Autumn Hills Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, resident and staff interviews, and review of the facility's smoking policy, the facility failed to ensure Resident #3's smoking materials were secured by staff. This affected one resident (#3) of one resident reviewed for smoking. The facility identified ten residents (#3, #23, #72, #46, #87, #90, #83, #12, #53 and #51) as smokers. The facility census was 106. Findings include: Review of medical record revealed Resident #3 was admitted to the facility on [DATE]. Diagnoses included motor neuron disease, osteoarthritis, muscle wasting and atrophy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/21/25, revealed Resident #3 had impairments of both upper extremities and was dependent for most activities of daily living (ADLs), except for eating, with which she required set-up or clean up assistance. Further review of the MDS revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated she was cognitively intact. 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.

Based on observation, record review, interview and facility policy review, the facility failed to ensure appropriate infection control practices were followed in the administration of medications through Resident #301's peripherally inserted central catheter (PICC) line. This affected one resident (#301) of one resident observed for intravenous medication administration. The facility census was 106. Findings include: Review of the medical record for Resident #301 revealed an admission date of 04/18/25 with diagnoses of methicillin susceptible staphylococcus aureus infection (MSSA) (a highly resistant bacteria) to left great toe, type two diabetes, and acute and subacute infective endocarditis. Provider orders included contact isolation due to MSSA infection, and Cefazolin Sodium (antibiotic) two milligrams intravenously per PICC twice daily. Observation of intravenous medication administration on 04/28/25 at 8:49 A.M. by Licensed Practice Nurse (LPN) #4150 revealed signage on Resident #301's door identifying contact precautions (wearing gown, gloves, and hand hygiene) to be used…

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 and policy review, the facility failed to maintain a sanitary environment for all residents. This affected six Residents (#14, #18, #26, #37, #76 and #86) of 17 residents reviewed for physical environment and had the potential to affect all residents in the facility. The facility census was 106. Findings include: Observation was conducted on 02/24/25 at 9:50 A.M. with the Assistant Director of Nursing (ADON) of the general facility environment including resident rooms and common areas throughout the facility. At the time of the observations, the ADON verified the following identified concerns: • In the main lobby, there was a drinking fountain with a moderate build-up of dust on the top of it. The lobby floor was noted to be only partially clean, as there were were mop swirls noted on the floor that stopped at the floor mats. There was white dust build-up between the floor mats. Footprints were noted within the dust build up. A visitor sign located in the lobby had white dust build-up on the base of the stand. • The main dining room floor was noted 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 record review, interview and policy review, the facility failed to timely notify a family member of a medication change for Resident #108. This affected one resident (#108) of ten residents reviewed for family notification of a change. The facility census was 106. Findings include: Review of the medical record for Resident #108 revealed an admission date of 01/16/25. Significant diagnoses included acute and chronic respiratory failure, dependence on a respirator, chronic obstructive pulmonary disease, Wernicke's encephalopathy and alcohol use with withdrawal and delirium The resident face sheet revealed Resident #108 had a Healthcare Power of Attorney (POA) listing his sister. A second sister was listed as POA should the first not be able to carry out the duties. Both sisters had phone numbers on the resident face sheet. Further review of the medical record revealed Resident #108 had a drug allergy (an immune system overreaction to a substance that is usually harmless to most people) to Depakote (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, interviews and policy review, the facility failed to collaborate with pharmacy services to ensure a medication listed as a drug allergy was not dispensed and administered to Resident #108 until determined to be safe for Resident #108 to receive the medication. This affected one resident (Resident #108) of ten residents who were reviewed for medication administration. The facility census was 106. Findings include: Review of the medical record for Resident #108 revealed an admission date of 01/16/25 with diagnoses including acute and