Flint Ridge Nrsg & Rehab Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to obtain physician ordered laboratory studies to ensure therapeutic medication levels were achieved. This affected one resident (#17) of five reviewed for unnecessary medications. The facility census was 76. Findings include: Review of Resident #17's medical record revealed an admission date of 03/09/13 with a hospital stay starting on 01/16/25 and ending with the resident's return on 01/19/25. Further review of Resident #17's medical record revealed diagnoses including a displaced intertrochanteric fracture of the left femur, chronic kidney disease stage four, dementia, obsessive-compulsive disorder, osteoporosis, hypothyroidism, major depressive disorder, anxiety, osteoarthritis, unspecified psychosis, epilepsy, hypertension, and chronic pain syndrome. Review of Resident #17's significant change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating the resident has a mild cognition…

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

Based on record review, staff interview, and policy review, the facility failed to ensure antibiotic use was appropriate. This affected one (Resident #40) of three residents reviewed for urinary tract infections (UTI). The facility census was 76. Findings include: Review of the medical record for the Resident #40 revealed an original admission date of 12/23/22 with a re-entry on 09/20/24. Diagnoses included unspecified systolic (congestive) heart failure, muscle weakness, difficulty walking, dysphagia in the oropharyngeal phase, cognitive communication deficit, Enterococcus as the cause of disease classified elsewhere, obstructive and reflux uropathy, benign prostatic hyperplasia with lower urinary tract symptoms, bilateral hearing loss, presence of a cardiac pacemaker, gastrointestinal hemorrhage, urinary retention, cardiac murmur, hypertension, and nonrheumatic aortic valve stenosis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/17/25, revealed the resident had impaired cognition with a brief interview for mental status (BIMS) score of 4, an indwelling…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the facility map accounted for all resident rooms and resident rooms provided a safe environment for residents. This affected five residents (#67, #68, #73, #97 and #99) of 25 residents residing on the Serenity Hall. The facility census was 72. Findings include: On 09/03/24 between 2:26 P.M. and 2:50 P.M., observation with Maintenance Director (MD) #326 revealed the following: a. Observation of the posted floor plans revealed Resident #97 and #99's room was labeled as a storage room. There was no evidence of room [ROOM NUMBER] on the floor plan. Interview with MD #326 at the time of the observation verified the facility had been approved in January 2024 for the storage room to be designated as a resident room; however the name plate outside room [ROOM NUMBER] stated Storage Room with masking tape listing the resident names and there was no room [ROOM NUMBER] labeled on the facility maps. b. Observation of Resident #67 and Resident #68's room 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.

Based on observation, dietary meal card review, and interview, the facility failed to provide ordered serving size and ensure whole milk was available for the breakfast meal. This affected seven residents (#19, #28, #41, #54, #71, #73 and #83) who were to receive whole milk and had the potential to affect any resident receiving meals from the kitchen except for seven residents (#17, #23, #67, #74, #78, #84 and #86) who did not receive anything by mouth. The census was 72. Findings include: Review of the Menu Extension dated 09/04/24 revealed breakfast meal included hot or cold cereal, juice, eight ounce glass of whole or 2% milk, six ounces of juice, four ounces of breakfast casserole (scrambled eggs with peppers) and a slice of toast. Review of the breakfast Dietary Meal Cards for Resident #19, #28, #41, #54, #71, #73 and #83 revealed daily items included whole milk. On 09/04/24 at 7:20 A.M., observation of the milk cooler revealed no whole milk was available for the breakfast meal. On 09/04/24 at 7:34 A.M., observation of the breakfast meal trayline service revealed [NAME] #309…

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, policy review and interview, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all residents except seven residents (#17, #23, #67, #74, #78, #84 and #86) who did not receive anything by mouth. The census was 72. Findings include: 1. On 09/04/24 between 7:06 A.M. and 7:20 A.M., observation of the kitchen with [NAME] #309 verified the following: a. The stove hood above the steamer and six burner stove and flat top had large loose, flaking paint with exposed rust extending the length of metal and in the corner/creases of the hood. b. Dust tendrils were observed blowing from the diamond shaped grating on both sides of the stove hood over the steamer and flat top. Heavy dust and grease build up was observed on top of the stove hood, along the electrical outlet boxes and wire guards adjacent to the stove and behind the dishwasher storage racks containing clean dishes ready for meal service. c. Dust and grease build up was observed on the exhaust fans above the trayline service area. 2. On 09/04/24 at 1:13 P.M.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, policy review and interview, the facility failed to provide a dignified meal experience. This affected one resident (#24) of four residents observed during meal service in the dining room. The census was 72. Findings include: Medical record review revealed Resident #24 was admitted on [DATE] with diagnoses including cerebral infarction, hypertension, dysphagia and cognitive communication disorder. On 09/03/24 at 11:55 A.M., observation of the dining room revealed Resident ##24, #25, #27 and #81 were seated at a table in the dining room. Resident #25, #27 and #81 were served their lunch meals and observed being verbally cued and/or physically assisted with their meal by State Tested Nurse Aide (STNA) #374. Resident #24 was observed sitting at the table watching Resident #25, #27 and #81 eat their food, and would randomly look at the other residents' eating their meals and then looking around the dining room. On 09/03/24 at 12:05 P.M., STNA #330 was observed bringing…

