Newark Nursing & Rehab

Based on medical record review, controlled substance log review, staff interview, and facility policy review, the facility failed to ensure residents were free from significant medication errors related to controlled medications. This affected six residents (#1, #3, #36, #62, #93, and #108) of seven residents reviewed for medication administration. The facility census was 105. Findings include: 1. Review of the medical record for Resident #1 revealed an initial admission date of 10/06/21 with a re-entry date of 03/09/25. Diagnoses included stage three chronic kidney disease, chronic obstructive pulmonary disease, and peripheral vascular disease. Review of Resident #1's physician order dated 03/09/25 revealed an order for Oxycodone (narcotic pain medication) 5 milligram (mg) tablet, give two tablets by mouth every eight hours for pain. Review of the Controlled Drug Receipt/Record/Disposition form revealed on 08/12/25, Resident #1 received the scheduled pain medication at 5:16 A.M. and again at 9:00 P.M. Resident #1's 2:00 P.M. dose had not been administered or signed out on the log.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to have resident funds available to the residents on the weekend. This affected one resident (#15) and had the potential to affect all residents with funds managed by the facility. The facility census was 105.Findings include: Review of Resident #15's medical record revealed an admission date of 03/10/23 and diagnoses including but not limited to diabetes, schizophrenia, other seizures, depression, bipolar disorder current episode mixed, severe, with psychotic features, anxiety disorder, hyperlipidemia, and hypertension. Review of Resident #15's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had intact cognition. Review of Resident #15's facility-managed funds account records dated June 2025 to August 2025 revealed there were no receipts for money released to Resident #15 from his facility-managed account on any weekend days. Interview on 08/12/25 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure Preadmission Screening and Resident Review (PASARR) assessments were accurately completed. This affected three residents (#7, #13, and #15) out of five residents reviewed for accurate PASARR assessments. The facility census was 105. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 02/18/2025. Diagnosis included major depressive disorder, post-traumatic stress disorder (PTSD), bipolar disorder, and seizures. Review of the PASARR for Resident #13 dated 01/31/25 revealed under Section E: Indication of Serious Mental Illness, that no mental disorders had been noted. Review of Resident #13's Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 08 out of 15 indicating moderately impaired cognition for daily decision-making abilities. Resident #13 was noted to display disorganized thinking and inattention. 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 record review and interview, the facility failed to complete a baseline care plan for Resident #2 within 48 hours of admission as required. This affected one resident (#2) of four residents reviewed for dementia care. The facility census was 105. Findings include: Review of Resident #2's medical record revealed an admission date of 06/04/25 and diagnoses including but not limited to dementia, frontotemporal neurocognitive disorder, atrial fibrillation, hypertension, major depressive disorder, hyperlipidemia, and osteoarthritis. Review of Resident #2's Minimum Data Set (MDS) admission assessment dated [DATE] revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS) due to being rarely or never understood, had behaviors of physical symptoms directed at others for four to six days during the assessment window, verbal symptoms directed toward others for one to three days during the assessment window, and rejection of care for four to six days during the assessment window.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the care plan included comprehensive psychosocial interventions to address identified behaviors. This affected one resident (#64) out of thirty residents reviewed for care planning. The facility census was 105.Findings include:Review of the medical record for Resident #64 revealed an admission date of 05/30/25 with diagnoses including depression, anxiety disorder, hypertension, and insomnia.Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] revealed Resident #64 was cognitively intact and has no mood or behavioral concerns.Review of the care plan dated 07/14/25 revealed the resident was known to make inappropriate and sexual comments to staff. Interventions included one-on-one supervision, every 15-minute and 30-minute checks as needed for safety of both this resident and others, referral to psych as needed, and staff monitoring for any inappropriate behaviors.Interview on 08/18/25 at 3:52 P.M. with Resident #64 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and staff interview, this facility failed to ensure care plans had been revised to accurately reflect enhanced barrier precautions and fluid restrictions had been discontinued. This affected two residents (#24 and #66) of 30 residents reviewed for care planning. The facility census was 105.Findings include:1.Review of the medical record for Resident #24 revealed an initial admission date of 08/09/24 and a re-entry date of 07/11/25. Diagnoses included chronic systolic heart failure, peripheral vascular disease, and atrial fibrillation. Review of Resident #24's Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03 out of 15 indicating a severely impaired cognition for daily decision-making abilities. Review of the undated care