Schoenbrunn Healthcare

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 infection control practices were maintained during wound care, dining, incontinence care, and medication administration. This had the potential to affect all 78 resident residing in the facility. Based on medical record review, observation, interview, and policy review the facility failed to ensure infection control practices were maintained during wound care, dining service, incontinence care, and medication administration. This affected Resident #3, #4, #9, #40, #43, #51 and #63 but had the potential to affect all 76 residents residing in the facility. Findings include: 1. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of peripheral vascular disease, above left knee ambulation, heart failure, chronic obstructive pulmonary disease, chronic kidney disease, non-pressure ulcers, neuromuscular dysfunctional bladder, diabetes, legally blind, and chronic pain.…

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, interviews, review of information located on Medscape.com, and policy review the facility failed to ensure a resident had an appropriate justification for the use of an antipsychotic medication and also failed to ensure residents had stop dates for antianxiety medications. This affected four (Resident #2, #8, #5 and #35) out of five reviewed for unnecessary medication review. Findings include: 1. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety, and depression. Review of Resident #2 's medication administration records (MAR) and orders dated 04/25/25 to 07/22/25 revealed Resident #2 was administered Seroquel (antipsychotic)12.5 milligrams (mg) at bedtime for dementia. Further review of Resident #2's MAR and orders dated 04/24/25 to 07/22/25 revealed no documented evidence the resident was ordered or administered any other medication to treat anxiety, depression, or dementia. Review of Resident #2 ' s psych…

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, review of the medical record, interview with staff and review of facility policy, the facility failed to ensure the call light was within reach of Resident #26. This affected one resident (Resident #26) of one reviewed for accommodation of need. Findings include: Review of the medical record revealed Resident #26 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, rhabdomyolysis, paroxysmal tachycardia, anxiety disorders, hypertension, major depressive disorder with psychotic symptoms, and muscle weakness. Review of the plan of care dated 08/18/20 revealed Resident #26 was at a risk for falls related to deconditioning, gait and balance problems, and psychoactive drug use. Interventions included to be sure the call light for Resident #26 was within reach and encourage resident to use it for assistance as needed.Review of the Annual Minimum Data Set assessment dated [DATE] revealed Resident #26 had moderately impaired cognition and was dependent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the medical record, and interview with staff, the facility failed to ensure the responsible party, physician and hospice were notified when Resident #27 spilled soup on herself causing a burn and when Resident #45 received a skin tear. This affected two residents (Resident #27 and #45) of five residents reviewed for accidents. Findings include:1. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included heart failure, atherosclerotic heart disease, dysphagia, extended spectrum beta lactamase resistance, glaucoma, retention of urine, osteoarthritis, hypothyroidism, major depressive disorder, generalized anxiety disorder and hypertension. Review of the Significant Change Minimum Data Set assessment dated [DATE] revealed Resident #27 had moderately impaired cognition.Observation of incontinence care with Certified Nursing Assistant (CNA) #144 and #224 on 07/30/25 at 1:36 P.M. revealed Resident #27 had two large blisters to both her…

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 a Level II Preadmission Screening and Resident Review (PASARR) was completed with a new psychiatric diagnosis. This affected one (Resident #34) of two residents reviewed for PASARR. The census was 76.Findings include: Review of Resident #34 ' s medical record revealed an admission date of 07/15/22 with diagnosis including vascular dementia, hypertension, anxiety disorder, and paranoid personality disorder. Review revealed the last PASARR submitted for the resident dated 07/08/22 did not indicate Resident #34 had a personality disorder.Record review revealed on 05/30/23 Resident #34 had a diagnosis of paranoid personality disorder added to his list of diagnoses.Review revealed there was no evidence of a subsequent PASARR submission, for a Level II consideration, to the state agency that included the new psychiatric diagnosis.Interview 07/26/25 at 1:10 P.M. with social services #213 verified there was not a PASARR submitted to the state agency for Level II consideration after the addition of the paranoid personality…