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 provide written notice before a resident's room was changed. This affected one resident (#99) of three residents reviewed for room changes. The facility census was 72. Findings include: Medical record review revealed Resident #99 was admitted on [DATE] with diagnoses including charcot's joint left ankle and foot and diabetes mellitus. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #99 was cognitively intact for daily decision-making. Review of Resident #99's Census revealed the following room moves: a. On 02/06/24, admitted to room [ROOM NUMBER]-A. b. On 02/07/24, moved to room [ROOM NUMBER]-A. c. On 02/23/24, moved to room [ROOM NUMBER]-B. d. On 09/05/24, moved to room [ROOM NUMBER]-B. Review of the medical record revealed no documented evidence that Resident #99 was provided written notification including the reason for the change on 02/07/24 or 02/23/24. On 09/11/24 at 11:01 A.M.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview, the facility failed to provide assistance with meals as needed. This affected one resident (#37) of four residents sampled. The census was 72. Findings include: Medical record review revealed Resident #37 was admitted on [DATE] with diagnoses including moderate intellectual disability, acute respiratory failure, pressure ulcers and schizoaffective disorder. Review of the Nursing Admission/re-admission Assessment - V 4 dated 08/31/24 revealed Resident #37 required limited assistance with eating. Review of the Skin and Wound Note dated 09/05/24 revealed Nurse Practitioner (NP) #908 assessed Resident #37 to have a Stage IV pressure ulcer to the coccyx, deep tissue injury to the left heel, right heel and left lateral foot. NP #908 indicated the resident had multiple factors that may impair wound healing including the risk of dehydration and malnutrition. Review of the dietitian Progress Notes dated 09/05/24 revealed Resident #37 was ordered a regular, puree…

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 timely develop and implement comprehensive, individualized and effective pressure ulcer care and treatment to promote the healing of pressure ulcers for Resident #37, who was admitted to the facility with multiple pressure ulcers present. This affected one resident (#37) reviewed for pressure ulcers. The facility identified eight residents with pressure ulcers. The census was 72. Findings include: Medical record review revealed Resident #37 was admitted on [DATE] with diagnoses including moderate intellectual disability, schizoaffective disorder, multiple pressure ulcers and anxiety. The resident also had a history of osteomyelitis, peripheral venous insufficiency, and chronic embolism/thrombosis of left popliteal vein. Review of the hospital Discharge Summary (hospital stay prior to Resident #37's admission to the facility) dated 08/31/24 revealed a specialty hospital Wound Progress Note dated 08/27/24 indicating…

