypertension, hypothyroidism, gastro-esophageal reflux disease without esophagitis, anemia, benign paroxysmal vertigo, qualitative platelet defects. Review of Resident #21's Braden Scale (predictor for pressure ulcers) dated 01/17/24 revealed not at risk for pressure. She had a potential problem for friction and shearing, mobility was slightly limited, walked occasionally, rarely moist. Review of Resident #21's quarterly MDS dated [DATE] revealed brief interview for mental status (BIMS) was 15 out of 15 (cognition intact). The resident was at risk for developing pressure ulcer/injuries. 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, record review, and interviews the facility failed to ensure foot care was provided for a resident. This affected one resident (#32) out of four reviewed for activities of daily living. Facility census was 57. Findings include: Review of the medical record revealed Resident #32 was admitted on [DATE] with diagnoses that included chronic embolism and thrombosis, celiac disease, protein-calorie malnutrition, and adult failure to thrive. The quarterly Minimum Data Set, dated [DATE] revealed Resident #32 had cognitive impairment and was dependent on staff for activities of daily living. A podiatry consent form was signed on 02/08/24. Observation on 03/19/24 at 8:09 A.M. revealed Resident #32 had long toenails with several toenails curling under the toes. Interview on 03/19/24 at 3:29 P.M. Registered Nurse (RN) #129 verified Resident #32 had long, jagged toenails. RN #129 also verified the toenails to the second and third toe on Resident #32's left foot were curling under the toes. Interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide range of motion services for residents. This affected two residents (#1, #48) of four residents reviewed for range of motion services. Facility census was 57. Findings include: 1. Review of the medical record revealed Resident #1 was admitted on [DATE] with diagnoses that included quadriplegia, epilepsy, and contracture of muscle-multiple sites. Range of motion assessment dated [DATE] revealed Resident #1 had full loss of voluntary movement to foot and ankle. The observation comments revealed Resident #1 had diagnosis of quadriplegia and range of motion was not inhibited, but Resident #1 was not able to move own extremities himself. The Functional abilities and goals assessment dated [DATE] revealed Resident #1 had functional limitations to both sides of upper extremity and lower extremity. Interview on 03/21/24 at 7:50 A.M. Registered Nurse (RN) #129 stated all residents were assessed quarterly for contracture's. RN #129 verified Resident #1…