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, interview and facility policy review, the facility failed to develop a comprehensive plan of care for pain management. This affected one (Resident #38) of two residents reviewed for pain management. Facility census was 76.Findings include: Review of Resident #38 ' s medical record revealed an admission date of 05/16/25 with diagnosis including chronic systolic heart failure, type 2 diabetes, atrial fibrillation, chronic obstructed pulmonary disease, and hypertension.Review of the 05/28/25 5-day Minimum Data Set (MDS) Assessment revealed the resident received as needed pain medications and had intact cognition.Review of Resident #38 ' s physician orders revealed orders for Norco 5/325 milligrams (mg) every 6 hours as needed and Tylenol 650 mg every 6 hours as needed. Interview on 07/28/25 at 4:08 P.M. with Resident #38 revealed he always has pain and it is somewhat controlled.Further review of the medical record revealed no evidence of a pain care plan.Interview on 07/30/25 at 1:01 P.M. with MDS Nurse #104 verified there was not a comprehensive pain plan of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and policy review the facility failed to ensure residents who required staff assistance with activities of daily living received showers per schedule and preferences. This affected two (Resident #4 and #46) of two residents reviewed for shower preferences. Findings include: 1. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of peripheral vascular disease, above left knee ambulation, heart failure, chronic obstructive pulmonary disease, chronic kidney disease, non-pressure ulcers, neuromuscular dysfunctional bladder, diabetes, legally blind, and chronic pain. Review of Resident #4 ' s orders dated 07/2025 revealed on 05/28/25 the resident was ordered showers on Monday, Wednesday, and Fridays per the resident ' s preference. Document refusals in the progress notes. Review of Resident #4 ' s Activity of Daily Living (ADL) care plan dated 05/02/16 and revised on 06/18/2020 revealed the resident required extensive assist of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the medical record, interviews with staff, review of the facility policy, the facility failed to ensure treatment orders were received for burns to Resident #27's thighs and failed to comprehensively assess a skin tear to Resident #45's leg. This affected two residents (Resident #27 and #45) of five residents reviewed for accidents.Findings include: 1. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included heart failure, atherosclerotic heart disease, dysphagia, extended spectrum beta lactamase resistance, glaucoma, retention of urine, osteoarthritis, hypothyroidism, major depressive disorder, generalized anxiety disorder and hypertension. Review of the Significant Change Minimum Data Set assessment dated [DATE] revealed Resident #27 had moderately impaired cognition.Observation of incontinence care with Certified Nursing Assistant (CNA) #144 and 224 on 07/30/25 at 1:36 P.M. revealed Resident #27 had two large blisters to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure residents had a comprehensive treatment plan in place for the use of hand splints to improve or maintain mobility. This affected one (Resident #60) of one residents reviewed for mobility. The census was 76. Findings include: Review of Resident #60 ' s medical record revealed the resident was admitted on [DATE] with diagnosis including multiple sclerosis, marasmic kwashiorkor, hypertension, major depressive disorder, and obstructive and reflux uropathy. Review of Resident #60 ' s Annual Minimum Data Set (MDS) dated [DATE] revealed no restorative days or minutes for splint or brace assistance, no impairment to the resident's upper extremities.Review of Resident #60 ' s physician orders revealed a resting wrist/hand splint to the left hand once daily for up to four hours on dayshift dated 04/25/25. Review of Resident#60 ' s care plans did not identify a resting hand splint.Review of Review of Resident #60's medication administration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the medical record, interview with staff and policy review, the facility failed to ensure fall interventions were in place for Resident #12. This affected one resident (Resident #12) of five reviewed for accidents.Findings include: Review of the medical record revealed Resident #12 was admitted to the facility on [DATE]. Diagnoses included atherosclerotic heart disease, severe protein calorie malnutrition, malignant neoplasm of the prostate, depression, peripheral vascular disease, adult failure to thrive, history of falling, transient ischemic attack, fracture of the fifth metatarsal of the left hand, emphysema, dementia, and hypertension.Review of the plan of care dated 11/01/24 revealed Resident #12 had a potential for falls related to history of falls, cachexia, and unsteady gait. Interventions did not include wearing hipsters. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #12 had moderately impaired cognition and had one fall with injury.…