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 oxygen tanks were safely transported. This affected two residents (#57 and #89) observed with oxygen. The facility identified 13 residents utilized oxygen. Findings include: 1. Medical record review revealed Resident #57 was admitted on [DATE] with diagnoses including unspecified dementia, chronic obstructive pulmonary disease and dependence on supplemental oxygen. Review of the electronic Physician Orders dated September 2024 revealed continuous oxygen 2 liters via nasal cannula (L/NC). On 09/03/24 at 11:52 A.M., observation revealed State Tested Nurse Aide (STNA) #416 was in the lobby area across from the nurses' station and was assisting Resident #57. STNA #416 was observed removing the oxygen regulator from an empty oxygen tank, applied the regulator to a new oxygen tank, applied the nasal cannula set on Resident #57, placed the full oxygen tank into a wheeled oxygen carrier, wedged the carrier between 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 closed medical record review, policy review, and interview, the facility failed to implement enteral feeding recommendations timely. This affected one resident (#2) of three residents reviewed for enteral feedings. The facility identified 13 residents who received nothing by mouth. The census was 72. Findings include: Closed medical record review revealed Resident #2 was admitted on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia, atrial fibrillation, total colectomy, gastrostomy, acute kidney failure with tubular, hemodialysis and protein-calorie malnutrition. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 was cognitively intact for daily decision-making, received nutrition 51% or more from a feeding tube, weighed 123 pounds and was 71 inches tall. Review of the discharge MDS 3.0 assessment dated [DATE] revealed the resident weighed 100 pounds and received nutrition 51% or more from a feeding tube. On 08/14/24, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, policy review and interview, the facility failed to ensure residents received oxygen per physician orders. This affected one resident (#57). The facility identified 13 residents that were ordered to receive oxygen. The census was 72. Findings include: Medical record review revealed Resident #57 was admitted on [DATE] with diagnoses including unspecified dementia, chronic obstructive pulmonary disease and dependence on supplemental oxygen. Review of the electronic Physician Orders dated September 2024 revealed continuous oxygen 2 liters via nasal cannula (L/NC). a. On 09/03/24 at 11:52 A.M., observation revealed State Tested Nurse Aide (STNA) #416 was in the lobby area across from the nurses' station and was assisting Resident #57. STNA #416 was observed removing the oxygen regulator from an empty oxygen tank, applied the regulator to a new oxygen tank, applied the nasal cannula set on Resident #57 and set the oxygen level to be administered to the resident. 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 medical record review, policy review and interview, the facility failed to maintain accurate medical records. This affected three residents (#2, #28, and #37) of five sampled residents. The census was 72. Findings include: 1. Medical record review revealed Resident #37 was admitted on [DATE] with diagnoses including moderate intellectual disability, acute respiratory failure and wounds. Review of the specialty hospital Wound Progress Notes dated 08/27/24 revealed Resident #37 had a left heel/calcaneus deep tissue pressure injury (DTPI). The wound measured 0.2 centimeters (cm) in length (l) by 1.8 (cm) in width (w). There was no depth documented. Review of the Nursing Admission/re-admission Assessment - V 4 dated 08/31/24 revealed Resident #37 had the following skin impairments: a. Left inner ankle pressure ulcer measuring 1.0 (cm) in (l) by 0.3 (cm) in (w) by zero depth(d). No stage was documented. b. Right heel pressure ulcer measuring 2.0 (cm) in (l) by 1.5 (cm) in (w) by zero (d). No stage was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, policy review and interview, the facility failed to ensure infection protocols were implemented when facility staff failed to ensure gloving and hand washing was completed during incontinence care and indwelling catheter supplies were maintained off the floor. This affected two residents (#28, #37). The census was 72. Findings include: 1. Medical record review revealed Resident #37 was admitted on [DATE] with diagnoses including moderate intellectual disability, schizoaffective disorder, multiple pressure ulcers and anxiety. On 09/11/24 between 10:09 A.M. and 10:31 A.M., observation of Resident #37's sacrum pressure ulcer treatment revealed Licensed Practical Nurse (LPN) #412, Registered Nurse (RN) #401 and State Tested Nurse Aide (STNA) #306 positioned the resident and removed the incontinence product. The incontinence product was saturated with dark yellow urine and pasty, dried stool was observed on the buttocks and around the wound edges. There was no dressing…

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 review of facility policy for wound care, this facility failed to ensure residents assessments were accurate to refect a pre-existing skin injury during admission assessments. This affected one (Resident #141) of four residents reviewed for skin care and prevention. The facility census was 70. Findings include: Review of the medical record for Resident #141 revealed an initial admission date of 07/23/23, and re-entry date of 11/29/23, and a discharge date of 12/13/23. Diagnoses included acute respiratory failure with hypoxia, altered mental status, and sepsis unspecified organism. Review of the plan of care dated 11/30/23 revealed Resident #141 was at risk for skin breakdown and has skin breakdown. Interventions include to apply triad cream twice a day after incontinence episode as needed, assist with repositioning and or turning at frequent intervals to provide pressure relief, keep skin clean and dry, assist with skin care based on residents limitations, 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 medical record review, and staff interview, this facility failed to ensure residents receiving antibiotics were monitored for effectiveness including obtaining and monitoring vital signs. This affected one (Resident #141) of the four residents reviewed for antibiotic use. The facility census was 70. Findings include: Review of the medical record for Resident #141 revealed an initial admission date of 07/23/23, and re-entry date of 11/29/23, and a discharge date of 12/13/23. Diagnoses included acute respiratory failure with hypoxia, altered mental status, and sepsis unspecified organism. Review of Resident #141's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident had an intact cognition for daily decision making abilities. Resident #141 required supervision assistance for personal hygiene and was dependent on staff for toileting, dressing, and transfers. Resident #141 was noted to be receiving…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy for medication administration, this facility failed to ensure residents thyroid medication was administered at the scheduled time. This affected one (Resident #41) of the four residents reviewed for accurate medication administration. The facility census was 70. Findings include: Review of the medical record for Resident #41 revealed an admission date of 04/13/23. Diagnoses included hemiplegia and hemiparesis following an cerebral infarction affecting the right dominant side, diabetes insipidus, anxiety disorder, obesity, and hypothyroidism. Review of Resident #41's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident had an intact cognition for daily decision making abilities. Resident required supervision or set up assistance for eating, oral care, toilet hygiene, dressing, personal hygiene. Noted to have an indwelling catheter and always…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy for charting and documentation, this facility failed to ensure information documented in residents medical records were accurate to reflect care provided. This affected one (Resident #41) of four residents reviewed for accurate medical record documentation. The facility census was 70. Findings include: Review of the medical record for Resident #41 revealed an admission date of 04/13/23. Diagnoses included hemiplegia and hemiparesis following an cerebral infarction affecting the right dominant side, diabetes insipidus, anxiety disorder, obesity, and hypothyroidism. Review of Resident #41's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident had an intact cognition for daily decision making abilities. Resident required supervision or set up assistance for eating, oral care, toilet hygiene, dressing, and personal hygiene. Noted to have an…