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, interview, and policy review the facility failed to ensure appropriate storage of resident nebulizer equipment. This affected one resident (#58) of one reviewed for respiratory care. Findings included: Record review revealed Resident #58 was admitted to the facility on [DATE] with diagnoses including heart failure and chronic obstructive pulmonary disease (COPD). Review of Resident #58's orders dated 02/12/24 revealed orders for Albuterol Sulfate Inhalation Nebulization Solution 1.25 milligram (mg)/3 milliliters (ml) inhale orally via nebulizer four times a day for shortness of breath. There was no evidence of orders on how frequently to change the tubing and mask. Review of Resident #58's COPD plan of care dated 02/16/24 revealed no evidence of storage or maintained of the nebulizer equipment. Observations on 03/19/24 at 9:34 A.M. of Resident #58's nebulizer equipment revealed the nebulizer mask was hanging off the dresser and not stored in a bag. Observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, facility failed to provide dental services to residents. This affected two residents (#26, #58) of four residents reviewed for dental services. The facility census was 57. Findings included: 1. Record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including epilepsy, major depression, chronic obstructive pulmonary disease, and cognitive communication deficit. Review of orders revealed Resident #26 had an order in place dated 10/16/21 to see audiologist, podiatrist, dentist, optometrist, and psychiatrist as needed. Review of a quarterly minimum data sets (MDS) dated [DATE] and 10/20/23 revealed Resident #15 had no difficulty chewing. Review of a care plan revised on 11/03/23 revealed Resident #26 had a care plan in place for being at risk for oral and dental health problems related to having her own natural teeth with some missing or broken, and reports of difficulty with chewing at times. Interventions included coordinate arrangements 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the facility contract, review of dental list, observation, interview, and policy review the facility failed to ensure dental services were offered timely. This affected three residents (#3, #15, and #58) of six reviewed for dental services. Findings included: 1. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including needing assistance with personal care, emphysema, COPD, dysphagia, heart failure, and gastro-esophageal reflux disease. Review of Resident #3's census revealed the resident primary insurance since 07/28/23 was Medicaid. Review of Resident #3's admission assessments dated 07/21/23 and 10/02/23 revealed no evidence the dental section was completed. Review of Resident #3's admission MDS dated [DATE] revealed the resident had obvious or likely cavity or broken natural teeth. Review of Resident #3's oral/dental plan of care dated 08/04/23 revealed the resident had no upper teeth or dentures or partials. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, McGreer's criteria review, and interview, the facility failed to ensure the criteria was met prior to antibiotics being administered. This affected one resident (#7) out of five residents reviewed for unnecessary medication. Facility census was 57. Findings include: Review of the medical record revealed Resident #7 was admitted on [DATE] and 11/09/23 with diagnoses that included atherosclerotic heart disease, hyponatremia, hypothyroidism, above knee right amputation, anemia in chronic kidney disease, and rheumatoid arthritis, The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #7 was cognitively intact and always incontinent of urine. A general note dated 03/15/24 at 3:26 P.M. revealed the certified nurse practitioner (CNP) reviewed the urine cultures and ordered Ceftriaxone (antibiotic) one gram intramuscular at bedtime for four days for a urinary tract infection. The CNP was notified Resident #7 did not meet the criteria for an antibiotic to be ordered. Interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the facility timeline for positive COVID-19 residents and staff, review of resident vaccination status, review of contact tracing, review of facility COVID-19 policies and procedures, review of the current Centers of Disease Control (CDC) Guidance Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes and interview the facility failed to implement adequate infection control measures including comprehensive contact tracing, proper personal protective equipment (PPE) use and implementation of transmission based precautions (TBP) following the identification of COVID-19 positive staff to prevent the spread of infection including COVID-19. This affected three residents (#20, #25 and #303) and had the potential to affect all 59 residents residing in the facility. Findings include: Observations of all residents completed during the survey period between 05/09/22 and 05/11/22 revealed no residents were in isolation/transmission based…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure Resident #253 and Resident #254 received and signed the appropriate Notice of Medicare Non-Coverage (NOMNC) form. This affected two residents (#253 and #254) of three residents reviewed for beneficiary protection notification. Findings include: 1. Review of Resident #253's medical record revealed the resident was admitted to the facility on [DATE] with the diagnoses of sepsis, acute respiratory failure with hypoxia, muscle wasting and atrophy and type two diabetes. Resident #253 was discharged from receiving Medicare Part A services on 03/18/22 and remained in the facility. The facility provided the resident NOMNC for Hospice services. The resident signed the form on 03/16/22. However, record review revealed the resident was not receiving Hospice services and the form issued was incorrect. On 05/12/22 at 8:04 A.M. interview with Social Work (SW) #70 verified Resident #253 was not provided the correct NOMNC form. SW #70 reported the resident…

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

Based on record review, review of a facility Self-Reported Incident (SRI), facility policy and procedure review and interview the facility failed to prevent the misappropriation of the anti-anxiety medication, Xanax prescribed for Resident #304. This affected one resident (#304) of one resident reviewed for abuse and misappropriation of funds/property. Findings include: Review of Resident #304's medical record revealed an admission date of 02/09/22. The resident was discharged on 02/25/22 to home with her family. Resident #304 had diagnoses including congestive heart failure, chronic pulmonary edema, diabetes mellitus, Sjogren syndrome, fatty liver, major depressive disorder, obstructive sleep apnea and anxiety. Review of the physician's medication orders, revealed an order, dated 02/09/22 for Xanax 0.25 milligrams (mg) by mouth every 12 hours as needed for anxiety. Review of the narcotic count sheet, dated 02/09/22 at 6:22 P.M. revealed Licensed Practical Nurse (LPN) #21 counted 50 Xanax tablets upon admission to the facility for the resident. Review of a self-reported incident…