chronic respiratory failure, dependence on a respirator, chronic obstructive pulmonary disease, Wernicke's encephalopathy, and alcohol use with withdrawal and delirium. The medical record indicated Resident #108 had a drug allergy (an immune system overreaction to a substance that is usually harmless to most people) to Depakote (a medication used for mood stabilization). Review of the records from a hospital emergency room visit prior to admission to 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, interview, record review, review of photographs provided by Resident #27's fiancée/power of attorney (POA) and facility policy review revealed the facility failed to provide timely incontinence care. This affected four residents (#1, #27, #54, and #57) out of seven residents reviewed for incontinence care and had the potential to affect 76 residents (#1, #2, #3, #4, #5, #7, #8, #9, #12, #13, #15, #16, #17, #18, #20, #21, #22, #23, #24, #26, #27, #29, #30, #31, #32, #33, #35, #36, #37, #38, #39, #40, #42, #43, #45, #48, #50, #51, #52, #53, #54, #55, #56, #57, #59, #60, #62, #63, #66, #67, #68, #69, #70, #71, #72, #74, #75, #76, #78, #81, #82, #83, #84, #85, #87, #91, #94, #86, #97, #99, #100, #101, #102, #103, #107, and #108) identified by the facility that required assistance with incontinence care. The facility census was 106. Findings include: 1. Review of the medical record for Resident #54 revealed an admission date of 12/11/24 with diagnoses including diabetes, heart failure, 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, interview, record review, facility assessment, review of photographs provided by Resident #27's fiancée/power of attorney (POA) and facility policy review, the facility failed to have adequate staffing to meet the needs of the residents. This affected four residents (#1, #54, #57, and #107) out of four residents reviewed on the 200 assignment (rooms 211 to 229) and one resident (#29) out of two residents reviewed for staffing in regard to prevention of pressure ulcers. The facility census was 106. Findings include: 1. Review of the medical record for Resident #27 revealed an admission date of 12/04/24 with diagnoses including anoxic brain damage, chronic respiratory failure, quadriplegia, and persistent vegetative state. Review of the care plan dated 12/05/24 revealed Resident #27 was dependent on staff with activities of daily living (ADL) due to anoxic brain damage, persistent vegetative state quadriplegia. Interventions included turning and repositioning every two hours, staff 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.

Based on interview, record review, and facility policy review, the facility failed to administer medications as ordered by the prescriber. This affected three residents (#1, #27 and #86) out of three residents reviewed for medication administration and had the potential to affect all 106 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 11/18/24 with diagnoses including anoxic brain damage, chronic respiratory failure, encephalopathy, epilepsy, tracheostomy status, gastrostomy status, persistent vegetative state and multiple sclerosis. Review of Resident #1's medication administration record (MAR) from January 2025 indicated an order dated 11/08/24 for valproic acid 250 milligrams (mg) per five milliliters (ml), give ten ml enterally four times daily for seizures at early (6:00 A.M. to 10:00 A.M.), noon (11:00 A.M. to 2:00 P.M.), PM (3:00 P.M. to 7:00 P.M.) and HS (8:00 P.M. to 12:00 A.M.). Review of Resident #1's MAR from January 2024 and medication administration audit report (MAAR) from 01/13/25 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 interview, record review, and facility policy review, the facility failed to treat Resident #86 with dignity and respect. This affected one resident (#86) and had the potential to affect all 106 residents who resided in the facility. Findings include: Review of the medical record for Resident #86 revealed an admission date of 01/14/25. Diagnoses included chronic obstructive pulmonary disease, diabetes mellitus type two with neuropathy, chronic respiratory failure, tracheostomy status, disturbances of salivary secretion, gastrostomy status, essential primary hypertension and depression. Interview on 01/21/25 at 8:05 A.M. with Resident #86 complained about a recent confrontation with Licensed Practical Nurse (LPN) #287 who when questioned about her medication schedule, responded rudely and thereafter retaliated by ignoring Resident #86, giving all other residents medications first before administering hers, making them late. Resident #86 detailed the nurse's rudeness, indicating LPN #287 angrily went to the room door then shouted back at Resident #86 of knowing how to read 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, interview and facility policy review, the facility failed to ensure Resident #27's medical records were accurate and did not contain false information. This affected one resident (#27) out of 12 medical records reviewed for accuracy of medical record. The facility census was 106. Findings include: Review of the medical record for Resident #27 revealed an admission date of 12/04/24 with diagnoses including anoxic brain damage, chronic respiratory failure, quadriplegia, and persistent vegetative state. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #27 had impaired cognition. He was dependent on staff for all activities of daily living (ADL) including rolling left and right, toileting hygiene, personal hygiene, transfers, and showers. He was always incontinent with bowel and bladder. He was at risk for developing pressure ulcers but had no unhealed pressure ulcers on admission. Review of the Skin Grid Pressure 3.0-V2 dated 12/19/24 and completed…

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, record review, review of video recordings provided by Resident #27's fiancée/power of attorney (POA), review of center for Medicare and Medicaid Services (CMS) and Health and Human Services (HHS) memorandum QSO-24-08-NH and facility policy review, the facility did not ensure proper infection control measures were followed including during wound care and donning enhanced barriers precautions (EBP) during care for Resident #27. This affected one resident (#27) out of three residents reviewed for wound care and EBP. This had the potential to affect seven additional residents identified by the facility with wounds (#22, #62, #70, #80, #88, #102, and #109) and 27 residents (#1, #5, #9, #10, #16, #18, #20, #23, #39, #42, #48, #52, #53, #67, #69, #78, #80, #81, #84, #86, #87, #93, #97, #100, #101, #102, and #107) identified by the facility on EBP. The facility census was 106. Findings include: Review of the medical record for Resident #27 revealed an admission date of 12/04/24 with diagnoses including anoxic brain damage, chronic respiratory failure,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide pre-procedure preparation for Resident #49 resulting in a delay in a procedure. This affected one resident (#49) of six residents reviewed for appointments. The facility census was 102. Findings include: Review of the medical record for Resident #49 revealed an admission date of 02/29/24 with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, diabetes mellitus type two, gastroenteritis and colitis, obstructive and reflux uropathy, and unspecified aphasia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had a severe cognitive deficit. Review of the September 2024 physician's orders included a virtual colonoscopy on 11/06/24 at 9:30 A.M. The order was dated 09/30/24. The virtual colonoscopy had an original schedule date of 09/27/24. Review of progress notes revealed Resident #49 was scheduled for a virtual colonoscopy on 09/27/24 at 9:00…

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, resident representative interview, resident interview, staff interview, observation, review of the facility assessment, and review of the facility policy, the facility failed to maintain sufficient levels of nursing staff services to provide activities of daily living (ADL) assistance to residents according to their plan of care. This affected six (Residents #2, #24, #54, #61, #62, and #70) and had the potential to affect all 108 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 01/20/23 with diagnoses including epilepsy, schizoaffective disorder, chronic obstructive pulmonary disorder, asthma, morbid obesity, generalized anxiety disorder, and hypertension. Review of the Minimum Data Set (MDS) assessment for Resident #2 dated 06/08/24 revealed the resident had intact cognition and required supervision or touching assistance with showers. Review of the care plan for Resident #2 revealed 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, shower schedule review, interview and policy review, the facility failed to ensure residents, who were dependent and/or required staff assistance for activities of daily living care, received timely and adequate assistance with showers and/or incontinence care, per the residents' plan of care and/or resident preference. This affected eight residents (#2, #24, #54, #61, #62, #70, #72, and #111) of 16 residents reviewed for showers. The facility census was 108. Finding includes: 1. Review of the medical record for Resident #2 revealed an admission date of 01/20/23. Diagnosis included epilepsy, schizoaffective disorder, bipolar type, chronic obstructive pulmonary disorder, asthma, morbid obesity, generalized anxiety disorder, hypertension, and muscle wasting and atrophy. Review of Resident #2's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition, she was independent with eating, oral hygiene, dressing, personal hygiene, and bed mobility.