plan revealed Resident #24 required enhanced barrier precautions for infection prevention. Observations completed on 08/11/25 at 10:00 A.M. and again on 08/19/25 at 11:00 A.M. revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, and staff interview, the facility failed to ensure fall interventions were in place. This affected two residents (#1 and #43) of five residents reviewed for fall safety. The facility census was 105. Findings include:1.Review of the medical record for Resident #1 revealed an initial admission date of 10/06/21 and a re-entry date of 03/09/25. Diagnoses included peripheral vascular disease, embolism and thrombosis of deep veins of the lower extremities, and unsteadiness on feet. Review of the physician orders for Resident #1 dated 02/25/25 revealed an order for the resident's bed to be in the lowest position when occupied. Review of the care plan dated 03/10/25 for Resident #1 revealed this resident was at risk for falls related to medication use, decrease mobility, non-ambulatory, and obesity comorbidities. Fall interventions included to be sure the call light is in reach, bed in lower position when occupied, and to follow facility fall protocol. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure nutritional supplements were implemented upon dietician and dialysis center recommendations for Resident #6. Additionally, the facility failed to implement interventions to prevent further weight loss for Resident #35. The affected two residents (#6 and #35) out of five residents reviewed for nutrition. The facility census was 105. Findings include: 1.Review of the medical record for Resident #6 revealed an admission date of 02/25/22 with diagnoses including end-stage renal disease, type two diabetes mellitus, gastroesophageal reflux disease, moderate protein-calorie malnutrition, and hypo-osmolality with hyponatremia. Review of the care plan dated 09/28/23 revealed Resident #6 was at risk for altered nutrition and hydration related to body mass index (BMI), therapeutic diet, and weight changes with fluid balance. The resident was noted to refuse facility weights, had a history of hospice care, and was known to refuse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure Resident #79's medical record included a physician order for hemodialysis treatments. This affected one resident (#79) of two residents reviewed for dialysis. The facility census was 105.Findings include: Review of Resident #79's medical record revealed an admission date of 02/26/25 and diagnoses including but not limited to orthopedic aftercare following surgical amputation, end stage renal disease, congestive heart failure, diabetes, left above the knee amputation, dependence on renal dialysis, hypertension, and anxiety disorder. Review of Resident #79's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident had intact cognition. Resident #79's MDS indicated the resident had rejected care one to three days in the MDS review window, the resident was independent with eating and was dependent for all other activities of daily living, was always incontinent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure the physician visited residents at the required frequency. This affected one resident (#2) of four residents sampled for dementia care. The facility census was 105. Findings include: Review of Resident #2's medical record revealed an admission date of 06/04/25 and diagnoses including but not limited to dementia, frontotemporal neurocognitive disorder, atrial fibrillation, hypertension, major depressive disorder, hyperlipidemia, and osteoarthritis. Review of Resident #2's Minimum Data Set (MDS) admission assessment dated [DATE] revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS) assessment due to being rarely or never understood, had behaviors of physical symptoms directed at others for four to six days during the assessment window, verbal symptoms directed toward others for one to three days during the assessment window, and rejection of care for four to six days during 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 record review, interview, and facility policy review, the facility failed to ensure pharmacy recommendations that were addressed by the physician were implemented in a timely manner. This affected one resident (#43) of five residents reviewed for unnecessary medications. The facility census was 105. Findings include: Review of the medical record for Resident #43 revealed an initial admission date of 04/05/24 and a re-entry date of 07/27/24. Diagnoses included vascular dementia with moderate mood disturbances, mood disorder, and anxiety. Review of physician orders for Resident #43 revealed an order dated 05/16/25 for Lorazepam (also known as Ativan, an antianxiety medication) 0.5 milligram (mg) tablet, give 0.5 mg by mouth every six hours as needed for anxiety and restlessness. Review of the pharmacy recommendation dated 05/19/25 revealed the resident was presently prescribed Lorazepam (Ativan) 0.5 mg by mouth every 6 hours as needed for anxiety. The form included a recommendation to please document duration and rationale for extended therapy of the as-needed order. 