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 Pre-admission Screening and Resident Review (PASARR) documentation and interview the facility failed to ensure updated PASARR's were completed following changes in condition, including the identification of mental health diagnoses and psychoactive medications for Resident #12 and Resident #36. This affected two residents (#12 and #36) of two residents reviewed for PASARR. Findings include: 1. Review of the medical record for Resident #12 revealed and admission date on 12/23/16. Resident #12 had diagnoses including psychotic disorder with delusions due to known physiological condition (10/14/21), psychotic disorder with hallucinations due to known physiological condition (03/02/21) and major depressive disorder-recurrent severed with psychotic symptoms (03/02/21). Review of PASARR, dated 12/19/16 revealed the resident had no indications of any mental health diagnoses or use of any psychoactive medications. There were not any additional PASARR's included in Resident #12's medical…

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

Based on observation, record review and interview the facility failed to ensure Resident #5, who was assessed to require staff assistance for activities of daily living (ADL) care received adequate and timely nail care to promote optimal hygiene. This affected one resident (#5) of two residents reviewed for activities of daily living (ADL). Findings include: Review of Resident #5's medical record revealed an initial admission date of 10/12/13 with the latest readmission date of 03/31/22 and diagnoses including cerebrovascular accident (CVA) with right sided hemiplegia, congestive heart failure, benign neoplasm of right choroid, seasonal allergic rhinitis, history of COVID-19, dysphasia, metabolic encephalopathy, peripheral vascular disease, hyperlipidemia, dysthymia, aphasia, chronic obstructive pulmonary disease, major depressive disorder, hypertension, insomnia and anxiety disorder. Review of the plan of care, dated 05/10/19 revealed the resident had an alteration in ADL performance/participation related to CVA with right hemiplegia, non-ambulatory, requiring a mechanical lift and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure all residents received adequate care and treatment. The facility failed to monitor bowel movements for Resident #45, who had a history of constipation, failed to provide thromboembolism-deterrent (TED) hose as ordered for Resident #27 and failed to complete accurate skin assessments to monitor bruising for Resident #202. This affected three residents (#27, #45, and #202) of three residents reviewed for quality of care. Findings include: 1. Review of the medical record for Resident #45 revealed an admission date of 05/08/17 and a readmission date of 10/26/21. Resident #45 had diagnoses including Parkinson's disease, bipolar disorder, dysthymic disorder, anxiety disorder, major depressive disorder, insomnia and irritable bowel syndrome with constipation. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/27/22 revealed Resident #45 had mildly impaired cognition with Brief…

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

Based on record review, review of facility policy and procedure and interview the facility failed to properly assess Resident #48's skin upon admission, timely identify a pressure area and implement a timely treatment to the pressure ulcer wound. This affected one resident (#48) of two residents reviewed for pressure ulcers. The facility identified two residents with pressure ulcers. Findings include: Review of the medical record for Resident #48 revealed an admission date of 04/01/22. Resident #48 had diagnoses including right above the knee amputation, seizure disorder, stage three chronic kidney disease and anemia. Review of the Self Functional Status assessment, dated 04/01/22 revealed Resident #48 was assessed as requiring extensive to dependent assistance from staff transfers and was non-ambulatory. An initial skin assessment performed on 04/01/22 at 5:11 P.M. was blank showing no evidence of skin impairment. A second skin assessment performed on 04/01/22 at 5:48 P.M. revealed the only skin impairment was an infected left great toenail. Review of the baseline plan of care,…

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 provide supplements as ordered to Resident #44 who had experienced weight loss and was on hemodialysis. This affected one resident (#44) of five residents reviewed for nutrition. Findings include: Review of the medical record revealed Resident #44 was admitted on [DATE] with diagnoses including acute on chronic systolic heart failure, end stage renal disease, type two diabetes mellitus, paroxysmal atrial fibrillation, unspecified protein-calorie malnutrition, hypertension, major depressive disorder and acquired absence of left leg below knee. Review of the plan of care, dated 04/13/22 revealed Resident #44 had a nutritional problem or potential problem related to diagnoses of heart failure, end stage renal disease on hemodialysis, major depression, vitamin D deficiency, severe metabolic acidosis. The care plan revealed the resident had increased needs due to a wound requiring supplementation. Interventions included providing and serving supplements as…

