Arbors At Oregon

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, staff interview, and review of the policy, the facility failed to develop comprehensive care plans which included supports for dental needs. This affected one (#1) of three residents reviewed for ancillary services. The facility census was 74. Findings Include: Review of Resident #1's medical record revealed an admission date of 03/22/22. Diagnoses included Alzheimer's disease, altered mental status, chronic kidney disease, history of stroke, muscle wasting and atrophy, osteoporosis, and symbolic dysfunction. Review of Resident #1's Minimum Data Set (MDS) Annual Review dated 03/13/24 Resident #1 had no obvious or likely cavity or broken natural teeth. Review of Resident #1's most recent Quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five indicating Resident #1 was severely cognitively impaired. Resident #1 required moderate assistance with toilet use, oral care, and dressing. Resident #1 displayed 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 AMENDED 08/27/24 Based on resident interview, medical record review, staff interview, observations, and review of policy, the facility failed to ensure residents and/or their representatives participated in resident care planning. This affected one (#129) of three residents reviewed for care plan participation. In addition, the facility failed to ensure resident care plans were reviewed and revised when a resident's smoking status changed. This affected one resident (#13) of three residents reviewed for smoking. The facility census was 74. Findings Include: 1. Review of Resident #129's medical record revealed an admission date of 07/11/24. Diagnoses included chronic obstructive pulmonary disease, respiratory failure, heart disease, anxiety disorder, and major depressive disorder. Review of Resident #129's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #129 was cognitively intact. Resident #129 required moderate assistance with toilet use,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to ensure alternative methods of communication were provided as indicated. This affected one (#17) of one sampled residents reviewed for alternate means of communication in a facility census of 74. Findings include: 1. Review of the medical record for Resident #17 revealed admission date of 01/10/22, with the diagnoses including: acute respiratory failure with hypoxia, cerebral infarction with left side hemiplegia and hemiparesis, chronic obstructive pulmonary disease, hypotension, seizure disorder, anxiety, depression, paranoid schizophrenia, coronary artery disease, bipolar disorder, chronic kidney disease, and benign neoplasm of heart. According to the most current minimum data set assessment dated [DATE] assessed Resident #17 with severe cognitive impairment, sometimes understands and understood, dependent on staff for the provision activities of daily living, incontinent of bowel and bladder, receives tube feeding for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview and review of the clinical protocol, the facility failed to identify, report and timely assess an alteration in skin integrity. This affected one (#19) of six resident reviewed for skin integrity. The facility census was 74. Findings include: Review of the medical record for Resident #19 revealed an admission date of 04/17/20, diagnoses included: chronic respiratory failure, nontraumatic intracerebral hemorrhage, type 2 diabetes mellitus, depression, anxiety disorder, dysphagia, hypertension, encephalopathy, and bipolar disorder. Resident #19 had a tracheostomy. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had no speech, rarely never is understood and sometimes understands others. Resident #19's cognitive status was unable to be assessed due to a memory problem. Resident #19 had functional impairments to both upper and lower extremities, utilized a wheelchair for mobility and was dependent for mobility, as well…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, medical record review, and staff interview, the facility failed to ensure audiology services were provided timely for residents with identified hearing concerns. This affected one resident (#70) of two residents reviewed for audiology services. The facility census was 74. Findings Include: Review of Resident #70's medical record revealed an admission date of 04/23/24. Diagnoses included conductive hearing loss, impacted earwax, and injury of thorax subsequent encounter. Review of Resident #70's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #70 was cognitively intact. Resident #70 required touching assistance with toilet use, bathing, and parts of dressing. Resident #70 was highly hearing impaired and did not have hearing aides at the time of the review. Resident #70 displayed no behaviors at the time of the review. Review of Resident #70's care plan revised 05/16/24 revealed supports and interventions