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. Review of the medical record for Resident #5 revealed an admission date of 11/14/21. Medical diagnoses included schizoaffective disorder (09/15/22), bipolar disorder (07/18/21), obsessive-compulsive disorder (07/18/21), anxiety disorder (07/18/21), major depressive disorder (07/18/21), and mild intellectual disabilities (07/18/21). Review of the annual MDS 3.0 assessment, dated 07/15/23, revealed Resident #5 had intact cognition and scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #5 required extensive assistance from two staff to complete Activities of Daily Living (ADLs). Review of Resident #5's PASRR, dated 01/28/22, revealed the document did not include Resident #5's diagnosis of anxiety disorder, obsessive-compulsive disorder, or schizoaffective disorder. The document also did not include Resident #5's use of anti-anxiety medication. Interview on 08/16/23 at 4:41 P.M. with Social Services Director (SSD) #210 confirmed an updated PASRR had not been completed 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 medical record review and staff interview, the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected three (Residents #5, #13, and #30) of three residents reviewed for Pre-admission Screening and Resident Review (PASRR). The census was 76. Findings include: 1. Review of the medical record for Resident #13 revealed Resident #13 was admitted to the facility on [DATE]. Resident #13's diagnoses included but were not limited to dementia, obsessive compulsive disorder (12/27/16), osteoporosis, hypothyroidism, vitamin D deficiency, major depressive disorder (03/09/13), anxiety disorder (03/09/13), unspecified psychosis not due to a substance or known physiological condition (03/09/13). Review of Resident #13's Minimum Data Set (MDS) assessment, dated 07/14/23, revealed she had mild cognitive impairment. Review of Resident #13's PASRR document, dated 02/15/12, revealed under Section D, the only diagnosis listed was mood disorder.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure resident care plans were revised to reflect changes in advanced directives. This affected one (Resident #7) out of 18 residents reviewed for advanced directives. The facility census was 76. Findings include: Review of the medical record for Resident #7 revealed Resident #7 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included but were not limited to major depressive disorder, anxiety, and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/27/23, revealed Resident #7 was cognitively intact. Resident #7 was receiving hospice care. Review of the physician orders for Resident #7 revealed an order dated 06/09/23 for Do Not Resuscitate - Comfort Care - Arrest (DNR-CC-Arrest). Review of the paper chart for Resident #7 revealed the first page was a label in bold print which indicated DNR-CC-Arrest. Review of the care plan for Resident #7 revealed a problem that outlined…

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, staff interviews, and facility policy review, the facility failed to ensure dietary recommendations to address weight loss were implemented in a timely manner. This affected one (Resident #64) of four residents reviewed for nutrition. The facility census was 76. Findings include: Review of the medical record for Resident #64 revealed an admission date of 07/14/23. Resident #64's medical diagnoses included fracture of right femur (lower leg bone), chronic obstructive pulmonary disorder (COPD), Type II Diabetes Mellitus with hyperglycemia (high blood sugar levels), dementia without behavioral disturbance, and dysphagia (difficulty swallowing). Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 07/21/23, revealed Resident #64 had impaired cognition and scored a six out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #64 required supervision from one staff with eating. Review of the care plan, dated 07/18/23, revealed Resident #64 had a potential to be at nutritional risk. Interventions included to provide…

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 interviews, and facility policy review, the facility failed to ensure medications were administered according to the physician ordered parameters. This affected two residents (Resident #30 and Resident #34) out of six residents reviewed for unnecessary medications. The facility census was 76. Findings include: 1. Review of the medical record for Resident #34 revealed Resident #34 was admitted on [DATE] with diagnoses which included but were not limited to metabolic neuropathy, polyneuropathy, low back pain, chronic pain, depression, rhabdomyolysis, thrombocytopenia, and edema. Review of Resident #34's quarterly Minimum Data Set (MDS) assessment, dated 05/16/23, revealed Resident #34 was cognitively intact. Review of Resident #34's physician orders revealed an order, dated 04/20/23, for Norco (narcotic medication) oral tablet 5-325 milligrams (mg), give one tablet every six hours as needed for a pain level of six to 10 out of 10, not to exceed three grams (gm) in 24 hours.…

