Orchard Villa

Based on medical record review, review of an authorization for the release of health information, review of electronic communications, and policy review, the facility failed to provide copies of the medical record to a resident representative in a timely manner. This affected one (Resident #125) of five reviewed for medical record requests. The facility census was 121. Findings include: Review of the medical record revealed Resident #125 had an admission date of 11/07/23 and a discharge date of 02/14/24. Diagnoses included hypertensive heart and chronic kidney disease with heart failure and stage five chronic kidney disease or end stage renal disease, type two diabetes mellitus with diabetic nephropathy and polyneuropathy, end stage renal disease, dependence on renal dialysis, anemia, noninfective gastroenteritis and colitis, abnormal weight loss, and acquired absence of the left foot. Review of the, Authorization for the Release of Health Information, form revealed one of Resident #125's family members requested a copy of the resident's medical record on 02/16/24. The family member…

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

Based on observations, staff interviews, and review of facility policy, the facility failed to date insulin pens after initial use and failed to date a vial of opened and used sterile water. This affected two out of four medication carts observed and had the potential to affect four (#54, #72, #75, and #119) residents with insulin pens that were opened and not dated. The facility census was 125. Findings include: Observation on 12/11/23 at 9:20 A.M. of medication storage for the medication cart on A hall on the skilled unit revealed one vial of sterile water that was opened and undated, one lantus insulin pen opened and undated, and one humalog insulin pen that was opened and undated for Resident #119. At the time of the observation Licensed Practical Nurse (LPN) #206 verified the opened and undated insulin pens for Resident #119 and sterile water. Observation on 12/11/23 at 11:30 A.M. of medication cart for A hall on the long term care unit revealed one opened and undated lantus insulin pen for Resident #54, one opened and undated lantus insulin pen for Resident #72, and one opened…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the medical record, resident and staff interviews and review of facility policy, the facility failed to ensure carpet was in good repair. This affected one (Resident #45) and had the potential to affect 23 (Residents 3, #9, #17, #18, #27, #28, #38, #39, #45, #46, #47, #53, #55, #73, #79, #81, #83, #84, #86, #89, #107, #118, and #121) who were indecently mobile and residing on the Bayshore hall. Additionally, the facility failed to ensure a resident's bathroom was kept in a clean and sanitary manner. This affected one (Resident #64) of one resident observed for bathroom cleanliness. The facility census was 124. Findings include: 1. Interview on 08/22/23 at approximately 9:30 A.M. with Resident #45 revealed the hallway carpet on Bayshore has a large snag and the resident was concerned she could trip and fall. Observation on 08/23/23 at 11:47 A.M. revealed in the walkway of the Bayshore hallway carpet, there was an indent of missing carpet and an area approximately one inch to one…