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

Based on medical record review and interview the facility failed to ensure medications for the treatment of respiratory illness were implemented timely and administered per orders and failed to ensure diagnostic testing results were timely available. This affected one (Resident #1) of one residents reviewed for respiratory care. The facility census was 76.Findings include: Medical record review revealed Resident #1 was admitted to the facility 06/29/23 with diagnoses including pneumonia, chronic respiratory failure with hypoxia, and diabetes. Review of Resident #1's chest x-ray results dated 06/30/25 revealed the resident had some opacities representing penumonitis. A computed tomography (CT) was recommended (of the chest).Review of Resident #1' s plan of care revealed two pneumonia plans of care were initiated on 07/02/25 however no interventions were initiated. Review of Resident #1's nurse practitioner note dated 07/03/25 revealed the resident had respiratory failure with hypoxia. New orders to schedule CT scan. Review of Resident #1's medical record revealed on 07/03/25 a CT 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 record review, facility policy review and interview, the facility failed to implement a comprehensive resident centered treatment plan to manage residents receiving hemodialysis. This affected one (Resident #39) of one residents reviewed for dialysis. The facility census was 76.Findings include: Review of the medical record for Resident #39 revealed an admission date of 07/02/25 with diagnosis including c-diff infection, end stage renal disease, type II diabetes, chronic obstructive pulmonary disease, atrial fibrillation, chronic systolic heart failure, and malignant neoplasm of prostate. Review of the physician orders revealed to weigh the resident before each hemodialysis treatment and after each hemodialysis treatment on Mon/Wed/ Friday and check for bruit (sound heard over an arteriovenous fistula, used for dialysis access, that indicates good bloodflow) and thrill (the pulsation felt over an arteriovenous fistula that indicates good bloodflow) to left arm fistula. The residents dialysis dates in July 2025 were as follows: 07/02/25, 07/04/25, 07/07/25, 07/09/25,…

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 interview and record review the facility failed to ensure antibiotic use was appropriate according to antibiotic stewardship protocols. This affected one resident (Resident #74) of three residents reviewed for antibiotics use. Facility census was 76.Findings include: Record review revealed Resident #74 an admission date of 06/22/22 with diagnosis including type II diabetes, neuralgia and neuritis, depression, anxiety and dementia.Review of the annual minimum data set (MDS) completed 04/14/25 revealed the resident had intact cognition and was frequently incontinent of urine and always incontinent of bowel.Review of the physician orders revealed a urinalysis with culture and sensitivity due to an elevated white blood cell count dated 07/17/25. The report returned on 07/21/25 with results showing 60,000-70,000 colony forming units per milliliter (cfu/ml) Escherichia Coli (E Coli) bacteria, 60-70,000 cfu/ml proteus mirabilis bacteria with possible extended-spectrum beta lactimase (ESBL). The resident started Tobramycin (antibiotic) solution 100 milligrams (mg) intramuscularly…

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 interview, the facility failed to ensure complete medical records were maintained in regard to activity participation and medication administration. This affected four (Residents #28, #30, #78 and #79) of four residents reviewed. Findings include: 1. Review of Resident #28's medical record revealed diagnoses including chronic obstructive pulmonary disease (COPD), anxiety order, depression with psychotic symptoms, dementia with mood disturbance and difficulty walking. A physician order dated 02/03/21 indicated Resident #28 was to be transferred with a mechanical lift. A plan of care initiated 08/17/20 indicated Resident #28 would remain active and social. Interventions included providing an activity calendar in Resident #28's room, talking about what was taking place, listening to interests, reminding Resident #28 of activities, making Resident #28 feel welcome, and monitoring for changes in needs. The interventions indicated Resident #28 liked to watch television (all kinds of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, review of activity calendars and interview, the facility failed to ensure an individualized activity program was developed based on resident preferences. This affected one (Residents #28) of three residents reviewed for activities. Findings include: Review of Resident #28's medical record revealed diagnoses including chronic obstructive pulmonary disease (COPD), anxiety order, depression with psychotic symptoms, dementia with mood disturbance and difficulty walking. A physician order dated 02/03/21 indicated Resident #28 was to be transferred with a mechanical lift. A plan of care initiated 08/17/20 indicated Resident #28 would remain active and social. Interventions included providing an activity calendar in Resident #28's room, talking about what was taking place, listening to interests, reminding Resident #28 of activities, making Resident #28 feel welcome, and monitoring for changes in needs. The interventions indicated Resident #28 liked to watch television (all…