for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure interventions to promote range of motion and limit contractures were implemented as ordered. This affected two (#24 and #19 ) of three sampled residents reviewed for range of motion. The facility census was 74. Findings include: 1. Review of the medical record of Resident #24 revealed an admission date of 09/19/19, with the diagnoses including: cerebral infarction with left side hemiplegia and hemiparesis, right and left lower leg muscle wasting and atrophy, chronic obstructive pulmonary disease, and chronic subdural hemorrhage. According to the minimum data set assessment dated [DATE] assessed Resident #24 with severe cognitive impairment, dependent on staff for the provision of activities of daily living (ADL), limited range of motion impairment on one side to the upper and lower extremities, utilized a wheelchair for mobility and propelled with substantial to maximal assistance from staff. 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, medical record review, resident interview, staff interview, and review of policy the facility failed to follow their policy to secure resident's smoking materials and failed to ensure residents smoked in the proper designated areas. This affected two (#70 and #13) of three residents reviewed for accidents and hazards. The facility census was 74. Findings Include: 1. Review of Resident #70's medical record revealed an admission date of 04/23/24. Diagnoses included conductive hearing loss, impacted earwax, and injury of thorax subsequent encounter. Review of Resident #70's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #70 was cognitively intact. Resident #70 required touching assistance with toilet use, bathing, and parts of dressing. Resident #70 displayed no behaviors at the time of the review. Review of Resident #70's care plan revised 05/16/24 revealed supports and interventions for self-care deficit and smoking.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, medical record review, and review of facility policy, the facility failed to provided adequate and timely care to prevent episode of incontinence for a resident who was continent of bowel and bladder. This affected one (#69) of two residents reviewed for bowel and bladder incontinence. The facility census was 74. Findings Include: Review of Resident #69's medical record revealed an admission date of 04/02/24. Diagnoses included hemiplegia and hemiparesis, stroke, peripheral vascular disease, depression, cognitive communication deficit, insomnia, and benign prostatic hyperplasia. Review of Resident #69's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #69 was cognitively intact. Resident #69 was dependent on staff for toilet use and dressing. Resident #69 required maximal assistance with bathing. Resident #69 was not on a toileting program and was noted to be always continent of urine and bowel.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and resident and staff interview, the facility failed to ensure dependent residents were provided with adequate grooming and hygiene. This affected one resident (#1) of three residents observed for the provision of activities of daily living in a facility census of 80. Findings include: Resident #1 admitted to the facility on [DATE] with the diagnoses including cerebral infarction with hemiplegia and hemiparesis affecting the left non-dominant side, hypertension, peripheral vascular disease, acute embolism and thrombosis of deep veins, depression, gastrostomy, dysphagia, and dysarthria. According to the Minimum Data Set assessment dated [DATE] assessed Resident #1 with intact cognition, the resident was dependent on staff for activities of daily living (ADLs), required substantial to maximal assistance with transfers, utilized a wheelchair and walker for mobility, was incontinent of bowel and bladder, received pain medication administration on a scheduled regimen and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, hospital documentation review, and review of a facility incontinence policy, the facility failed to ensure dependent residents received timely and sufficient care related to bowel incontinence. This affected one (#3) of three residents reviewed for the provision of incontinence care services in a facility census of 80. Findings include: Resident #3 admitted to the facility on [DATE] with the diagnoses including atrial fibrillation, congestive heart failure, type II diabetes mellitus, below the knee amputation of the left leg, hypertension, benign prostatic hyperplasia, leukemoid reaction, and right foot amputation. According to the most current Minimum Data Set assessment dated [DATE] assessed Resident #3 with intact cognition, the resident was dependent on staff for the completion of activities of daily living, utilized an indwelling urinary catheter, was frequently incontinent of bowel, and was at risk for pressure ulcer development with moisture associated skin…