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

Based on observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure an effective pest control program. This had the potential to affect 11 (#1, #9, #17, #40, #46, #53, #83, #86, #89, #107, and #121) residents residing on the Bayshore unit. The facility census was 124. Findings include: Observation on 08/21/23 at 4:36 P.M. of the Bayshore unit dining area revealed multiple gnats flying around the refrigerator. A gnat trap on top of the refrigerator had approximately 15 gnats sitting on the trap. Interview on 08/22/23 at 7:30 A.M. of Resident #86 revealed there were gnats everywhere, including in the halls, resident rooms, and in the dining area. Resident #86 stated she believed they were coming from the drains. Observation on 08/22/23 at 2:18 P.M. with Maintenance Supervisor (MS) #276 verified the gnats in the dining area on the Bayshore unit. MS #276 stated they tried to keep up with the gnats and housekeeping put out the gnat traps. MS #276 stated the gnat trap must be full and needed emptied. While the facility had an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure an appropriate copy of a resident's advanced directive was maintained in the resident's medical record. This affected one (Resident #383) of one resident reviewed for advanced directives. The facility census was 124. Findings include: Review of the medical record revealed Resident #383 was admitted on [DATE]. Diagnoses included urinary tract infection, acute kidney failure, hypertensive heart and chronic kidney disease, chronic kidney disease, pressure ulcer sacral region stage II, hyperkalemia, hyperlipidemia, diverticulosis of large intestine without perforation or abscess without bleeding. Review of the physician order dated 08/10/23 revealed Resident #383's advanced directive was Do Not Resuscitate Comfort Care-Arrest (DNRCC-Arrest). Review of the care plan dated 08/13/23 revealed Resident #383 had chosen advanced directive of DNRCC-Arrest. The medical record did not include a signed copy of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to ensure dependent residents received nail care. This affected one (Resident #47) of four residents reviewed for activities of daily living. The census was 124. Findings included: Review of the medical record revealed Resident #47 was admitted on [DATE]. Diagnoses included Alzheimer's disease, dementia with agitation, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and schizoaffective disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was moderately cognitively impaired. Resident #47 required extensive two person assistance for personal hygiene and was dependent upon staff for bathing. Review of the care plan revised on 04/03/23 revealed Resident #47 required extensive assistance with personal hygiene and for staff to provide nail care as needed. Further review of the medical record revealed no documentation showing the resident received nail…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, and staff interview, the facility failed to ensure TED hose were applied per physician order. This affected one (Resident #61) of one resident reviewed for edema. The facility census was 124. Findings include: Review of Resident #61's medical record revealed an admission date of 05/19/22 and a readmission date of 07/06/22. Diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), type II diabetes, bipolar disorder, schizoaffective disorder, congestive heart failure (CHF), and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 was cognitively intact and required extensive assistance with dressing. Review of a plan of care focus area, revised 12/08/22, revealed Resident #61 was at risk for decreased cardiac output and abnormal lab values related to CHF, hyperlipidemia, use of anticoagulant medication, and use of diuretics. Interventions included knee high…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, and staff interview, the facility failed to follow audiology recommendations to better assist with hearing. This affected one (Resident #14) of one reviewed for hearing. The census was 124. Findings include: Review of Resident #14's medical record revealed an admission date of 10/26/22. Diagnoses included end stage renal failure, congestive heart failure, and diabetes mellitus. Review of Resident #14's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. Review of Resident #14's most recent care plan revealed she had a communication problem related to a hearing deficit and was required to wear hearing aids. Review of the Audiology Group progress note dated 07/12/23 revealed the staff and family had noticed a recent decrease in Resident #14's responsiveness and she complained of newly decreased hearing. Recommendations were for the attending physician or nursing staff to complete wax removal from both ears. The audiologist would…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure a hand splint was used to prevent contractures per physician order. This affected one (Resident #68) of one reviewed for contractures. The facility census was 124. Findings include: Review of Resident #68's medical record revealed an admission date of 12/29/22. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, aphasia, type II diabetes, congestive heart failure (CHF), major depressive disorder, asthma, atherosclerosis, and dysphagia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #68 was cognitively intact and required extensive assistance with dressing, personal hygiene, toilet use, locomotion, and bed mobility. Review of the plan of care revised 04/13/23 revealed Resident #68 had potential for alteration in skin integrity related to immobility, incontinence, and splint usage.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident interview, and staff interview, the facility failed to ensure fall interventions were in place for two (Residents #10 and #90) of three reviewed for falls. The facility census was 124. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 12/01/22 with diagnoses of hemiplegia and hemiparesis, dementia, and repeated falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had impaired cognition and required extensive assistance of two people for bed mobility, transfers, and toileting. Review of Resident #10's current care plan revealed he was at risk for falls with a history of falls. Interventions included using a call sign to remind him to ask for assistance and having the call light accessible when in his room. Observation on 08/23/23 at 9:12 A.M. revealed Resident #10 in bed with his call light wrapped around the bottom of his enabler bar, with the call light button dangling…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to implement tube feeding recommendations in a timely manner. This affected one (Resident #62) of one reviewed for tube feedings. The facility identified three residents who received tube feedings. The facility census was 124. Findings include: Review of Resident #62's medical record revealed an admission date of 11/15/22 and a readmission date of 01/15/23. Diagnoses included unspecified severe protein calorie malnutrition, dysphagia, type II diabetes, spinal stenosis, hypertension, osteoarthritis, and personal history of pulmonary embolism. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was cognitively intact, had a feeding tube, and received 51% or more of total calories through tube feeding. Review of a plan of care focus area, revised 08/09/23, revealed Resident #62 required a feeding tube to assist in maintaining or improving nutritional status related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to provide physician ordered medication. This affected one (Resident #382) of one reviewed for availability of medications. The census was 124. Findings include: Review of Resident #382's medical record revealed an admission date of 07/28/23. The resident was discharged home on [DATE]. Diagnoses included Parkinson's disease, dementia, congestive heart failure, diabetes mellitus type II, and auditory hallucinations. Review of Resident #382's entrance Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired. Review of Resident #382's progress note dated 07/28/23 revealed the resident was admitted from home for respite care via family. The medication list provided by the family was sent to the medical doctor for review. Review of Resident #382's admission records revealed an order for magnesium citrate 1,000 milligrams (mg), which was to be taken by mouth daily. Review of Resident #382's Medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, resident interview, and policy review, the facility failed to ensure medications were stored properly. This affected one (Resident #7) of four reviewed for medication storage. The facility census was 124. Findings Included: Review of Resident #7's medical record revealed an admission date of 01/01/20. Diagnoses included chronic obstructive pulmonary disease, schizophrenia, heart failure, and atrial fibrillation. Review of Resident #7's quarterly Minimum Data Set (MDS) dated [DATE] revealed he had an intact cognition. The resident required one person limited assistance for activities of daily living and supervision/set up help for eating. Review of Resident #7's most recent care plan revealed he had impaired cognition function/impaired thought process related to impaired decision making, short term memory loss, and mild confusion. The resident suffered from ineffective breathing patterns as evidenced by shortness of breath on exertion and lying flat at times, labored…