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure Resident #61 and Resident #70 had call lights in reach at all times for reasonable accomodation of needs. This affected two residents (Resident #61, and #70) of five residents reviewed for resident right to reasonable accomodation of needs. The facility census was 108. Finding includes: 1. Review of the medical record for Resident #61 revealed an admission date of 06/08/24. Diagnoses included unspecified fracture of first lumbar vertebra, hepatic encephalopathy, multiple rib fractures right and left side, esophageal varices without bleeding, type two diabetes mellitus, cognitive communication deficit, mild protein-calories malnutrition, difficulty in walking, muscle weakness, need for assistance with personal care, and muscle wasting with atrophy. Review of Resident #61's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition. She required setup or cleanup assistance with eating. She required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review and interview, the facility failed to ensure Resident #111, who had an indwelling urinary (Foley) catheter was provided care (including the administration of an antibiotic) as directed by the resident's urologist for a diagnosis of benign prostatic hyperplasia with lower urinary tract infection. This affected one resident (#111) of 16 sampled residents. Findings include: Review of Resident #111's closed medical record revealed an initial admission date of 05/25/24 with a hospital stay from 06/01/24 to 06/05/24 and then a final discharge to the hospital on [DATE]. Resident #111 had diagnoses including fracture of first lumbar vertebrae, non-displaced fracture or right index finger, left sided rib fracture, syncope and collapse, type II diabetes mellitus, laceration to right hand, muscle wasting and atrophy, repeated falls, benign prostatic hyperplasia with lower urinary tract infection, hypertension, pulmonary nodule, and thyroid nodule. Record review revealed the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and facility policy review the facility failed to maintain a medication administration error rate of less than five percent (%). The facility medication error rate was calculated to be 6.06% and included two errors of 33 opportunities. This affected one resident (#107) of three residents observed during the medication administration. The facility census was 108. Findings include: Review of the medical record for Resident #107 revealed an admission date of 08/11/23 with diagnosis including type II diabetes mellitus (DM), heart failure, hypertension, and long term use of insulin. Review of Resident #107's physician orders dated August 2024 revealed the resident was to receive Carvedilol (Coreg) 12.5 milligrams (mg) by mouth twice a day for heart failure with an order to hold the medication if the resident's systolic blood pressure (SBP) was less than 110 millimeters of Mercury (mmHg). The resident also had an order to receive insulin, Toujeo SoloStar…

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 pain medication was ordered and was timely available for administration for Resident #26. This affected one resident (#26) of three residents reviewed for medication administration. The facility census was 105. Findings include: Review of the medical record for Resident # 26 revealed an admission date of 06/13/24 with diagnoses including malignant neoplasm of the pelvic bones, sacrum, coccyx, scapula, skull, and face (bone cancer), chronic obstructive pulmonary disease, prediabetes, hypertension, and the presence of atherosclerotic heart disease of the coronary artery with the presence of aortocoronary bypass graft (bypass due to the narrowing of arteries that supply blood to the heart muscle). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact. Review of the physician order dated 06/13/24 revealed an order for the administration of Morphine 30 milligrams…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review the facility failed to ensure timely and appropriate care of non-pressure skin conditions. This affected one resident (Resident #35) of two residents reviewed for non-pressure skin areas. The facility census was 107. Findings include: Review of Resident #35's medical record revealed an admission date of 04/13/12 and diagnoses including chronic kidney disease stage three, non-pressure chronic ulcer of right calf, type two diabetes, anemia, chronic venous hypertension with ulcer of right extremity, adjustment disorder with mixed anxiety and depressed mood, lymphedema, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 was cognitively intact, did not reject care and required the extensive assistance of two staff for bed mobility. Resident #35 required substantial/maximal assistance to roll left and right. Resident #35 did not have any pressure ulcers but had one venous/arterial ulcer.…