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 and resident interview, and policy review, the facility failed to notify resident representatives of a change in condition requiring a transfer to the hospital. This affected two (#27 and #66) of four residents reviewed for change in condition. The facility census was 65. Findings include: 1. Review of the medical record for Resident #27 revealed an admission date of 05/09/23 with diagnoses including chronic atrial fibrillation, congestive heart failure, type two diabetes, hypertension, amputation between the left knee and ankle, and acquired absence of the right foot. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 was assessed as cognitively intact and was dependent on staff for activities of daily living (ADLs). Review of a nurses note dated 02/03/24 at 11:16 A.M. revealed Resident #27 was sent to the hospital for evaluation and treatment. Further review of the note and the medical record revealed no evidence Resident #27's family or…

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 complete admissions procedures and documents per the facility policy. This affected two (#66 and #67) of three reviewed for admissions. The facility census was 65. Findings include: 1. Review of the medical record for Resident #66 revealed an admission date of 12/14/23 and discharge date of 01/01/24. Diagnoses included acute on chronic respiratory failure with hypoxia, dependence on respirator, tracheostomy, type two diabetes, right-sided heart failure, atrial fibrillation, cellulitis of bilateral lower limbs, alcoholic hepatitis, alcoholic cirrhosis of liver, depression, and anxiety. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was assessed as cognitively intact and was dependent on staff for activities of daily living (ADLs). Review of the entire medical record revealed no admission paperwork was available for Resident #66. Interview on 03/20/24 at 11:18 A.M. with Admissions Staff #755…

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 interview, staff interview, and review of the electronic mail (e-mail) correspondence), the facility failed to honor Resident #45's preference for showers and grooming. This affected one (#45) of three residents reviewed for activities of daily living. The facility census was 64. Findings include: Review of the medical record revealed Resident #45 was admitted to the facility on [DATE]. Diagnoses included syncope and collapse, hypotension, acute kidney failure, chronic kidney disease, dysphagia, hereditary and idiopathic neuropathy, hypertension, hyperlipidemia, muscle weakness, intervertebral disc displacement lumbar region, and allergic rhinitis. Review of Resident #45's admission nursing evaluation dated 01/05/24, revealed the resident was alert, short-term and long-term memory were intact, and the resident's independent cognitive skills for decision-making were consistent and reasonable. Resident #45 required the assistance of one staff for activities of daily living.…

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

Based on observation, medical record review, staff interview, and policy review, the facility failed ensure medications as ordered by a physician. A total of two medications were administered in error out of 36 opportunities for a medication error rate of 5.55 percent (%). This affected two (#3 and #22) of four residents observed for medication administration. The facility census was 56. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 05/17/23 with a diagnosis of nicotine dependence. Review of the most current physician orders dated October 2023 for Resident #3 revealed a nicotine transdermal patch, seven (7) milligrams per 24 hours was ordered. Observation of medication administration on 10/11/23 at 7:40 A.M. with Registered Nurse (RN) #367 revealed RN #367 pulled and administered a nicotine transdermal patch, 14 milligrams per 24 hours to Resident #3. Interview on 10/11/23 at 10:31 A.M., with RN #367 verified Resident #3 was ordered a nicotine transdermal patch, 7 milligrams per 24 hours, and confirmed RN #367 administered a nicotine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, review of the medical record, and review of policy, the facility failed to ensure a resident dependent on staff assistance was provided showers. This affected one (#27) of three residents reviewed for showers. The facility census was 55. Findings include: Review of the medical record for Resident #27 revealed an admission date of 08/11/23, with diagnoses of congestive heart failure, transient ischemic attack, and abnormalities of gait and mobility. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had impaired cognition and required one-person physical assist for bathing. There was no indication Resident #27 refused care. Review of the medical record for Resident #27 revealed she preferred showers three times weekly (Monday, Wednesday, Saturday). Review of the nurse aide tasks completed by aides revealed Resident #27 received a shower on 09/06/23. Review of the September 2023 Treatment Administration Record (TAR)…