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 and interview, the facility failed to maintain acceptable infection control practices including proper procedures for residents in droplet isolation and/or quarantine to prevent the spread of infection including COVID-19. This affected five residents (#37, #212, #311, #312 and #313) and had the potential to affect all 66 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #311 revealed an admission date of 07/02/21 with diagnoses including sepsis due to Escherichia coli (E-coli), lobar pneumonia and droplet precautions due to new admission COVID-19 quarantine. On 07/12/21 at 9:30 A.M. Maintenance Director #16 was observed standing in Resident #311's room assisting the resident with her television. Maintenance Director #16 was observed wearing only a surgical mask. On Resident #311's door prior to entering the room was a sign indicating to wear a gown, gloves, N-95 mask and goggles prior to entering…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview the facility failed ensure comprehensive and individualized care plans were developed for all residents. This affected four residents (#7, #25, #32 and #47) of 21 sampled residents who care plans were reviewed. Findings include: 1. Review of Resident #47's medical record revealed a re-admission to the facility on [DATE] and latest re-admission of 05/09/21. The resident had diagnoses including encounter for orthopedic aftercare, dysphagia, anxiety disorder, pressure induced deep tissue damage of right heel, anemia, urine retention, diabetes mellitus, encephalopathy, peripheral vascular disease, severe morbid obesity, repeated fall, atrial fibrillation and hypertension. Review of the resident's admission assessment dated [DATE] indicated the resident was incontinent of urine one or more times a shift and incontinent of bowel. Review of the resident's five day Minimum Data Set (MDS) 3.0 assessment, dated 05/16/21 revealed the resident had clear speech,…

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, facility policy and procedure review and interview the facility failed to promote Resident #311's dignity when staff failed to ensure the resident's urinary drainage collection bag was covered and not visible to other residents/staff/visitors. This affected one resident (#311) of one resident reviewed for dignity. Findings include: Review of the medical record for Resident #311 revealed an admission date of 07/02/21 with diagnosis including severe protein calorie malnutrition, major depressive disorder, and acute kidney failure with an artificial opening of the urinary tract. Review of Resident #311's admission Minimum Data Set (MDS) 3.0 assessment, dated 07/09/21 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident had a moderately impaired cognition for daily decision making abilities. Resident #311 required limited assistance from one staff member for bed mobility, dressing, and personal hygiene and was totally dependent on one staff member for toilet use. Resident #311 was noted to require the use of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and policy review the facility failed to notify the physician when Resident #19 experienced a significant weight loss. This affected one resident (#19) of 21 sampled residents. Findings include: Review of the medical record for Resident #19 revealed an admission date of 12/11/20 with diagnoses including chronic obstructive pulmonary disease, congestive heart failure, diabetes, dysphagia and adult failure to thrive. Review of a Minimum Data Set (MDS) 3.0 assessment, completed 12/23/20 revealed a Brief Interview for Mental Status score of 12, indicating moderately impaired cognitive status. The MDS revealed the resident was 69 inches tall, required supervision with eating and had experienced weight loss. Review of weight records revealed the resident weighed 149.8 pounds on admission on [DATE]. On 12/29/20 the resident weighed 133.6 pounds. A progress note by the dietician on 12/31/20 indicated the resident's weight had been stable for seven days. Meal intakes were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and facility policy review the facility failed to ensure residents were provided with personal privacy. This affected three residents (#5, #19 and #212) of three residents reviewed for privacy. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 12/11/20 with diagnoses including chronic obstructive pulmonary disease, congestive heart failure and adult failure to thrive. A Minimum Data Set (MDS) 3.0 assessment completed 04/08/21 indicated the resident had moderately impaired cognitive skills and required extensive assistance from two staff with transfers and walking. On 07/13/21 at 8:37 A.M. the surveyor was conducting an interview with Resident #19. Resident #19 was in bed and the room door was closed. At that time, Housekeeping Aide #13 opened the door to Resident #19's room and entered without knocking first. She proceeded into the bathroom to place soap and then left the room. She did not speak to the resident or the…

