The Gardens Of St. Francis

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and a facility catheter care policy, the facility failed to ensure an indwelling urinary catheter was maintained in a manner to prevent infection and care plan interventions were maintained to prevent dislodgement. This affected one (#7) of two residents reviewed for indwelling urinary catheters. The census was 52. Findings include: Review of the medical record revealed Resident #7 admitted to the facility on [DATE] with the diagnoses including, urinary tract infection, sepsis secondary to urinary tract infection, obstructive and reflux uropathy, ureter stent placement, coronary artery disease, coronary artery bypass graph, cerebral vascular accident, hypertension, moderate protein calorie malnutrition, and metabolic encephalopathy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was assessed with moderate cognitive impairment, utilized a wheelchair or walker for mobility, required partial to moderate assistance with…

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 a facility policy, the facility failed to ensure resident pain was effectively managed. This affected one (#23) of two residents reviewed for pain management. The facility census was 52. Findings Include: Review of Resident #23's medical record revealed an admission date of 01/18/22. Diagnoses included major depressive disorder, visual hallucinations, dysphagia, dementia, anxiety disorder, osteoarthritis, adjustment disorder, and pseudobulbar affect. Review of Resident #23's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #23 was rarely or never understood. A Staff Assessment for Mental Status was completed and Resident #23 was assessed with memory problems. Resident #23 required extensive assistance with bed mobility, transfers, eating, and toilet use. Resident #23 received scheduled and as needed pain medications. Resident #23 displayed facial…

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, medical record review, and review of facility policy, the facility failed to ensure medications were administered within ordered time frames. This affected one (#203) of two residents reviewed for medications. The facility census was 52. Findings Include: Review of Resident #203's medical record revealed an admission date of 01/19/24. Diagnoses included multiple fractures of right side ribs, respiratory disorder, protein calorie malnutrition, muscle weakness, chronic obstructive pulmonary disease (COPD), and pleurodynia (pain in upper abdomen or chest when breathing). Review of Resident #203's care plan revised 01/23/24 revealed supports and interventions for risk for pain, risk for decline for activities of daily living, behavior of being verbally aggressive, COPD, and desire to return back home. Review of Resident #203's physician orders revealed Resident #203 had medications ordered for one time a day, two times a day, three times a day, four times a day, at bed time, and as needed (PRN). Further review of the physician…

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

Based on observation, medical record review, staff interview, and facility medication administration policy, the facility failed to ensure medications were administered in accordance with physician orders and within prescribed time frames producing a medication error rate greater than five (5) percent (%). This resulted in three medication errors out of 27 opportunities for a medication error rate of 11.11%. This affected one (#154) of three residents observed for medication administration. The facility census was 52. Findings include: Observation on 01/30/24 at 10:38 A.M. revealed Licensed Practical Nurse (LPN) #445 obtained Resident #154's medications from the medication cart and preparing for administration. LPN #445 placed medications including the medication for bone health alendronate sodium oral tablet 70 milligrams (mg) and the diuretic Bumex oral one (1) mg, and proceeded into Resident #154's room administering the medications at 10:48 A.M. Interview with Resident #154 at this time confirmed she had previously consumed breakfast between 8:00 A.M. and 9:00 A.M. Observation…

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, resident and staff interview, and review of the facility policy, the facility to failed to ensure medications were stored in a safe and secure manner. This affected one (#5) of one residents observed for medication storage. The census was 52. Findings included: Review of the medical record for Resident #5 revealed an admission date of 01/23/21 with diagnoses which included diabetes mellitus, anxiety disorder, and insomnia. Review of the physician orders for Resident #5 revealed an order for the antianxiety medication Klonopin 0.5 milligrams (mg) to take one tablet by mouth twice daily, the pain medication gabapentin capsule 100 mg to give one capsule by mouth twice daily, and the sleep aid melatonin three (3) mg by mouth at bedtime for insomnia. Review of the medication administration record (MAR) for January 2024 revealed Resident #5 received Klonopin, gabapentin, and melatonin at bedtime on 01/29/24 which were signed as given by Licensed Practical Nurse (LPN) #479. Interview with Resident #5 on 01/30/24 at 8:15 A.M. verified there were…