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 tube feedings were labeled and dated per standard of nursing practice. This affected two residents (Resident's #36 and #73) of five reviewed for tube feeding. The facility census was 107. Findings include: 1. Review of the medical record for Resident #36 revealed an admission date of 06/03/21. Diagnoses included hydrocephalus, chronic or unspecified gastric ulcer with hemorrhage, acquired absence of parts of the digestive tract, and gastrostomy status. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #36 had impaired cognition. The assessment indicated the resident required a feeding tube. Review of the physician's orders for August 2022 revealed Resident #36 had an order dated 07/11/22 for enteral feed every shift at 70 milliliters an hour for twenty-two hours. The enteral feed was to be off from noon to 2:00 P.M. daily. Observation on 08/15/22 at 11:32 A.M. of Resident #36 revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to implement/maintain proper infection control practices related to urinary catheter care for Resident #30, related to care of an intravenous site for Resident #5 and related to meal delivery for Resident #9 and #19. This affected one of one resident reviewed for urinary catheters, one of resident reviewed for intravenous site care and two of three residents observed receiving meal trays on the 100 hall. Findings include: 1. Review of the medical record for Resident #30 revealed a admission date of 03/06/19 with diagnoses including obstructed bladder and use of a suprapubic urinary catheter, a flexible tune inserted into the bladder through the lower abdominal wall. The Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #30 had impaired cognition, required extensive assistance from staff for toileting and had an indwelling urinary catheter. The care plan date 07/02/19 revealed care plans in place related to Resident #30'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure respect and dignity was maintained for Residents #109 and #268. This affected two residents out of two residents reviewed for dignity. The facility census was 109. Findings include: 1. Review of the medical record for Resident #109 revealed the resident was admitted on [DATE] with diagnoses including dementia, urinary incontinence and chronic kidney disease. The annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #109 had impaired cognition and required extensive assistance from staff for bed mobility, transfers and eating. Observation of lunch on 08/25/19 at 12:15 P.M. in the main dining room revealed State Tested Nursing Assistants (STNAs) #86 and #96 reposition Resident #109 in front of multiple other residents. Resident #109 was in a Broda chair, a specialized wheelchair that allows for multiple positions with a tilt-in-space design and increased cushioning. STNA #86 and #96 positioned the Broda chair to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure call lights were in reach for Residents #63 and #89. This affected two of 109 residents observed at the facility during the initial screening portion of the survey. Findings include: 1. Review of Resident #63's medical record revealed an admission date of 07/12/18 and a readmission date of 05/29/19 with diagnoses including blindness in the right eye, low vision in the left eye, low blood sugar, diabetes mellitus, adjustment disorder with anxiety and major depressive disorder. Resident # 63's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was moderately cognitively impaired and required extensive assistance with two staff for most activities of daily living. Review of the care plan dated 07/12/18 revealed interventions including staff to ensure her call light was kept within reach when she was in her room. Interview on 08/25/19 at 2:29 P.M., during the initial screening with Resident #63…

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

Based on observation and interview the facility failed to maintain the environment in a clean and sanitary manner. This affected three residents (Residents #6, #7, and #268) of 109 residents in the facility. Findings include: Observations during the initial tour of the facility and screening of all residents on 08/25/19 from 8:17 A.M. to 11:37 A.M. revealed the following concerns: In Resident #6's room, there were used, dirty gloves rolled up in a ball laying on the floor. Registered Nurse (RN) #58 verified this concern on 08/25/19 at 10:30 A.M. There was a bed pan turned upside down on the floor in Resident #7's room. This was verified by Social Worker #55 on 08/25/19 at 10:21 A.M. In Resident #268's room at 9:57 A.M., RN #58 verified there were cracker wrappers and napkins on the floor, the bed side tray table was sticky and had dried spills on it, and dirty dishes were sitting on the night stand next to a urinal that was one third full of urine.