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 review of the facility self-report incident (SRI) and investigation, staff interview and review of facility policy, the facility failed to prevent misappropriation of resident medication. This affected 13 residents (#1, #5, #14, #20, #25, #28, #29, #70, #71, #72, #73, #74 and #75) of 13 residents reviewed for misappropriation. The facility census was 65. Findings include: Review of SRI #252381, dated 09/27/24, revealed local law enforcement notified the facility that during the search of a facility employee's vehicle, medication packages with residents' names were found. The employee was identified as Licensed Practical Nurse (LPN) #211. Residents #1, #5, #14, #20, #25, #28, #29, #70, #71, #72, #73, #74, and #75 were identified in the SRI as the residents with medications found in LPN #211's vehicle. Review of the facility investigation revealed a total of 70 medication packages for Residents #1, #5, #14, #20, #25, #28, #29, #70, #71, #72, #73, #74, and #75 were found in LPN #211's car. The medications included 22 packages of Mirtazapine, 23 packages of Metoprolol, one…

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 interview, medical record review, review of a facility self-reported incident (SRI) and investigation, staff interview and review of facility policy, the facility failed to ensure allegations of staff to resident abuse were reported timely. This affected one resident (#03) of three residents reviewed for abuse. The facility census was 65. Findings include: Review of the medical record revealed Resident #03 was admitted on [DATE] with diagnoses that included acute and chronic respiratory failure with hypoxia, myocardial infarction, anxiety disorder and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/09/24, revealed Resident #03 was cognitively intact. Review of SRI #252690, dated 10/06/24, revealed Resident #03 alleged that on 09/30/24, State Tested Nursing Assistant (STNA #174) was angry and punched a nearby wall. The SRI stated although the alleged incident occurred on 09/30/24, the Administrator was not notified until 10/06/24 at approximately…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review and interview, the facility failed to develop a discharge plan of care. This affected one resident (#75) of four sampled residents. The facility census was 73. Findings include: Closed medical record review revealed Resident #75 was admitted on [DATE] with diagnoses including cerebral infarction, diabetes mellitus type-1, tracheostomy and anoxic brain injury. Resident #75 was discharged from the facility on 08/14/24. Review of the electronic mail correspondence (dated 07/12/24) between Resident #75's power of attorney and Social Service Designee (SSD) #177 revealed additional information was needed from a home care provider of products/services regarding any and all orders being placed that SSD #177 had placed. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment (dated 07/31/24) revealed Resident #75 was moderately impaired for daily decision-making and had no active discharge planning or referrals made regarding discharge for the resident. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure comprehensive care plans were revised with resident preferences. This affected one resident (#75) of four sampled residents. The census was 73. Findings include: Closed medical record review revealed Resident #75 was admitted on [DATE] with diagnoses including cerebral infarction, diabetes mellitus type-1, tracheostomy and anoxic brain injury. Resident #75 was discharged from the facility on 08/14/24. Review of the admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #75 was cognitively intact for daily decision-making and frequently incontinent of urine and bowel. Review of the care plan: Preferences (initiated 04/11/24 and revised 08/09/24) revealed Resident #75 had the right to make lifestyle choices as evidenced by preferring to appear more masculine and desiring to grow a beard. Resident #75 also preferred to be addressed as they/them pronouns during stay and keep the room warmer regardless of outside…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review, policy review and interview, the facility failed to ensure tracheotomy care was completed as ordered. This affected two residents (#64, #75) reviewed for tracheostomy care. The facility identified no residents currently in the facility with a tracheostomy. The census was 73. Findings include: 1. Closed medical record review revealed Resident #64 was admitted on [DATE] with diagnoses including cerebral infarction, epilepsy, acute tracheitis without obstruction, hypertension and acute kidney failure. Resident #64 was discharged from the facility on 09/13/24. Review of the admission Minimum Data Set 3.0 assessment (MDS) (dated 07/16/24) revealed the resident received oxygen, suctioning and tracheostomy care. Review of the electronic Physician Orders (dated 07/09/24) revealed tracheostomy care was to be completed every shift, aerosol and cool mist was to be changed weekly, oxygen tubing and set up was to be changed weekly, and 35% trach collar 5 liters of oxygen via cool mist was to be…