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, hospice records, staff interview, and facility policy review, the facility failed to ensure hospice records were available for review to allow for effective collaboration between the facility and the hospice provider. This affected one resident (#43) of one resident reviewed for hospice care. The facility census was 105. Findings include:Review of the medical record for Resident #43 revealed an initial admission date of 04/05/25 and a re-entry date of 07/27/24. Diagnoses included vascular dementia, cerebral atherosclerosis, disorders of the bone density and structure, and hypertension. Review of Resident #43's Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 09 out of 15 indicating severely impaired cognition for daily decision-making abilities. Interview on 08/19/25 at 12:49 P.M. with a hospice staff member revealed Resident #43 was planned to received Certified Nursing Assistant (CNA) services three times…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility failed to ensure Resident #75's wound and living space were free from pests. This affected one resident (#75) of six residents sampled for wounds. The facility census was 105. Findings include: Review of Resident #75's medical record revealed an admission date of 01/31/05 and diagnoses including malignant neoplasm of head and face, squamous cell carcinoma, autistic disorder, diabetes, anxiety disorder, peripheral vascular disease, hypertension, acquired absence of right leg below the knee, and non-pressure chronic ulcer of other part of left lower leg with other specified severity. Review of Resident #75's Minimum Data Set (MDS) significant change in status assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 13 indicating the resident was cognitively intact and had no recorded behaviors. Further review revealed Resident #75 required set up assistance for eating and was dependent on staff for all other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure comprehensive care plans were developed in the areas of diabetes, depression, anticoagulants, activities, and skin picking behaviors. This affected five residents (#2, #33, #56, #84, and #85) of thirty residents reviewed for care planning. The facility census was 102. Findings include: 1. Review of Resident #56's medical record revealed an admission date of 06/07/24 with diagnoses including respiratory failure, chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder, encounter for orthopedic aftercare following surgical amputation, other chronic pain, type two diabetes mellitus, bipolar disorder, and fibromyalgia. Review of Resident #56's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #56's physician orders dated 06/07/24 revealed an order for Insulin Glargine Subcutaneous (sq)Solution Pen-injector 100 units per milliliter (ml). Sixty units…

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, interview, and review of scheduled activities, the facility failed to ensure residents were offered or assisted in attending activities and failed to provide activities as scheduled. This affected four (#14, #22, #406, #52) of five residents reviewed for participation in activities. The facility census was 102. Findings include: 1. Review of the medical record for Resident #52 revealed an admission date of 7/10/2019, Diagnoses included moyamoya disease, hemiplegia, history of a cerebral infarction, and a left hand contractor. Review of Resident #52's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was severely impaired, had a memory problem, untied a wheelchair, and had an upper extremity impairment. Review of Resident #52's Care Plan dated 07/28/24 revealed the resident had impaired cognitive function related to confusion, poor safety awareness, and a cerebrovascular accident. Interventions included to encourage the resident to participate in…

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

Based on observations, staff and resident interviews, review of lunch meal tickets, review of the dietary spreadsheet, review of the menu, review of the emergency food menu, and facility policy review, the facility failed to ensure two residents (Residents #22 and #33) received all the foods as ordered according to their meal tickets and the facility failed to ensure there was an emergency food stock in a designated area of the facility. The deficient practices affected two residents (Residents #22 and #33) and had the potential to affect all of the residents who resided at the facility, except Resident #93 who had an ordered nothing by mouth (NPO) diet. The facility census was 102. Findings Include: Review of the daily menu for the lunch meal on Tuesday, 08/27/24, revealed the planned meal was barbecue cheeseburgers on a bun with lettuce, tomato, and a pickle spear, confetti coleslaw, French fries with ketchup, and an oatmeal raisin cookie. Review of the dietary spreadsheet for the lunch meal on Tuesday, 08/27/24, revealed for a resident on an ordered renal diet, the resident…

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

Based on observations, staff interview, and facility policy review, the facility failed to ensure pureed foods were prepared to an appropriate texture, requiring surveyor intervention. The deficient practice had the potential to affect four residents (Residents #8, 22, 46, and 60) who had an ordered pureed diet. The facility census was 102. Findings Include: Observation on 08/27/24 at 10:23 A.M. of the preparation of pureed foods with [NAME] #201 revealed the cook placed six barbecue hamburgers into the blender and started blending. At 10:36 A.M., [NAME] #201 stopped the blender and poured the pureed barbecue hamburgers into a silver serving dish. [NAME] #201 tasted the pureed food item and confirmed she felt it was an appropriate at serve to the residents. There was no other staff present at the time of the observation to taste the pureed food. At 10:38 A.M., this surveyor tasted the pureed barbecue hamburgers and found there were dime size bits of gristle or fat in the food. Interview on 08/27/24 at 10:39 A.M. with [NAME] #201 confirmed the pureed barbecue hamburgers were not 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.