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was coded accurately for falls with injury for Residents #39. This affected one of 28 residents reviewed for assessments. Findings include: Review of Resident #39's medical record revealed she was admitted to the facility on [DATE]. Diagnoses for Resident #39 included dementia, osteoporosis, and hemiplegia/hemiparesis (muscle weakness or partial paralysis) of her right side following a cerebral infarct (stroke). Review of the nursing progress note dated 07/26/19 revealed Resident #39 was found on the floor next to her bed and her right leg was bent at an odd angle. Resident #39 was examined and found to have fractured her right tibia and right fibula (bones in the lower leg) related to the fall. Review of the Fall Incident Log between 07/26/19 and 08/26/19 revealed Resident #39 fell on [DATE]. Review of the minimum data set (MDS) 3.0 Significant Change Assessment, dated 08/12/19, indicated Resident #39 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop an individualized and person-centered care plan for Resident #36 related to pain control and Resident #113 related to activities. This affected two of 28 residents reviewed for comprehensive care plans. Findings include: 1. Review of Resident #36's medical revealed an admission date 03/14/19. Diagnoses included muscle weakness, gout, and rheumatoid arthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had slightly impaired cognition, received pain medication as needed, and received an opioid pain reliever for five days in the seven day review period. Review of the June 2019 Medication Administration Record (MAR) revealed Resident #36 had an order for tramadol, 50 milligram tablet (opioid pain medication), to be given every six hours as needed for pain. Resident #36 had received it for five day in June 2019. Review of Resident #36's current care plan, last revised on 07/26/19, revealed no care plan 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 interview and record review, the facility failed to notify/invite Resident #41's representative for care conferences and failed to document care conferences in the clinical record and failed to revise and update the care plan for Resident #30. This affected two of 28 residents reviewed for care planning. Findings include: 1. Review of the medical record for Resident #30 revealed a admission date of 03/06/19 with diagnoses including obstructed bladder, Methicillin Resistant Staphylococcus Aureus (MRSA) infections, enlarged prostate and psychotic disorder. The Minimum Data Set MDS 3.0 dated 6/12/19 revealed the resident had impaired cognition, required extensive assistance for toileting, had a indwelling urinary catheter and was incontinent of bowel. The final laboratory results dated [DATE] from a urinalysis revealed Resident #30 had Extended Spectrum Beta-Lactamase (ESBL) infection in his urine. This is a bacteria that produces an enzyme, ESBL, which makes it resistant to antibiotic treatment. 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, interview and record review, the facility failed to ensure oral care was completed for Resident #88, who received nothing to eat or drink by mouth. This affected one resident of one resident reviewed for oral care. Findings include: Resident #88 was admitted on [DATE] and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), sepsis, chronic kidney disease, anxiety disorder and cerebral infarction (stroke). The care plan for Resident #88 dated 10/08/18 revealed oral care should be provided as needed. Resident #88's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he required extensive assistance with one staff person for personal hygiene. Observation of Resident #88 on 08/15/19 at 1:23 P.M. revealed him laying in bed and he began pointing to his mouth. The surveyor leaned closer to hear Resident #88 and his breath smelled very bad. State Tested Nurse Aid (STNA) #88 was in the room at that time and verified Resident #88's breath smelled bad…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to provide tracheostomy care to Resident #41 following appropriate infection control practices. This affected one of one resident reviewed for tracheostomy care. Findings include: Review of Resident #41's medical record revealed an admission date of 01/02/19. Diagnoses included heart failure, tracheostomy (an opening with a tube inserted into the neck and windpipe for breathing), use of oxygen, and dementia without behavioral disturbance. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 had an impaired cognition. Resident #41 also required limited assistance of one staff for bed mobility, transfers and toilet use. Resident #41 also required staff provide tracheostomy care. Observation on 08/27/19 at 10:31 A.M. with Respiratory Therapist (RT) #52 revealed RT #52 used hand sanitizer and put on gloves that were in Resident #41's room. Then RT #52 removed various personal items from the resident's bedside tray…

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.