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 residents received adequate assistance to ensure safety while providing incontinence care and repositioning. This affected one (#45) of one resident reviewed for safety. The facility census was 55. Findings include: Review of the medical record for Resident #45 revealed an admission date of 07/19/23, with diagnoses of tracheostomy status and intracerebral hemorrhage. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had intact cognition and required extensive assistance of two staff for bed mobility, dressing, toileting, and hygiene. Review of the current care plan for Resident #45 revealed he had an activities of daily life self-care performance deficit and required two people for assistance with bed mobility and toileting. Review of a physician order dated 07/23/23 revealed Resident #45 was on a specialty air mattress. Observation on 09/11/23 at 9:27 A.M., revealed State Tested Nurse…

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

Based on medical record review, staff interview, and policy review, the facility failed to accurately document the administration of controlled substances. This affected one (#76) of three residents reviewed for medication administration. The facility census was 55. Findings include: Review of the closed medical record for Resident #76 revealed an admission date of 07/07/23 and a discharge date upon death at the facility of 07/24/23, with diagnoses of anorexia, anxiety, and malignant neoplasm to the middle third of the esophagus. Review of Resident #76's comprehensive Minimum Data Set (MDS) assessment, dated 07/14/23, revealed Resident #76 had impaired cognition, was totally dependent on one person for eating, required extensive assistance of two people for bed mobility, and transfers, and required extensive assistance of one person for locomotion, dressing, toileting, and hygiene. Review of Resident #76's medical record revealed she was admitted to the facility on hospice care. Review of Resident #76's admitting physician orders dated 07/07/23, revealed a physician's order for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and policy review, the facility failed to provide a clean environment. This affected one (#20) of three residents reviewed for environment. The facility census was 55. Findings include: Review of Resident #20's medical record revealed an admission date of 08/25/23, with diagnoses including congestive heart failure, diabetes mellitus, acute respiratory failure, acute kidney disease. Review of Resident #20's Minimum Data Set (MDS) assessment dated [DATE] revealed an intact cognition. He required an extensive assistance for all activities of daily living except eating in which he was independent and required only set up help. Observations on 09/11/23 at 9:12 A.M., revealed Resident #20's room had a splatter substance on the ceiling approximately two feet from the entrance door. The substance was dark tan in appearance and the splatter was approximately three feet long. Interview on 09/11/23 at 9:13 A.M., with Resident #20 revealed the stain had been on 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 staff interview, the facility failed to ensure residents received intravenous antibiotics per physician order in a timely manner. This affected two residents (#1 and #3) of three residents reviewed for medication administration. The facility census was 60. Findings include: 1. Record review for Resident #1 revealed the resident was admitted to the facility on [DATE] and discharged to home on [DATE]. Diagnoses for Resident #1 included sepsis, wounds, and cellulitis. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and was receiving antibiotics. Review of the care plan dated 07/06/23 revealed Resident #1 had risks for cellulitis due to sepsis. Interventions included to administer antibiotics per order, follow procedures for reporting infections, and to monitor and document signs of change. Review of the admission orders dated 06/27/23 revealed Resident #1 was admitted to the facility on an intravenous (IV) antibiotic.…

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, staff interview, and review of facility policy, the facility failed to serve meals in a sanitary manner. This affected three (#3, #27, and #45) of 59 residents residing in the facility. The facility census was 59. Findings include: Observation on 10/04/22 at 7:51 A.M., revealed numerous residents were in the dining area of the facility eating the breakfast meal. State Tested Nurse Aide (STNA) #271 was observed touching Resident #3 and Resident #27's toast with a bare hand. STNA #208 was also observed touching Resident #45's English muffin with a bare hand. Interviews immediately after observation, with STNA #208 and STNA #271, verified staff were picking up ready-to-eat food items with their bare hands. Both staff members reported they thought this was acceptable. Observation on 10/04/22 at 12:27 P.M., of the lunch meal revealed STNA #234 was observed writing with a pen and then touching Resident #45's dinner roll with a bare hand. Interview immediately after observation, with STNA #231, verified the staff member touched Resident #45's dinner roll with her bare…