Based on review of the arbitration agreement and staff interview, the facility failed to ensure the arbitration agreement notified residents of their right to rescind the agreement within 30 days. The deficient practice affected 51 residents (Residents #2, 6, 10, 11, 14, 16, 21, 22, 29, 31, 34, 35, 42, 43, 44, 47, 48, 50, 51, 56, 58, 64, 66, 67, 69, 70, 71, 72, 73 74, 77, 78, 79, 81, 82, 83, 84, 86, 87, 88, 89, 91, 92, 97, 98, 100, 101, 405, 406, 407, and 409) who agreed to enter into the arbitration agreement. The facility census was 102. Findings Include: Review of the facility Arbitration Agreement, Agreement to Resolve Legal Disputes through Binding Arbitration, undated, revealed the agreement did not inform residents of their right to rescind the agreement within 30 days of signing the agreement. Interview on 08/27/24 at 5:02 P.M. with the Admissions Director (AD) #205 confirmed the agreement did not include the above information. AD #205 stated the facility's corporate office developed the agreement for the facility and she was not aware the agreement did not include all 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 observation, interview, and record review, the facility failed to ensure Resident #406 was clean shaven, as preferred. This affected one resident (#406) of five residents reviewed for activities of daily living. The facility census was 102. Findings include: Review of Resident #406's medical record revealed an admission date of 08/09/24 with diagnoses including chronic venous hypertension, chronic systolic heart failure, peripheral vascular disease, dysphagia and hypertension. Review of Resident #406's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. He required substantial or maximal assistance with personal hygiene. Further review of Resident #406's medical record revealed the last documented evidence of Resident #406 being shaved was with a bed bath on 08/19/24 when it was indicated CNA #234 shaved the resident. Observation on 08/25/24 at 2:59 P.M. and 08/27/24 at 9:08 A.M. revealed Resident #406 was unshaven with heavy stubble…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review the facility failed to ensure skin assessments and monitoring were completed. This affected two residents (#3 and #84) of three residents reviewed for skin conditions. The facility census was 102. Findings include: 1. Review of Resident #84's medical record revealed an admission date of 03/10/2023. Diagnoses included schizophrenia, anxiety disorder, pruritus, and paresthesia of the skin. Observation on 08/25/24 at 10:47 A.M. revealed Resident #84 lying in bed. His bilateral arms and left leg were observed to have numerous open and closed scabbed areas some noted to be as large as a dime. Some of the areas were noted to have a scant amount of blood surrounding the areas. The resident was observed to be picking at his skin areas. The resident reported that he feels like he is always itching and picks at his arms and legs constantly due to the itching. Review of Resident #84's After Visit Dermatology Summery dated 08/20/24 revealed the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to ensure Resident #52 was given the opportunity to wear her recommended palm guard. This affected one resident (#52) of one residents reviewed for limited range of motion (ROM). The facility census was 102. Findings include: Review of the medical record for Resident #52 revealed an admission date of 7/10/2019. Diagnoses included moyamoya disease, hemiplegia, history of a cerebral infarction, and a left-hand contractor. Review of Resident #52's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had severely impaired cognition, had a memory problem, utilized a wheelchair, and had an upper extremity impairment. Review of Resident #52's Care Plan dated 07/28/24 revealed the resident had potential for pain related to a left-hand contracture. Interventions included a left-hand palm guard to be place on in morning and be taken off at night. The care plan also stated the resident has an activity of daily livings self-care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, medical record review, and facility investigation review the facility failed to maintain adequate supervision to ensure Resident #78 did not leave the facility's secured unit and complete a thorough investigation into her unsupervised departure from the secured unit. The facility also failed to ensure a safe environment for Resident #29. This affected two (Resident #29 and Resident #78) of seven residents reviewed for accidents. The facility census was 102. Findings include: 1. Review of the medical record for Resident #78 revealed an admission date of 11/10/2022. Diagnoses include cerebral infarction, nontraumatic intracerebral hemorrhage, and dementia. Review of Resident #78's Annual Minimum Data Set (MDS) dated [DATE] revealed the resident had a severe cognitive impairment. The resident could independently ambulate. Review of Resident #72's care plan dated 6/27/2024 revealed the resident is at high risk for elopement related to dementia. The care plan was initiated 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 interview and record review revealed the facility failed to provide timely treatment for Resident #85's urinary tract infection (UTI). This affected one resident (#85) of four residents reviewed for UTI's. The facility census was 102. Findings include: Review of Resident #85's medical record revealed an admission date of 11/10/23 with diagnoses including acute respiratory failure with hypoxia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, encephalopathy, dysphagia, major depressive disorder, cognitive social or emotional deficit, and gastro-esophageal reflux disease without esophagitis. Review of Resident #85's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was rarely or never understood. He had a urinary catheter. Review of Resident #85's progress note dated 07/27/24 revealed Resident #85 had Clostridium difficile (C. Diff) and a new order was placed for Vancomycin 125 milligrams (mg) four times a day for