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

Based on observation, staff interview, and review of facility policy, the facility failed to cover food during hall tray delivery to residents rooms and ensure food was dated properly to prevent food borne illnesses. This had the potential to affect all 53 residents who received food from the kitchen. The facility census was 53. Findings include: 1. Observation on 08/30/21 at 11:44 A.M. of hall tray service on the C Hall revealed the meal cart was placed in the common area of the hall. State Tested Nursing Assistant (STNA) #319 was observed removing lunch trays from the meal cart, walking down the hall and delivering to the resident rooms. Observation of the lunch trays revealed cupcakes on the meal trays had a plastic cover over the top, but the bottom portion, approximately half of the cupcake, was exposed. Interview on 08/30/21 at 11:50 A.M. of STNA #319 verified the bottom portion of the cupcakes were not properly covered during delivery to resident rooms. STNA #319 stated the cupcakes should have been placed in a cup and the plastic cover then placed over them to ensure they…

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, review of the facility policy and review of the Centers for Disease Control (CDC) guidance, the facility failed to properly wear facemasks while providing resident care, failed to monitor residents for signs and symptoms of COVID-19 and failed to wear an N95 respirator while performing staff testing for COVID-19 to potentially limit the transmission of COVID-19. This had the potential to affect 53 of 53 residents who reside in the facility. In addition, the facility failed to store oxygen tubing in a sanitary manner, affecting one (#25) resident reviewed for oxygen tube storage. The facility census was 53. Findings include: 1. Observation on 08/30/21 at 8:05 A.M. of the reception area revealed all staff were screened for symptoms of COVID-19 upon entrance into the facility. Outside the door of the reception desk was a cart with facemasks. A sign hanging on the cart stated to wear a facemask over both the nose and mouth. Observation on 08/30/21 at 12:28 P.M. of the second…

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, review of the facility census record for resident COVID-19 testing, staff interview, review of the facility policy, review of staff COVID-19 testing logs, staff laboratory results, and review of guidance from the Centers for Medicare and Medicaid Services (CMS), the facility failed to document resident COVID-19 test results in the electronic medical record (EMR), failed to timely follow up with the laboratory staff COVID-19 test results and failed to monitor a resident who refused COVID-19 testing during a facility outbreak. This had the potential to affect 53 of 53 residents who reside in the facility. Findings include: 1. Review of the facility census for resident testing for COVID-19, dated 08/24/21 and 08/25/21, revealed Residents #16, #49, #37, #22, #1, #50, #305, #27, #14, #40, #28, #44, #10, #205, #13, #43, #12, #52, #47, #45, #4, #35, #24, #206, #36, #7 and #15 were tested for COVID-19 following a positive staff COVID-19 test result, resulting in facility outbreak testing.…

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, resident and staff interview and policy review, the facility failed to maintain a comfortable temperature in the main dining room. This affected seven (#3, #6, #14, #16, #21, #36, and #43) of seven residents observed eating in the main dining room. The facility census was 53. Findings include: Observation on 08/30/21 at 12:00 P.M. of the main dining room for the lunch meal revealed the room to be very cold. Observation on 08/31/21 at 12:09 P.M. revealed Resident #3, Resident #6, Resident #14, Resident #16, Resident #21, Resident #36 and Resident #43 were sitting in the main dining room while waiting on their lunch meal. All the residents' were observed to be wearing a jacket or sweater and Resident #43 had a blanket lying across her lap. The room temperature seemed very cold. Resident interviews on 08/31/21 at 12:20 P.M. with Resident #3, Resident #6, Resident #14, Resident #16, Resident #21, Resident #36 and Resident #43 revealed it is always very cold in the dining room. Resident #43 stated that is why she has to have a blanket across her legs and we all…

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, staff interview and policy review, the facility failed to develop and/or implement care plan interventions. This affected four (#1, #5, #28 and #49) of 22 residents reviewed for care plans. The facility census was 53. Findings include: 1. Review of the medical record revealed Resident #1 was admitted on [DATE]. Diagnoses included multiple fractures of ribs, right side, subsequent encounter for fracture with routine healing, anxiety disorder, muscle weakness, gastro-esophageal reflux, overactive bladder, atrial fibrillation, major depressive disorder, essential hypertension and weakness. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had moderate cognitive impairment with a BIMS of nine out of 15. Resident #1 required extensive assist with one person assist for bed mobility, transfers, walking in room and corridor, toilet use, personal hygiene was total dependence for bathing with one person physical assist. No pressure ulcers;…