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, observation, staff interview, and review of facility policy, the facility failed to ensure staff practiced hand hygiene and utilized personal protective equipment appropriately when providing care to residents on transmission-based precautions. This had the potential to affect 12 (#4, #9, #14, #17, #28, #30, #38, #39, #43, #51, #54, and #155) of 12 residents identified to be on transmission-based precautions. The facility census 59. Findings include: Review of facility-provided documentation revealed Resident #4, #9, #14, #17, #28, #30, #38, #39, #43, #51, #54, and #155 were on transmission-based precautions (TBP) as a precaution for COVID-19. Observation on 10/03/22 at 11:23 A.M. of the designated COVID-19 quarantine hallway entrance, revealed a set of double-doors with signage instructing those entering to wear an N 95 mask, eye protection, gown, and gloves prior to entering any resident rooms. Upon entering the double-doors, a three-drawer cart was located immediately to the right, which contained masks, gowns, gloves, and face shields. Observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff and resident interview, the facility failed to ensure residents were placed into proper fitting beds. This affected one resident (#46) out of 24 residents observed for the provision of assistive devices and furniture. The facility census was 59. Findings include: Resident #46 admitted to the facility on [DATE] with the diagnosis including, chronic obstructive pulmonary disease, atrial fibrillation, osteoarthritis, peripheral vascular disease, polyneuropathy, arthropathy, gastrointestinal hemorrhage, gastrostomy, history of cellulitis bilateral lower extremities, dysphagia, pulmonary hypertension, heart failure, contracture of muscle left lower extremity, bilateral lower extremity edema, cardiac pacemaker, history of stage three pressure ulcer to bilateral heels, and hypertension. Review of the minimum data set (MDS) assessment dated [DATE] revealed Resident #46 was assessed with intact cognition, dependent on staff for activities of daily living including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to notify the physician and responsible party of a significant weight loss. This affected one resident (#45) out of four residents reviewed for nutrition. The facility census was 59. Findings include: Review of Resident #45's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, dementia, muscle weakness, schizoaffective disorder, bipolar disorder, anxiety, dementia, and gastro-esophageal reflux disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 was cognitively impaired, and required the extensive assistance of two staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Resident #45's plan of care dated 08/04/22 revealed the resident was at risk for nutritional deficit related to chronic disease status and altered diet. Interventions included monitoring/recording/reporting to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure the Minimum Data Set (MDS) assessments were completed accurately. This affected one resident (#20) out of three residents reviewed for oxygen use. The facility census was 59. Findings include: Review of Resident #20's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and muscle weakness. Review of Resident #20's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. The resident required limited assistance of one staff for bed mobility, transfers, toilet use, and personal hygiene. The assessment indicated the resident had not used oxygen. Review of Resident #20's physician orders identified an order dated 07/20/22 for oxygen at four liters per minute via nasal cannula continuously. Review of the Respiratory Administration Record for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review and staff interview, the facility failed to ensure treatments were completed per physician order. This affected one resident (#18) out of one reviewed for a skin tear. The facility census was 59. Findings include: Review of the medical record revealed Resident #18 was admitted on [DATE]. Diagnoses included cerebral infarction due to unspecified occlusion or stenosis of the left middle cerebral artery, type two diabetes, dysphagia following cerebral infarction, acute respiratory failure with hypoxia, anxiety, muscle wasting and atrophy of the left and the right lower extremity, hypertension, vitamin D deficiency, encephalopathy, and seizures. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #18 severely impaired cognition. Resident #18 required extensive assistance of two staff for Activities of Daily Living. Review of the Care Plan dated 07/26/22 revealed Resident #18 had the potential for impairment to skin integrity related to muscle weakness,…