five days. Review 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 observation, interview, and record review the facility failed to care plan and implement interventions for Resident #86's autism and failed to monitor and effectively treat his anxiety. This affected one resident (#86) of three reviewed for mood and behaviors. The facility census was 102. Findings include: Review of Resident #86's medical record revealed an admission date of 03/15/23 with diagnoses including autistic disorder, dysphagia, chronic pain syndrome, anxiety disorder, depressive disorder, Barrett's esophagus, gastroparesis, and diaphragmatic hernia. Review of Resident #86's plan of care dated 03/28/23 revealed the potential for adverse side effects of psychotropic drug use related to antianxiety medication. Interventions included documenting the side effects of medication, notifying the physician of any mental status changes that occur, observing and documenting any abnormal behavior or moods, and observing and reporting any signs of drug related complications. Review of the Preadmission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and review of medical records the facility failed to ensure #56 who was on anticoagulants were monitored for side effects of the medication and had care plans in place for the anticoagulant. This affected one resident (#56) of five residents reviewed for unnecessary medications. The facility census was 102. Findings include: Review of Resident #56's medical record revealed an admission date of 06/07/24 with diagnoses including respiratory failure, chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder, encounter for orthopedic aftercare following surgical amputation, other chronic pain, type two diabetes mellitus, bipolar disorder, and fibromyalgia. Review of Resident #56's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #56's physician order dated 06/07/24 revealed an order for Apixaban (an anticoagulant) oral tablet five milligrams twice a day. Review of Resident #56's physician's orders revealed no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review revealed the facility failed to monitor behaviors for Residents' #22, #56, and #306 who were receiving psychotropic medications. This affected three residents (#22, #56, and #306) of five reviewed for unnecessary medications. The facility census was 102. Findings include: 1. Review of Resident #22's medical record revealed an admission date of 07/01/24 with diagnoses including pneumonitis due to inhalation of food and vomit, dysphagia, type two diabetes mellitus, unspecified intellectual disabilities, peripheral vascular disease, anxiety disorder, epilepsy, unspecified dementia with anxiety, depression, and hypertension. Review of Resident #22's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 had intact cognition. Review of Resident #22's plan of care dated 08/01/24 revealed he used psychotropic medications related to disease process. Interventions included administering medications as ordered, discussing with physician and family need…

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, interview, manufacturer guidelines, and facility policy review the facility failed to remove expired medications and securely store multi-use insulin vials. This deficient practice had the potential to affect any resident requesting flu vaccination, any new admission requiring tuberculosis (TB) testing, and affected one resident (Resident #84) out of four residents reviewed during medication administration. The facility census was 102. Findings Include: a) An observation on 08/26/24 at 10:09 A.M. revealed in Unit one's medication storage refrigerator an opened multi-use vial of Tubersol (tuberculosis (TB)) solution with out an opened date on either the vial or the packaging box. The TB solution had an expiration date of 04/2007 and had been dispensed from the pharmacy on 02/24/24. Interview on 08/26/24 at 10:09 A.M. with Licensed Practical Nurse (LPN) #290 confirmed the opened multi-use TB solution vial without an opened date. LPN #290 stated once the vial was opened it could only be used for 30 days and then was to be disposed. Review of the manufacturer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and facility policy review the facility failed to ensure proper hand hygiene was conducted during meal service, and failed to ensure Enhanced Barrier Precautions (EBP) were implemented. This deficient practice had the potential to affect residents residing on the Memory Unit and had affected two residents (Resident #62 and #406) out two residents reviewed for EBP implementation. The facility census was 102. Findings Include: An observation on 08/26/24 at 8:18 A.M. during breakfast meal service on the Memory Unit revealed State Tested Nursing Assistants (STNAs) #224 and #244 serving the meal trays to residents sitting in the dining room on the memory unit. Observation of STNA #244 adjusting clothing several times after bending over the table to assist the resident with food preparation and then returning to the food tray cart and removing another meal tray from the cart and serving the tray to the resident. STNA #244 was not observed sanitizing or washing hands after…