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 implement interventions for positioning, skin conditions, and post fall monitoring. This affected four (#30, #1, #49, and #44) of 22 residents reviewed for care and treatment. The facility census was 53. Findings include: 1. Review of Resident #30's medical record revealed an admission date of 01/12/17. Diagnoses included unspecified dementia without behavioral disturbance; hemiplegia and hemiparesis following cerebral infarction; atherosclerotic heart disease of native coronary artery without angina pectoris; and open-angle glaucoma. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #30 was moderately cognitively impaired and required extensive one person physical assistance with Activities of Daily Living (ADL's). Review of a physician order, dated 12/04/18, revealed half lap tray to wheelchair for positioning. Review of the plan of care, revised 02/06/19, revealed Resident #30 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, observation, staff interview and review of facility policy, the facility failed to treat residents with dignity. This affected one (#30) resident reviewed for dignity. The facility census was 53. Findings include: Review of Resident #30's medical record revealed an admission date of 01/12/17. Diagnoses included unspecified dementia without behavioral disturbance; hemiplegia and hemiparesis following cerebral infarction; atherosclerotic heart disease of native coronary artery without angina pectoris; and open-angle glaucoma. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #30 was moderately cognitively impaired and had highly impaired vision. Review of the plan of care, revised on 02/06/19, revealed Resident #30 had an activities of daily living (ADL's) self care performance deficit due to her limited mobility, left sided weakness and impaired vision due to her diagnosis of cardiovascular accident (CVA) and glaucoma. Interventions included introduce…

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 and staff interview, and review of facility policy, the facility failed to ensure residents choices were honored. This affected one (#13) of three reviewed for choices. The facility census was 53. Findings include: Review of Resident #13's medical record revealed an admission date of 02/19/21. Diagnoses included Alzheimer's disease, cognitive communication deficit, dysphagia, major depressive disorder, insomnia, anxiety disorder, and dementia. Review of Resident #13's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of eight out of 15 indicating Resident #13 was moderately cognitively impaired. Resident #13 required extensive assistance with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. Review of Resident #13's care plan revised 07/10/21 revealed supports and interventions for risk for wandering/elopement, risk for decrease in socialization, confusion, communication problem, 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, observation, staff interview, and review of facility policy, the facility failed to notify the physician or resident representative regarding of resident change in condition involving skin tears, falls and/or resident noncompliance with medical devices. This affected two (#1 and #25) of three residents reviewed for notification. The facility census was 53. Findings include: 1. Review of the medical record for Resident #1 was admitted on [DATE]. Diagnoses included multiple fractures of ribs, right side, subsequent encounter for fracture with routine healing, anxiety disorder, muscle weakness, gastro-esophageal reflux, overactive bladder, atrial fibrillation, major depressive disorder, essential hypertension and weakness. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #1 had a Brief Interview Mental Status score of nine out of 15 indicating moderate cognitive impairment. Resident #1 required extensive assist with one person assist for 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 medical record review, staff interview, and review of facility's policy, the facility failed to provided written notification of hospital transfer and discharge to the resident, the resident representative, and the ombudsman. This affected two (#204 and #28) of four residents reviewed for transfer and discharge. The facility census was 53. Findings include: 1. Review of Resident #204's medical record revealed an admission date of 01/29/19 and a discharge date of 04/09/20. Diagnoses included cellulitis, heart failure, anxiety disorder, lymphedema, and major depressive disorder. Review of Resident #204's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score 12 out of 15 indicating Resident #204 was moderately cognitively impaired. Resident #204 required extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. Review of Resident #204's progress notes revealed on 03/31/20 Resident #204 was transferred and admitted to the hospital…

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 provide written notice of the bed hold policy prior to transfer to the hospital. This affected one (#28) of two sampled residents reviewed for hospitalization. The facility census was 53. Findings include: Review of Resident #28's medical record revealed an admission date of 02/19/16 and a discharge date of 04/03/21 with a readmission date of 04/05/21 and a discharge date of 06/24/21. Diagnoses included unspecified fracture of sacrum, subsequent encounter for fracture with routine healing, unspecified dementia without behavioral disturbance, hypothyroidism, urgency of urination, Alzheimer's Disease, anxiety disorder, major depressive disorder, recurrent, rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement and gastro-esophageal reflux without esophagitis. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #28 had a BIMS score of 03, indicating severe…