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, staff interview, policy review, and review of the dressing package instructions, the facility failed to ensure timely wound assessment and wound treatments were provided in accordance with physician orders. This affected one resident (#08) out of three residents reviewed for pressure ulcers. The facility census was 59. Findings include: Resident #08 admitted to the facility on [DATE] with the diagnosis including, chronic respiratory failure, ventilator dependent, epilepsy, hemoptysis, peripheral vascular disease, tracheostomy, indwelling urethral stent with neuromuscular dysfunction of bladder, contractures, anemia, persistent vegetative state, gastrointestinal hemorrhage, atrial fibrillation, gastrostomy, encephalopathy, and hypertension. Review of the minimum data set assessment dated [DATE] revealed Resident #08 was assessed with severe cognitive impairment, total dependence on staff for the completion of activities of daily living, utilized an indwelling urinary…

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, staff interview, facility policy review, and hospital documentation review, the facility failed to provide the care and treatment to a resident utilizing an indwelling urinary catheter to main urinary function. This affected one (#8) of two individuals reviewed for the placement and care of urinary catheters. The facility census of 59. Findings include: Review of Resident #8's medical record admitted to the facility on [DATE], with the diagnosis including: chronic respiratory failure, ventilator dependent, epilepsy, hemoptysis, peripheral vascular disease, tracheostomy, indwelling urethral stent with neuromuscular dysfunction of bladder, contractures, anemia, persistent vegetative state, gastrointestinal hemorrhage, atrial fibrillation, gastrostomy, encephalopathy, and hypertension. Review of the minimum data set (MDS) assessment dated [DATE], Resident #8 was assessed with severe cognitive impairment, total dependence on staff for the completion of activities of daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the facility policy, the facility failed to monitor, recognize, and assess a resident who sustained significant weight loss. This affected one (#45) of four residents reviewed for nutrition. The facility census was 59. Findings include: Review of Resident #45's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, dementia, muscle weakness, schizoaffective disorder, bipolar disorder, anxiety, dementia, and gastro-esophageal reflux disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 was cognitively impaired, and required the extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of Resident #45's plan of care, dated 08/04/22, revealed the resident was at risk for nutritional deficit related to chronic disease status and altered diet. Interventions included…

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 and family interviews and review of facility policies, the facility failed to ensure the administration of tube feeding was assessed, monitored and timely treated when gastrointestinal changes occurred. This affected one (#8) of three residents reviewed for the administration of tube feeding. The facility census was 59. Findings include: Review of Resident #8's medical record revealed an admission date of 10/04/19, with the diagnoses including: chronic respiratory failure, ventilator dependent, epilepsy, hemoptysis, peripheral vascular disease, tracheostomy, indwelling urethral stent with neuromuscular dysfunction of bladder, contractures, anemia, persistent vegetative state, gastrointestinal hemorrhage, atrial fibrillation, gastrostomy, encephalopathy, and hypertension. Review of the minimum data set (MDS) assessment dated [DATE], revealed Resident #8 was assessed with severe cognitive impairment, total dependence on staff for the completion of activities of daily living,…

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, staff interview, and review of facility policy, the facility failed to ensure Central Venous Catheters were maintained in accordance with physician orders. This affected one (#7) of one residents reviewed for the maintenance of a CVC and identified by the facility with a CVC inserted. Facility census 59. Findings include: Review of Resident #7's medical record revealed admission date of 03/27/20, with the diagnoses including: chronic respiratory failure, dysphagia following cerebral infarction, type 2 diabetes mellitus, resistance to specified beta lactam antibiotics, quadriplegia, tracheostomy, ventilator dependent, peripheral vascular disease, methicillin resistant staphylococcus aureus suspected carrier, edema, chronic pain syndrome, urinary tract infection, anxiety disorder, blindness, neuromuscular dysfunction of bladder, gastrostomy, seizure disorder, contractures, major depression, and hypertension. Review of the the minimum data set (MDS) assessment dated…