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 review of facility policies, the facility failed to ensure food was prepared in a sanitary manner. This affected one (Resident #54) directly, and had the potential to affect all residents in the facility. All residents residing in the facility received food from the kitchen. The facility census was 124. Findings include: 1. Review of the medical record for Resident #54 revealed an admission date of 07/09/19 with a diagnosis of Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #54's cognition was not assessed. Further review revealed Resident #54 required supervision with setup help only for eating. Review of the current physician order for Resident #54 revealed he received a regular diet with regular textures and thin liquids. Observation on 08/21/23 at 12:30 P.M. revealed Registered Nurse (RN) #283 preparing a peanut butter and jelly sandwich. RN #283 held the bread in her left hand while spreading peanut butter 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 review of physician orders, review of treatment administration records (TAR), and staff interview, the facility failed to ensure treatment administration was accurately documented in the medical record. This affected two (#61 and #68) of two residents reviewed for treatments. The facility census was 124. Findings include: 1. Review of Resident #61's medical record revealed an admission date of 05/19/22 and a readmission date of 07/06/22. Diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), type II diabetes, bipolar disorder, schizoaffective disorder, congestive heart failure (CHF), and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 was cognitively intact and required extensive assistance with dressing. Review of a plan of care focus area revised 12/08/22 revealed Resident #61 was at risk for decreased cardiac output and abnormal lab values related to CHF, hyperlipidemia, use of anticoagulant…

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

Based on review of immunization records, staff interview, review of facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure pneumococcal vaccinations were offered and administered per CDC recommendations. This affected three (Residents #53, #64, and #68) of five reviewed for pneumococcal vaccination. The facility census was 124. Findings include: 1. Review of Resident #53's medical record revealed an admission date of 01/05/23. Diagnoses included atherosclerotic heart disease, hypertensive urgency, obesity, hypertension, and difficulty walking not elsewhere classified. Review of Resident #53's immunization record revealed the resident received pneumococcal vaccine Prevnar 13 (PCV13) on 10/01/19. There was no evidence Resident #53 received a dose of PCV20 or PPSV23. 2. Review of Resident #64's medical record revealed an admission date of 06/26/23. Diagnoses included encounter for orthopedic aftercare following surgical amputation, other complications of amputation stump, type II diabetes, end stage renal disease,…

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 reviews, resident, resident representative and staff interviews, and policy review, the facility failed to invite residents and their representatives to quarterly care plan conferences and did not hold quarterly care plan conferences. This affected three (#14, #16, and #91) of three residents reviewed for comprehensive care plan conferences. The facility census was 102. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 01/10/18. Diagnosis included dorsalgia, fibromyalgia, hyperlipidemia, polyosteoarthritis, essential (primary) hypertension, unspecified hearing loss, personal history of transient ischemic attack and cerebral infarction without residual deficits, unspecified displaced fracture of surgical neck of left humerus, hypo-osmolality and hyponatremia, unspecified dementia without behavioral disturbance, major depressive disorder recurrent, epileptic seizures related to external causes, and muscle weakness. Review of the most recent Minimum…

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 interviews and review of policy, the facility failed to apply orthotic devices as ordered. This affected one (#81) of three residents reviewed for limited range of motion. The facility census was 102. Findings include: Review of the medical record for Resident #81 revealed an admission date of 01/13/21 and a readmission date of 04/05/21. Diagnoses included pneumonitis due to inhalation of food and vomit; acute respiratory failure with hypoxia; hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side; contracture left hand; contracture left knee; and morbid (severe) obesity due to excess calories. Review of the Modification of Annual Minimum Data Set (MDS) assessment, dated 04/12/21, revealed Resident #81 was cognitively intact; required extensive two person physical assistance with dressing; and total two person physical assistance with transfers. Review of the care plan revealed Resident #81 had a self care performance deficit related to limited range of motion left hand contracted and decreased…