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, policy review and interview, the facility failed to ensure proper gloving and hand washing was completed during incontinence care. This affected one resident (#26) observed for incontinence care. The facility identified 41 incontinent residents. The census was 73. Findings include: Medical record review revealed Resident #26 was admitted on [DATE] with diagnoses including dementia, obstructive and reflux uropathy and functional incontinence. On 09/16/24 between 2:00 P.M. and 2:05 P.M., observation of Resident #26's incontinence care revealed State Tested Nurse Aide (STNA) #144 and Housekeeping Aide #155 gathered supplies, washed their hands and applied gloves. Resident #26's incontinence product was removed and observed to be urine soaked. STNA #144 cleansed and rinsed the perineal area, rolled the resident on her right side and cleansed and rinsed the anus and buttocks. STNA #144 placed a clean incontinence product on the resident, adjusted the resident's gown, call…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review and interviews the facility failed to ensure Resident #64 received comprehensive and individualized care to prevent/treat constipation. This affected one resident (Resident #64) of two residents reviewed for bowel and bladder management. The census was 72. Findings included: Review of the medical record revealed Resident #64 was admitted to the facility on [DATE]. Diagnoses included respiratory failure, chronic obstructive pulmonary disease, alpha-1-antitrypsin deficiency, emphysema, anxiety disorder, protein-calorie malnutrition, dehydration, constipation (06/28/23) and hypertension. Review of the plan of care dated 07/05/23 revealed Resident #64 had bowel incontinence related to side effects of medication. She had no incontinence pattern identified on the three-day bowel and bladder tracker. Interventions included to observe for a pattern of incontinence and initiate toileting schedule if indicated, provide a bedpan or bedside commode, provide loose fitting 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, review of the medical record and interview with staff the facility failed to ensure Resident #10, #37 and #49 had physician ordered adaptive equipment for meals. This affected three residents (Resident #10, #37 and #49) of six residents reviewed for nutrition. The census was 72. Findings included: 1. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. Diagnoses included dysphagia, acute respiratory failure, proteins-calorie malnutrition, dementia, weakness, cerebral infarction, and paraplegia. Review of the physician's orders revealed Resident #49 had an order for a plate guard (a metal food bumper that clips onto a plate and makes scooping food onto utensils easier), dated 08/15/22. Observation on 02/13/24 at 8:15 A.M. revealed Resident #49 was in the atrium eating her breakfast. Her plate guard was not on her plate but was lying on the table. An interview at this time with State Tested Nursing Assistant (STNA) #100 stated she did not know why it 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 policy review the facility failed to accurately obtain and document resident weights. This affected one (Resident #20) of four residents reviewed for nutritional services. The facility census was 72. Findings include: Review of Resident #20's medical record revealed an admission date of 11/21/23 with diagnoses that included non-displaced fracture of right great toe, chronic obstructive pulmonary disease, diabetes mellitus, congestive heart failure and hypertension. Review of Resident #20's weights revealed a weight of 242 pounds upon admission on [DATE], 213.5 pounds on 11/28/23 (loss of 28.5 pounds in three days), 214.6 pounds on 12/11/23, 228 pounds on 01/15/24 (gain of 13.4 pounds in 34 days), 214.4 pounds on 01/30/24 (loss of 13.6 pounds in 15 days) and 237.0 pounds on 02/02/24 (gain of 22.6 pounds in three days). No evidence of any attempted re-weights to check for accuracy were noted. Weights were obtained by varying methods (sitting, standing, wheelchair…

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 interview, medical record review, observation and staff interview, the facility failed to ensure hospital discharge medications were followed and medications provided as ordered. This affected one resident (#37) of three residents reviewed for medications upon discharge from the hospital. The facility census was 74. Findings include: Interview with Resident #37 on 09/26/23 at 9:20 A.M. revealed she had recently returned to the facility after admission to the hospital. She indicated she was prescribed Norco (opioid pain medication) and had an order upon discharge from the hospital that should have been provided upon admission to the facility. Resident #37 indicated she had not received the Norco when requested and staff alerted her she did not have any to administer. Resident #37 stated she was provided other pain relief medications, but the Norco would work better. Review of Resident #37's medical record revealed an admission date of 06/06/23 with admission diagnoses that included diabetes…