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

Based on observation, record review and interview the facility failed to comprehensively assess Resident #25's behavior patterns. This affected one resident (#25) of 21 sampled residents. Findings include: Review of the medical record for Resident #25 revealed an admission date of 12/19/19 with diagnoses including schizoaffective disorder, dementia, major depressive disorder and anxiety disorder. The resident was receiving an antidepressant medication daily and was receiving Hospice services. Review of a Minimum Data Set (MDS) 3.0 assessment completed 04/20/21 revealed the resident had severely impaired cognition and no behaviors noted. On 07/13/21 at 8:30 A.M., 1:20 P.M. and 2:40 P.M., on 07/14/21 at 8:58 A.M. and 12:25 P.M. and on 07/15/21 at 8:38 A.M. and 10:05 A.M. Resident #25 was observed in bed with his head covered up with a blanket. On 07/15/21 at 10:45 A.M. interview with Registered Nurse (RN) #35 revealed Resident #25 refuses to get out of bed most of the time and always has his head under the covers. RN #35 revealed she did not know why he always kept his head covered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident record review, interview interview and policy review this facility failed to ensure resident assessments were accurate to reflect each residents specific care needs. This affected one resident (#32) of 21 residents reviewed for assessments. Findings include: Review of Resident #32's medical record revealed an admission date of 03/25/18 with diagnoses including protein-calorie malnutrition, dementia without behavioral disturbances and cognitive communication deficit. Review of Resident #32's compressive Minimum Data Assessment (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident with a moderately impaired cognition for decision making abilities. Resident #32 was noted to reject care. Resident #32 required supervision from one staff member for bed mobility and bathing and required limited assistance from one staff member for transfers, ambulation, dressing, toilet use and personal hygiene. Resident #32 was assessed…

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

Based on medical record review and staff interview the facility failed to refer a resident with a newly evident serious mental disorder to the appropriate State-designated authority for a Preadmission and Resident Review (PASRR) Level II assessment/determination upon change in status. This affected one resident (#7) of one resident reviewed for PASRR. Findings include: Review of the medical record for Resident #7 revealed an admission date of 09/24/19. Record review revealed PASRR results, effective 09/24/19 which indicated the resident had no indications of serious mental illness. Therefore, a PASRR Level II review was not warranted/completed. Further record review revealed the resident was admitted for an inpatient psychiatric stay from 03/25/20 to 04/09/20. A physician's progress note on 04/13/20 revealed the resident was recently back after a psychiatric hospitalization. Per staff he had been yelling, shouting and threatening staff and other residents. A diagnosis of schizophrenia with antipsychotic use was noted in the progress notes. A diagnosis of schizoaffective disorder 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 observation, medical record review and staff interview the facility failed to ensure Resident #59's baseline plan of care addressed the resident's bruising and skin tears. This affected one resident (#59) of 21 sampled residents who care plans were reviewed. Findings include: Review of Resident #59's medical record revealed an original admission date of 06/16/21 with the latest readmission of 07/11/21. The resident had diagnoses including rhabdomyolysis, left hip pressure ulcer, pressure ulcer of sacral region, abdominal aortic aneurysm, presence of artificial hip joint bilaterally, dysphagia and fall. Review of the resident's readmission assessment, dated 07/11/21 revealed the resident was readmitted to the facility with a pressure ulcer to his left hip measuring 18.0 centimeters (cm) in length by 9.0 cm width with no stage specified, a pressure ulcer to right heel measuring 1.0 cm by 1.5 cm with no stage specified. The resident also had a scab to the back of his right hand measuring 1.0 cm by 0.7 cm and the back of his left hand measuring 1.7 cm by 0.2 cm. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview the facility to revise Resident #47's plan of care to reflect the resident's incontinence of bladder. This affected one resident (#47) of 21 sampled residents whose care plans were reviewed. Findings include: Review of Resident #47's medical record revealed a re-admission to the facility on [DATE] with a latest re-admission of 05/09/21. The resident had diagnoses including encounter for orthopedic aftercare, dysphagia, anxiety disorder, pressure induced deep tissue damage of right heel, anemia, urine retention, diabetes mellitus, encephalopathy, peripheral vascular disease, severe morbid obesity, repeated fall, atrial fibrillation and hypertension. Review of the resident's admission assessment, dated 03/31/21 indicated the resident was incontinent of urine one or more times a shift and incontinent of bowel. Review of the plan of care, dated 04/27/21 revealed the resident was incontinent of bladder. Interventions included notify nursing if resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview the facility failed to ensure Resident #5 and Resident #47, who required staff assistance for activities of daily living received timely and adequate personal care/shaving assistance to maintain good hygiene. This affected two residents (#5 and #47) of five residents reviewed for activities of daily living (ADL) care. Findings include: 1. Review of Resident #5's medical record revealed an original admission date of 09/20/16 with the latest readmission of 03/17/21 and admitting diagnoses of encephalopathy, malaise, contracture of right hand, intracerebral hemorrhage, cerebral vascular accident (CVA) with right sided hemiplegia, dysphagia, schizoaffective disorder, major depressive disorder, dementia with behavioral disturbances, anxiety disorder, hyperlipidemia, overactive bladder, aphasia and hypertension. Review of the plan of care, dated 12/11/19 revealed the resident had an activities of daily living (ADL) self-care performance deficit related to CVA,…