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

Based on observations, staff interviews, and medical record reviews, policy reviews, the facility failed to ensure a resident was transferred properly to prevent a fall and failed to implement fall precautions as ordered and care planned. This affected three (#81, #55, and #6) of three residents reviewed for falls. The facility census was 102. Findings include: 1. Review of the medical record for Resident #81 revealed an admission date of 01/13/21 and a readmission date of 04/05/21. Diagnoses included pneumonitis due to inhalation of food and vomit; acute respiratory failure with hypoxia; hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side; and morbid (severe) obesity due to excess calories. Review of the modification and annual Minimum Data Set (MDS) assessment, dated 04/12/21, revealed Resident #81 was cognitively intact, required two person physical assistance with transfers and bed mobility, had no resistance to care, and had one fall with no injury. Review of the care plan revealed Resident #81's fall interventions included mechanical lift…

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, staffing schedule review and review of policy, the facility failed to ensure tube feeding care was provided and documented as ordered. This affected one (#73) of one resident reviewed for tube feeding. The facility identified five residents with tube feeding. The facility census was 102. Findings Include: Review of Resident #73's medical record revealed an admission date of 03/25/21. Diagnoses included chronic respiratory failure, chronic kidney disease, persistent vegetative state, dysphagia, convulsions, tracheostomy, heart failure, aphasia, and contracture. Review of Resident #73's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 was in a persistent vegetative state. Resident #73 was totally dependent on staff for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. Resident #73 had a tracheostomy care and suctioning at the time of the review. Review of Resident #73's care plan revised 04/08/21 revealed supports 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 interviews, staffing schedule review and review of the facility policy, the facility failed to ensure tracheostomy care was provided and documented as ordered on second shift. This affected one (#73) of one resident reviewed for tracheostomy care. The facility identified two residents with tracheotomies. The facility census was 102. Findings include: Review of Resident #73's medical record revealed an admission date of 03/25/21. Diagnoses included chronic respiratory failure, chronic kidney disease, persistent vegetative state, dysphagia, convulsions, tracheostomy, heart failure, aphasia, and contracture. Review of Resident #73's Minimum Data Set (MDS) dated [DATE] revealed Resident #73 was in a persistent vegetative state. Resident #73 was totally dependent on staff for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. Resident #73 had a tracheostomy care and suctioning at the time of the review. Resident #73 received respiratory therapy seven days…

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, dialysis center staff and facility staff interviews, medical record review, and review of facility policy, the facility failed to accurately assess a resident dialysis Central Venous Catheter (CVC). This affected one (#52) of one resident reviewed for dialysis treatment. The facility identified 12 residents receiving dialysis treatment. The facility census was 102. Findings include: Review of the medical record for Resident #52 revealed an admission date of 04/03/21. Diagnoses included sepsis, arthritis, end stage renal disease, long term use of insulin, morbid obesity, and heart disease. Review of the admission Minimum Data Set (MDS) assessment for Resident #52, dated 04/09/21, revealed a Brief Interview for Mental Status (BIMs) score of 14, indicating the resident was cognitively intact. Additionally, the assessment indicated the resident received dialysis treatment. Review of the hospital admission paperwork dated 04/03/21 revealed the resident was admitted to the facility with a double lumen hemodialysis catheter in his right chest. Review of the most…

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 policy, the facility failed to ensure a pharmacist accurately reviewed a resident's medication regimen. This affected one (#43) of five reviewed for unnecessary medications. The census was 102. Findings include: Review of Resident #43's medical record revealed an original admission date of 11/20/19 and a most recent admission date of 08/30/20. Diagnoses included respiratory failure, toxic encephalopathy, major depression, anemia, fibromyalgia, anxiety disorder, and unspecified dementia without behavioral disturbances. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had short and long-term memory problems. Review of a physician's order dated 08/30/20 revealed Resident #43 was ordered the antidepressant Trazodone 50 milligrams (mg) and to give one and one-half tablets to equal 75 mg daily. Review of a medication regimen review (MRR) dated 10/23/20 revealed the pharmacist reviewed Resident #43's Trazodone…

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.