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, policy review, and staff interview, the facility failed to obtain physician orders for residents receiving oxygen therapy and maintain the oxygen equipment per policy. This affected two (#13 and #255) of four residents reviewed for oxygen therapy. Findings include: 1. Review of medical record for Resident #13 admitted on [DATE], with diagnoses including: malignant neoplasm of bronchus or [NAME], obstructive and reflux uropathy, dysphagia, alcohol abuse, anxiety, asthma, barrett's esophagus, benign prostatic hyperplasia with lower urinary tract symptoms, heart failure, epilepsy, atherosclerotic heart disease of native coronary artery, major depressive disorder, hyperlipidemia, hypertension, and transient cerebral ischemic attack. Review of Minimum Data Set (MDS) assessment for Resident #13 dated 07/25/22 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognitively intact. Resident #13 was independent for Activities of Daily Living (ADL'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 observation, resident interview, and staff interview, the facility failed to maintain comfortable temperatures in a dining room. This affected two residents (Resident #23 and #63) eating lunch in the Windsor dining room. The facility census was 75. Findings include: Observation on 11/12/19 at 11:44 A.M. in the Windsor dining room revealed the thermostat temperature was 63 degrees Fahrenheit. The heat setting was on and was set at 74 degrees Fahrenheit. Observation on 11/12/19 at 11:48 A.M. revealed Resident #23 and Resident #63 in the Windsor dining room waiting for lunch. Interview on 11/12/19 at 11:50 A.M. with Resident #63 revealed the dining room was cold and that she would like a blanket. Resident #23 stated he was a little cold. Interview on 11/12/19 at 11:59 A.M., Maintenance Director #300 revealed the furnace providing heat to the Windsor dining room has not been functioning since 11/11/19. A call has been made for service. Maintenance Director #300 utilized a temperature laser to determine the temperature where the residents were sitting to be 69 degrees Fahrenheit.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and observation, the facility failed to follow physician orders to obtain blood sugars before meals for one (#66) of four residents reviewed for medication administration. The facility identified 25 residents with orders for routine blood sugar checks. The facility census was 75. Findings include: Review of Resident #66's medical record revealed the resident was admitted on [DATE]. Diagnosis included type two diabetes mellitus. Review of the physician orders for November 2019 revealed an order for the rapid acting insulin Insulin Aspart 100 units per milliliter to be injected before meals and at bedtime based on sliding scale. A sliding scale requires a blood sugar to be checked in order to administer insulin. Review of the weights and vital signs summary revealed no blood sugar was documented to have been obtained before the breakfast meal on 11/13/19. Observation on 11/13/19 at 11:01 A.M., of Resident #66's medication administration revealed Licensed Practical Nurse…

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

Based on observation, medical record review, and staff interview, the facility failed to provide a resident with full visual privacy in her bedroom. This affected one (#46) of 12 residents who reside in semi-private bedrooms on the D Hall. The census was 75. Findings include: Review of Resident #46's medical record revealed an admission date of 11/23/99. Diagnoses included peripheral vascular disease, mild intellectual disabilities, edema, pain, and muscle weakness. Review of the most recently completed Minimum Data Set (MDS) assessment, dated 10/08/19, revealed Resident #46 had severely impaired cognition. Observation of the D Hall on 11/12/19 between 8:15 A.M. and 9:30 A.M. revealed resident Resident #46's bed had no privacy curtain to ensure full visual privacy. The hooks for the privacy curtain were in place on the track around Resident #46's bed. Additional observations made on 11/12/19 at 4:43 P.M., on 11/13/19 at 10:46 A.M., 2:22 P.M. and 3:38 P.M., and on 11/14/19 at 9:12 A.M., 10:53 A.M. and 1:23 P.M. revealed Resident #46 laying in her bed while her roommate was laying 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.