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 develop and implement individualized and meaningful activities to meet the total care needs of Resident #11 and Resident #53. This affected two residents (#11 and #53) of three residents reviewed for activities. Findings include: 1. Review of Resident #53's medical record revealed an admission date of 06/06/21 with diagnosis including adult failure to thrive, local infection of the skin and subcutaneous tissue, pressure ulcer of the sacral region, deep tissue damage of the left heel and pressure ulcer of the right heel. Review of Resident #53's Activity Assessment/Evaluation, dated 06/07/21 revealed the resident's current interests included arts/crafts, sports, music, spiritual/religious activities, walking/wheeling outdoors, watching television, watching movies, talking/conversing, listening to the radio, and groups and organizations. Resident #53 did not take naps throughout the day. Review of the plan of care, dated 06/07/21 revealed Resident #53 had impaired cognitive and thought processes related 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.

Based on observation, record review and interview the facility failed to assess and monitor Resident #59 related to bruising and skin tears. This affected one resident (#59) of two residents reviewed for skin conditions. Findings include: Review of Resident #59's medical record revealed an original admission date of 06/16/21 with the latest readmission of 07/11/21 and diagnoses including rhabdomyolysis, left hip pressure ulcer, pressure ulcer of sacral region, abdominal aortic aneurysm, presence of artificial hip joint bilaterally, dysphagia and fall. Review of the resident's five day Minimum Data Set (MDS) 3.0 assessment, dated 06/23/21 revealed the resident had clear speech, usually understood others, made himself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of zero. The resident required extensive assistance of two staff for bed mobility, transfers, toilet use and was non-ambulatory. The assessment indicated the resident had skin tears. Review of the resident's readmission assessment, dated 07/11/21 revealed the…

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

Based on observation, medical record review and staff interview the facility failed to ensure Resident #7 received proper treatment to maintain vision and hearing abilities. This affected one resident (#7) of one resident reviewed for communication. Findings include: Review of the medical record for Resident #7 revealed an admission date of 09/24/19. Review of a psychiatric progress note, dated 06/14/21 revealed the clinician documented the resident was seen for psychiatric medication management. The resident was seen for anxiety and mood swings. The clinician documented the resident was extremely hard of hearing making the exam difficult. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 06/30/21 revealed the resident had moderate difficulty with hearing and had no hearing aids. The MDS also revealed the resident had moderately impaired vision and had no glasses On 07/14/21 at 9:30 A.M. the surveyor attempted to speak to the resident. The resident was noted to be extremely hard of hearing. Interview with Registered Nurse #35 on 07/15/21 at 10:00 A.M. confirmed 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.

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 adequately and comprehensively assess pressure ulcers for Resident #47 and Resident #59 upon admission and/or re-admission to the facility. This affected two residents (#47 and #59) of four residents reviewed for pressure ulcers. Findings include: 1. Review of Resident #47's medical record revealed the resident was re-admitted to the facility on [DATE] and had a latest re-admission of 05/09/21 with diagnoses including encounter for orthopedic aftercare, dysphagia, anxiety disorder, pressure induced deep tissue damage of right heel, anemia, urine retention, diabetes mellitus, encephalopathy, peripheral vascular disease, severe morbid obesity, repeated fall, atrial fibrillation and hypertension. Review of the resident's admission assessment, dated 03/31/21 revealed the resident was admitted to the facility with a SDTI to the right heel measuring 7.8 centimeters (cm) in length by 8.0 cm width. The…

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

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure the resident environment remained free of accident hazards related to smoking. This affected one resident (#34) of two residents reviewed for accidents. Findings include: The facility identified two residents who smoked cigarettes, Residents #34 and #162. The facility identified smoking times for residents were at 7:00 A.M., 11:00 A.M., 3:00 P.M., 7:00 P.M. and 9:00 P.M. each day. Review of the medical record for Resident #34 revealed an admission date of 11/08/20 with diagnoses including diabetes, peripheral vascular disease and right above the knee amputation. Review of a plan of care, revised on 03/18/21 revealed Resident #34 was a smoker. The goal was for the resident not to sustain harm or injury related to unsafe smoking practices. Interventions included to assess for changes in mental status that would effect his ability to smoke safely, educate resident on smoking policies, monitor for burn holes in clothing, burn marks, etc., monitor for instances of non…