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, interview, and facility policy review the facility failed to maintain a safe, functional home like environment. This deficient practice affected one resident (Resident #29) out of four residents reviewed for environment. Findings Include: An observation on 08/25/24 at 2:10 P.M. revealed in Resident #29's room the rubber toe plate covering at the bottom of the wall under the sink was loose and falling off the wall revealing moderate sized hole approximately three feet long extending from the end of the wall to the corner of the two walls. The hole was approximately two inches wide and was deep enough for the dry wall material and the wall support boards to be exposed. The rubber toe plate covering was also falling off the shorter wall to the right of the sink exposing the dry wall material behind the rubber toe plate covering. A review of the medical record for Resident #29 revealed admission date 12/04/21 with diagnoses including cancer of the head, face, and neck, chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, 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 record review, staff interview, review of the grievance log, review of a fall investigation, and facility policy review, the facility failed to timely notify one resident's (Resident #101) representative of a fall resulting in hospitalization. This affected one (Resident #101) of three residents reviewed for notification of changes. The facility census was 95. Findings Include: Review of the closed medical record for former Resident #101 revealed an initial admission date on 01/15/14, a readmission date on 04/16/16, and a discharge date on 01/03/24 due to passing away. Medical diagnoses included dementia with behavioral disturbance, traumatic subdural hemorrhage without loss of consciousness, weakness, unsteadiness on feet, lack of coordination, cognitive communication deficit, anxiety disorder, post-traumatic stress disorder (PTSD), major depressive disorder with psychotic symptoms, and peripheral vascular disease. Review of Resident #101's profile revealed the resident's daughter was the resident's…

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 financial record review and staff interview, the facility failed to maintain resident financial records according to established standards. This affected 64 (Residents #19, #31, #86, #8, #81, #47, #1, #58, #21, #7, #53, #45, #10, #18, #39, #85, #36, #67, #74, #49, #2, #6, #69, #51, #34, #44, #80, #60, #5, #11, #77, #50, #88, #66, #55, #79, #75, #89, #90, #76, #32, #72, #40, #17, #38, #64, #28, #91, #71, #23, #70, #29, #9, #46, #78, #57, #20, #41, #92, #25, #65, #42, #13, and #43) of 64 residents who have personal funds accounts with the facility. The census was 85. Findings Include: Review of Residents #34, #80, #23, and #41 financial records revealed they did not have quarterly statements available for review. Two more residents were requested, and they were not available for review as well. Interview with Administrator on 10/12/22 at 2:27 P.M. confirmed they do not have resident fund quarterly statements for any of the residents. She confirmed they have a new business office manager, who is trying to fix things, but they currently do not have any quarterly statements 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 observation, interview, and record review, the facility failed to follow droplet precautions during meal pass and did not implement isolation precautions for Resident #72 as ordered. This affected seven residents (#12, #72, #73, #83, #84, #285, and #286) and had the potential to affect all 85 residents residing in the facility. Findings include: 1. Observation on 10/11/22 from 12:15 P.M. to 12:28 P.M. of meal pass revealed State Tested Nursing Aide (STNA) #89 enter Resident #84's room. Resident #84 had a sign indicating droplet precautions and personal protective equipment (PPE) on his door. STNA #89 placed a meal tray on Resident #84's bedside table and moved the bedside tablet in front of him. STNA #89 was wearing an N-95 mask and eye protection. STNA #89 exited Resident #84's room, she did not sanitize her hands, replace her mask, or clean her eye protection. She then entered Resident #73's room and adjusted his pillow. STNA #89 applied a gown and gloves and entered Resident #286's room and delivered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of liability notices, review of quarterly statements, resident interview, and staff interview, the facility failed to ensure residents received the appropriate liability notices when their Medicare (MCR) Part A services ended and ensure a Medicaid (MCD) eligible resident received appropriate notification of charges. This affected three (Resident #32, #37, and #65) of three residents reviewed for liability notices and one (Resident #60) of one residents reviewed for resident billing and charges. Findings include: 1. A review of Resident #32's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a stroke with hemiplegia (paralysis) and hemiparesis (weakness) affecting the left non-dominant side, aphasia, hypertension, atrial fibrillation, and peripheral vascular disease. A review of Resident #32's census list revealed she had a payer change on 05/17/22 and again on 05/28/22. The census list did not specify what the change in payer status was. 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 record review, staff interview, and policy review, the facility failed to ensure their consulting pharmacist made recommendations for gradual dose reduction (GDR) attempts with the use of psychotropic medications as required during their monthly medication regimen review. The facility also failed to ensure pharmacy recommendations were followed up on or responded to timely by the physician. This affected four (Resident #4, #47, #54 and #60) of five residents reviewed for unnecessary medications. Findings include: 1. A review of Resident #54's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a history of a stroke with hemiplegia affecting her left non-dominant side, MoyaMoya disease (a narrowing of the blood vessels that supplied the brain with blood), aphasia, major depressive disorder, and restlessness and agitation. A review of Resident #54's active physician's orders revealed the resident had an order to receive Klonopin (an anti-anxiety medication) 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain accurate and complete records relating to catheter care for Resident #60, diagnoses for Resident #28, hospitalization for Resident #62, and hospice for Resident #81. This affected four residents (#28, #60, #62, and #81) of 27 records reviewed. The facility census was 85. Findings include: 1. Observation on 10/11/22 at 4:26 P.M. revealed Resident #60 had a catheter. Review of the medical record for Resident #60 revealed an admission date of 09/14/21 with diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus, rheumatoid arthritis, schizophrenia, morbid obesity, and neuromuscular dysfunction of the bladder. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #60 had intact cognition. Resident #60 had an indwelling urinary catheter. Review of the plan of care dated 09/06/22 revealed Resident #60 had the potential for complications related to 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 interview and record review the facility failed to ensure Resident #60 was treated with respect and allowed to control the temperature in her room. This affected one resident (#60) of two reviewed for dignity. The facility census was 85. Findings include: Interview on 10/11/22 at 4:26 P.M. with Resident #60 revealed Agency State Tested Nursing Aide (STNA) #100 had been rude to her. She reported she keeps her room cold at night to aide her breathing, however, Agency STNA #100 entered her room and stated she was not going to work when it was so cold, and she turned off the air conditioning. Resident #60 reported the aide had turned off the air conditioning despite Resident #60 telling her she wanted it on, the aide then began yelling at her during transfer assistance. Review of the medical record for Resident #60 revealed an admission date of 09/14/21 with diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus, rheumatoid arthritis, schizophrenia, morbid obesity, 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 financial record review and staff interview, the facility failed to provide evidence that spend down notifications were given as required. This affected seven (Residents #45, #34, #80, #38, #64, #23, and #41) of 64 residents who have personal funds accounts with the facility. The census was 85. Findings Include: Review of the following residents personal funds accounts revealed they had a total amount of money within $200 of the allowed amount ($2,000), and there was no evidence the facility had provided the resident with a spend down notification: Resident #45 had a current total amount of $2,121.92 in her personal funds account. Resident #34 had a current total amount of $3,210.99 in her personal funds account. Resident #80 had a current total amount of $9,187.03 in her personal funds account. Resident #38 had a current total amount of $2,509.55 in her personal funds account. Resident #64 had a current total amount of $2,146.11 in her personal funds account. Resident #23 had a current total amount of $6,345.58 in her personal funds account. Resident #41 had a current…

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 refusal of care policy review, the facility failed to ensure the physician was notified of a resident's refusal of medication. This affected one (Resident #85) of the one resident reviewed for physician notification. The facility census was 85. Findings include: Review of the medical record for Resident #85 revealed an initial admission date of 06/23/16 with a re-entry date of 08/25/20 and a discharge date of 08/17/22. Diagnoses included diabetes, heart disease, heart failure, and hypertension. Review of Resident #85's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 01 indicating a severely impaired cognition for daily decision making abilities with disorganized thinking. Resident #85 was noted to display physical and verbal behaviors and rejection of care. Resident #85 required extensive assistance from two staff members for bed mobility and transfers and extensive assistance from 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 interview and record review the facility failed to complete Pre-admission Screening and Resident Review (PASARR) timely for Resident #12 and accurately for Resident #28. This affected two residents (#12 and #28) of four reviewed for PASARR's. The facility census was 85. Findings include: 1. Review of the medical record for Resident #12 revealed an initial admission on [DATE], her diagnoses included Parkinson's disease, chronic kidney disease stage three, bipolar disorder, colostomy status, and mild intellectual disabilities. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 had impaired cognition. Review of the hospital exemption from preadmission screening notification dated 03/21/22 revealed Resident #12 had a mood disorder and a panic or other severe anxiety disorder. The document indicated the nursing facility was responsible for initiating a resident review prior to the 30th day following admission from the hospital. Review of the medical record on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interview, the facility failed to ensure residents had active care plans in place in the areas of contractures and oxygen use. This affected three (Resident #9, #54 and #73) of 27 residents reviewed for care plans. Findings include: 1. A review of Resident #9's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included chronic obstructive pulmonary disease (COPD), sleep apnea, and vascular dementia. A review of Resident #9's active physician's orders revealed the resident had an order in place to receive oxygen at 2 liters per minute (LPM) via nasal cannula every shift. The order was not added to the physician's orders until 10/11/22. A review of Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues. He was able to make himself understood and was able to understand others. His cognition was moderately impaired. He was not known to display any behaviors nor 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 record review, resident interview, and staff interview, the facility failed to ensure care planning conferences were held for residents and residents and/ or their families were invited to attend. This affected two (Resident #27 and #39) of two residents reviewed for care planning conferences. Findings include: 1. A review of Resident #27's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included chronic renal failure, heart failure, adult onset diabetes mellitus and an altered mental status. A review of Resident #27's Minimum Data Set (MDS) assessments that had been completed revealed the resident had an admission MDS completed