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 and procedure review and interview the facility failed to ensure Resident #8 and Resident #28 received the correct administration rate of oxygen as ordered. This affected two residents (#8 and #28) of four residents reviewed for respiratory care. Findings include: 1. Review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of hypertensive heart disease with heart failure, chronic kidney disease, unspecified diastolic (congestive) heart failure, chronic obstructive pulmonary disease and panlobular emphysema. Review of Resident #8's physician's orders, dated 01/08/22 revealed the resident was to receive oxygen at two liters per minute (LPM) via nasal cannula. The order indicated the oxygen may be removed for care, ambulation or as needed. A plan of care, dated 04/22/22 addressed the resident's alteration in cardiac and respiratory function with an intervention to administer oxygen per orders. On 05/10/22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to complete pre-dialysis and post-dialysis assessments for Resident #44. This affected one resident (#44) of one resident reviewed for dialysis. Findings include: Review of the medical record revealed Resident #44 admitted to the facility on [DATE] with diagnoses including acute on chronic systolic heart failure, end stage renal disease, type two diabetes mellitus, paroxysmal atrial fibrillation, unspecified protein-calorie malnutrition, hypertension, major depressive disorder and acquired absence of left leg below knee. Review of the care plan, dated 04/13/22 revealed Resident #44 needed hemodialysis related to end stage renal disease. Interventions included encouraging the resident to go to dialysis appointments, monitoring access port to right upper chest every shift, monitoring intake and output, monitoring vital signs as ordered, monitoring for signs of infection, monitor for new or worsening peripheral edema and working with the resident to relieve…

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

Based on record review, facility policy and procedure review and interview the facility failed to discontinue the medication Acidophilus for Resident #46 timely after a pharmacy recommendation/physician agreement was obtained related to the medication. This affected one resident (#46) of five residents reviewed for unnecessary medication use. Findings include: Review of the medical record for Resident #46 revealed an admission date 08/24/18. Resident #46 had diagnoses including stroke, hemiplegia, chronic kidney disease and vascular dementia. Review of a pharmacy recommendation, dated 09/09/21 revealed the pharmacist recommended a review of the vitamin supplement Acidophilus. The physician addressed the recommendation on 09/13/21 and documented agreement with the discontinuation of the Acidophilus. Review of the September 2021 Medication Administration Record (MAR) for Resident #46 revealed the Acidophilus was still given every day from 09/13/21 through 09/30/21. The October 2021 Medication Administration Record (MAR) for Resident #46 revealed the Acidophilus was still given every…

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

Based on record review and interview the facility failed to ensure adequate justification for the increase in the medication Depakote prescribed for Resident #51 for agitation related to bipolar disorder. This affected one resident (#51) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #51's medical record revealed an admission date of 07/12/21 with the admitting diagnoses of atherosclerotic heart disease, chronic kidney disease, hypertension, major depressive disorder, personal history of COVID-19, Alzheimer's disease, polyosteoarthritis, vitamin D deficiency, gastro-esophageal, bipolar disease, anemia, hyperparathyroidism, hypothyroidism and glaucoma. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/22/22 revealed the resident had clear speech, understood others, made himself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of five of 15. The assessment revealed the resident required extensive assistance from two staff for bed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy and procedure review and interview the facility failed to maintain Resident #303's medical record in a complete and accurate manner related to documentation of oxygen rate of administration. This affected one resident (#303) of four residents reviewed for respiratory care. Findings include: Review of Resident #303's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including acute congestive heart failure, pneumonia, other nonspecific abnormal findings of the lung, chronic obstructive pulmonary disease and unspecified asthma. Review of Resident #303's physician's orders revealed an order, dated 04/27/22 to administer oxygen at 1.5 liters per minute (LPM) via a nasal cannula continuously every shift for congestive heart failure and pneumonia. A plan of care, dated 04/27/22 addressed the resident's altered cardiac status and chronic obstructive pulmonary disease with an intervention to administer oxygen via a nasal…

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.