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 staff and resident interview the facility failed to maintain resident over bed tables, window blinds and wheelchairs in good repair and failed to ensure the main shower room on the second floor was free of storage for optimal resident use. This had the potential to affect 16 residents (#9, #19, #20, #23, #29, #33, #38, #48, #59, #64, #65 #366, #367, #368, #369 and #370) who resided on the second floor and five residents (#4, #5, #7, #26 and #51) who resided on the first floor Gardenway unit. The facility census was 66. Findings include: 1. On 03/21/22 at 8:42 A.M. interview with Resident #65 revealed concerns the shower room was full of stuff. The resident indicated she had a hard time getting showers with one aide taking her into the shower. The resident revealed there was a ramp going up into and down from the shower and it was scary coming down the ramp from the shower. On 03/22/22 at 2:41 P.M. observation of the second floor lower shower room revealed there was storage in the room. There were 10 cartons of facemasks, five boxes of eight ounce cold packs,…

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 residents who required staff assistance with activities of daily living received timely and adequate nail care to promote proper hygiene. This affected five residents (#26, #44, #45, #56 and #367) of five residents reviewed for activities of daily living. Findings include: 1. Review of Resident #26's medical record revealed a 09/11/20 admission with diagnoses including age related debility, vascular dementia with behavioral disturbance, non traumatic intracerebral hemorrhage, hemiplegia and hemiparesis following cerebral infarction. Review of the Activities of Daily Living (ADL) plan of care, dated 09/14/20 revealed the resident had an ADL self-care performance deficit related to generalized weakness, physical debility, hemiplegia/hemiparesis and confusion. Interventions included check nail length, trim and clean on bath day and as necessary. Review of the 10/12/22 quarterly Minimum Data Set…

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 Resident #367 received the appropriate consistency of food in a form designed to meet the resident's needs. This affected one resident (#367) and had the potential to affect nine additional residents (#5, #17, #23, #25, #26, #27, #30, #51 and #60) who were to receive a mechanical soft diet. The facility census was 66. Findings include: Review of Resident #367's medical record revealed the resident was admitted to the facility on [DATE] heart failure, difficulty in walking and muscle weakness. Review of Resident #367's care plan, dated 03/18/22 revealed to provide diet as ordered and to report choking or difficulty chewing with the charge nurse. Review of Resident #367's medical record revealed an order, dated 03/19/22 for a regular diet with mechanical soft texture (food items) and thin liquid consistency. On 03/21/22 at 12:38 P.M. observation Resident #367's lunch tray revealed the resident was served whole kernel corn, mashed…

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, Centers for Disease Control (CDC) guidance, facility policy and procedure review and interview, the facility failed to ensure contaminated N95 masks were stored and discarded appropriately following care of residents in droplet isolation precautions and failed to ensure infection control guidelines were maintained when completing Resident #48's pressure ulcer wound care to prevent the spread of infection including COVID-19. This affected one resident (#48) of one resident reviewed for pressure ulcer wound care, one resident (#366) of one resident reviewed for droplet isolation precautions and had the potential to affect all 16 residents (#9, #19, #20, #23, #29, #33, #38, #48, #59, #64, #65, #366, #367, #368, #369 and #370) who resided on the second floor. The facility census was 66. Findings include: 1. Review of Resident #366's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease with acute…

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 new Preadmission Screening and Resident Reviews (PASARR) were completed following the identification of new mental health diagnoses for residents. This affected two residents (#5 and #44) of two residents reviewed for PASRR Level II services. Findings include: 1. Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE]. Resident #5 had diagnoses including symbolic dysfunction, unspecified psychosis not due to a substance of known physiological condition, major depressive disorder, hallucinations, unspecified dementia without behavioral disturbance, and generalized anxiety disorder. Record review revealed a 12/06/19 admission Preadmission Screening and Resident Review (PASARR). The PASARR included a diagnosis of unspecified psychosis and a diagnosis of dementia. The determination included no indication of serious mental illness. Record review revealed on 07/02/20 a diagnosis of schizoaffective…

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.