on 02/13/22. Quarterly MDS assessments were completed on 05/19/22 and again on 08/15/22. A review of Resident #27's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. He was not known to display any behaviors nor was he known to reject care. He 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 record review, resident interview, staff interview, and policy review, the facility failed to ensure a resident was provided assistance with showers/ bathing as desired. This affected two (Residents #9, and #20) of four residents reviewed for activities of daily living (ADL's). Findings include: 1. A review of Resident #9's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included vascular dementia, major depressive disorder, chronic obstructive pulmonary disease, muscle weakness, adult failure to thrive, unsteadiness on feet, and lack of coordination. A review of Resident #9's admission assessment dated [DATE] revealed it was the resident's preference to receive a bath/ shower twice a week. It was not clear what shift or days of the week the resident preferred or was scheduled to receive that bathing activity. A review of Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and his cognition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide adequate care for Resident #54 and Resident #73 who had contractures. This affected two residents (#54 and #73) of two residents reviewed for limited range of motion. The facility census was 85. Findings include: 1. Review of the medical record revealed Resident #73 admitted on [DATE] with diagnoses including traumatic subarachnoid hemorrhage with loss of consciousness, acute respiratory failure with hypoxia, encounter for attention to tracheostomy, encounter for attention to gastrostomy, metabolic encephalopathy, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #73 was rarely or never understood. The resident had a limitation in range of motion (ROM) of both sides of her upper and lower extremities. Review of the plan of care revealed it did not address Resident #73's contractures. Review of the physician's order dated 10/07/22 revealed an order to apply hand 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, interview, and record review revealed the facility failed to ensure Resident #60 received the required two-person assistance with transfers. This affected one resident (#60) of four reviewed for accident hazards. The facility census was 85. Findings include: Observation on 10/17/22 from 1:28 P.M. to 1:37 P.M. revealed State Tested Nursing Aide (STNA) #39 pushing a hoyer lift into Resident #60's room and closing the door at 1:37 P.M. STNA #39 exited the room by herself. Interview on 10/17/22 at 1:37 P.M. with STNA #39 verified she transferred Resident #60 using a hoyer lift by herself. She confirmed a transfer with hoyer lift required two staff members, but she was the only aide on the unit and Resident #60 needed to be transferred and placed on the bed pan immediately. Review of the medical record for Resident #60 revealed an admission date of 09/14/21 with diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus, rheumatoid arthritis, schizophrenia, morbid…

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, resident interview, staff interview, and policy review, the facility failed to ensure a resident received oxygen at the appropriate flow rate as ordered by the physician. This affected one (Resident #9) of three residents reviewed for respiratory care. Findings include: A review of Resident #9's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included chronic obstructive pulmonary disease (COPD), sleep apnea, atrial fibrillation and vascular dementia. A review of Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and his cognition was moderately impaired. He was not known to display any behaviors nor was he indicated to reject care. He was independent with no set up help needed for transfers and ambulation. His active diagnoses coded included COPD. Oxygen therapy was indicated to have been provided while a resident in the facility. A review of Resident #9's active…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and review of the facility's drug reference information, the facility failed to ensure a resident receiving Digoxin had their apical pulse checked prior to the administration of the medication. This affected one (Resident #27) of five residents reviewed for unnecessary medications. Findings include: A review of Resident #27's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included atrial fibrillation. A review of Resident #27's physician's orders revealed he had an order to receive Digoxin 250 micrograms (mcg) by mouth every morning for atrial fibrillation. The order had been in place since 02/07/22. The physician's orders did not include any parameters to hold the medication if the resident's apical pulse was less than 60 beats per minute. A review of Resident #27's medication administration record (MAR's) for October 2022 revealed the resident was receiving Digoxin 250 mcg by mouth every morning as ordered. There was no documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure residents receiving psychotropic medications had an adequate indication for use, gradual dose reductions (GDR's) were attempted, and were monitored appropriately for side effects associated with their use. This affected two (Resident #4 and #54) of five residents reviewed for unnecessary medications. Findings include: 1. A review of Resident #54's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a history of a stroke with hemiplegia to the left non-dominant side, MoyaMoya disease (narrowing of the blood vessels that supplied the brain with blood), aphasia, restlessness and agitation and major depressive disorder. A review of Resident #54's active physician's orders revealed the resident had an order to receive Klonopin (an anti-anxiety medication) 1 milligram (mg) by mouth (po) two times a day and 2 mg po at bedtime for seizures (not in medical history). The physician's…

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.