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, facility policy and procedure review and interview the facility failed to implement timely and effective interventions to ensure Resident #19 maintained acceptable parameters of nutritional status, such as body weight. This affected one resident (#19) of three residents reviewed for nutrition. Findings include: Review of the medical record for Resident #19 revealed an admission date of 12/11/20 with diagnoses including chronic obstructive pulmonary disease, congestive heart failure, diabetes, dysphagia and adult failure to thrive. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 12/23/20 revealed a Brief Interview for Mental Status (BIMS)score of 12 indicating moderately impaired cognitive status. The MDS revealed the resident was 69 inches tall, required supervision with eating and had experienced weight loss. Review of the weight records revealed the resident weighed 149.8 pounds on admission on [DATE]. On 12/14/20 the resident weighed 132.2 pounds (a weight loss of 17.6…

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 implement a comprehensive and individualized plan for Resident #11, who had a diagnosis of dementia to ensure the resident received the appropriate treatment and services to attain or maintain her highest practicable physical, mental, and psychosocial well-being. This affected one resident (#11) of five residents reviewed for unnecessary medication use. Findings include: Review of the medical record for Resident #11 revealed an admission date of 12/04/20 with diagnoses including dementia, anxiety disorder, and depressive disorder. The resident was currently receiving an antianxiety medication, Buspar three times daily. The anti-anxiety medication had been started on 12/14/20 and then increased on 12/21/20 and 04/28/21. An admission Minimum Data Set (MDS) 3.0 assessment, dated 12/11/20 indicated the resident had severely impaired cognition and had physically inappropriate behaviors and socially inappropriate behaviors. A quarterly MDS 3.0 assessment on 07/02/21 indicated the resident had physically and verbally…

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 pharmacy recommendations for Resident #7 and Resident #38 were addressed timely by the physician. This affected two residents (#7 and #38) of three residents reviewed for unnecessary medications. Findings include: 1. Review of Resident #38's medical record revealed an original admission date of 01/08/18 with the latest readmission of 11/08/19 and admitting diagnoses of cirrhosis of liver, chronic kidney disease, vascular dementia, cerebrovascular disease, dementia encephalopathy, convulsions, atrial fibrillation, major depressive disorder, generalized muscle weakness, dysphagia, insomnia and benign prostatic hyperplasia. Review of a pharmacy recommendation, dated 03/08/21 revealed the pharmacist recommended a gradual dose reduction (GDR) for the resident related to an order for Trazadone. The physician failed to address the recommendation until 05/10/21 at which time the physician agreed with the recommendation and reduced the medication 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.

Based on record review, facility policy and procedure review and interview the facility failed to ensure medications were administered only when necessary and with adequate and appropriate monitoring including laboratory testing to monitor for effectiveness and optimal dose. This affected two residents (#7 and #38) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #38's medical record revealed an original admission date of 01/08/18 with the latest readmission of 11/08/19 and admitting diagnoses of cirrhosis of liver, chronic kidney disease, vascular dementia, cerebrovascular disease, dementia encephalopathy, convulsions, atrial fibrillation, major depressive disorder, generalized muscle weakness, dysphagia, insomnia and benign prostatic hyperplasia. Review of the resident's plan of care revealed the resident was on anticoagulant therapy related to atrial fibrillation. Interventions included to administer medication as ordered, monitor as ordered by physician, labs as ordered, report abnormal lab results to physician,…

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

Based on observation, record review and interview the facility failed to implement behavioral interventions, including non pharmacological approaches prior to administering psychoactive medications and failed to timely evaluate the effectiveness of psychoactive medications for Resident #11. This affected one (Resident #11) of five residents reviewed for unnecessary medication use. Findings include: Review of the medical record for Resident #11 revealed an admission date of 12/04/20 with diagnoses including dementia, anxiety disorder and depressive disorder. Record review revealed the resident was currently receiving the antianxiety medication, Buspar 15 milligrams (mg) three times daily. The antianxiety medication had been started on 12/14/20 at 10 milligrams twice daily and then increased on 12/21/20 to 10 milligrams three times daily and then on 04/28/21 was increased to 15 milligrams three times daily. A nursing progress note, dated 12/14/20 at 2:44 P.M. revealed the nurse practitioner was in and updated on resident with increased anxiety. New orders for Buspar and Vistaril.…

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 physician ordered laboratory testing was completed as ordered and/or failed to ensure the physician was promptly notified of resident laboratory results which fell outside the clinical reference ranges. This affected two residents (#5 and #7) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 09/24/19. a. The resident had physician's orders dated 12/29/20 for the medication Depakote (valproic acid) 125 milligrams three times a day for schizoaffective disorder and Lipitor 80 milligrams daily for hyperlipidemia (high lipids in the blood). The resident had a physician's order, dated 02/25/21 for a lipid panel and valproic acid level to be drawn every six months. A lipid panel is a blood test that measures lipids such as triglycerides and high-density lipoprotein (HDL). A valproic acid level measures the amount of valproic acid medication in the blood stream. Review of laboratory test results, dated 03/05/21 revealed…

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