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

Based on medical record review and staff interview, the facility failed to accurately reflect resident hospice status in the Minimum Data Set (MDS) assessment. This affected one (#18) of two residents reviewed for accuracy of assessments. The facility census was 53. Findings include: Review of Resident #18's medical record revealed an admission date of 11/09/20. Diagnoses included Alzheimer's disease, malignant neoplasm of unspecified site of left female breast, atrial fibrillation, acute kidney failure and pulmonary hypertension. Review of the quarterly Minimum Data Set (MDS) dated , 06/30/21, revealed Resident #18 was moderately cognitively impaired. The MDS did not reflect Resident #18 received hospice services. Review of the plan of care, revised on 06/30/21, revealed Resident #18's family planned for the resident to remain at the facility for long term care services and the resident was utilizing Hospice Agency #1. Interview on 09/01/21 at 10:29 A.M. of the Director of Nursing (DON) verified the MDS did not correctly reflect Resident #18's status for receiving hospice services.…

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 a residents care plan was reviewed and revised when a resident experienced multiple fall. This affected one (#1) out of 22 sampled residents care plans reviewed. The facility census was 53. Findings include: Review of the medical record revealed Resident #1 was admitted on [DATE]. Diagnoses included multiple fractures of ribs, right side, subsequent encounter for fracture with routine healing, anxiety disorder, muscle weakness, gastro-esophageal reflux, overactive bladder, atrial fibrillation, major depressive disorder, essential hypertension and weakness. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had moderate cognitive impairment with a BIMS of nine out of 15. Resident required extensive assist with one person assist for bed mobility, transfers, walking in room and corridor, toilet use, personal hygiene was total dependence for bathing with one person physical assist. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review observation, staff interview and review of facility policy, the facility failed to provide assistance to a resident who was dependent on staff for eating. This affected one (#18) of two residents reviewed for activities of daily living (ADL's). The facility census was 53. Findings include: Review of Resident #18's medical record revealed an admission date of 11/09/20. Diagnoses included Alzheimer's disease, unspecified; malignant neoplasm of unspecified site of left female breast; unspecified atrial fibrillation; acute kidney failure; and pulmonary hypertension. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #18 was moderately cognitively impaired and required extensive two person physical assistance with bed mobility and transfers and extensive one person assistance with eating, toilet use and personal hygiene. Review of the plan of care, revised on 02/14/21, revealed Resident #18 had an activities of daily living (ADL's) self care performance…

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 and staff interview, and review of a facility practice document, the facility failed to ensure residents received annual vision and hearing screenings. This affected two (#24 and #53) of three reviewed for vision and hearing services. The facility census was 53. Findings include: 1. Review of Resident #24's medical record revealed an admission date of 02/19/21. Diagnoses included chronic respiratory failure, major depressive disorder, chronic obstructive pulmonary disease, morbid obesity, and sleep apnea. Review of Resident #24's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #24 was cognitively intact. Resident #24 required extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. Resident #24 displayed no behaviors during the review period. Review of Resident #24's care plan revised 08/16/21 revealed Resident #24's hearing was within functional limits…

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 pressure relieving devices were in working condition. This affected one (#53) of three residents reviewed for pressure ulcer care. The facility census was 53. Findings include: Review of Resident #53's medical record revealed an admission date of 02/23/20. Diagnoses included acute kidney failure, cellulitis, persistent atrial fibrillation, stage three pressure ulcer of sacral region, spinal stenosis of the lumbar region without neurogenic claudication, peripheral vascular disease and chronic diastolic (congestive) heart failure. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #53 was cognitively intact, required extensive two person assist with Activities of Daily Living (ADL's) and had one stage four pressure ulcer. Review of the plan of care plan of care, revised on 02/24/20, revealed Resident #53 had a pressure ulcer on the coccyx. Interventions included pressure redistribution…

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, staff interview and policy review, the facility failed to ensure fall interventions were in place in accordance with a residents care plan. This affected one (#49) of five residents reviewed for falls. The facility census was 53. Findings include: Review of the medical record for Resident #49 revealed an admission date of 12/27/15. Diagnoses included unspecified non-displaced fracture of second cervical vertebra, subsequent encounter for fracture with healing, displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, muscle weakness, Alzheimer's Disease, cerebral infarction, chronic obstructive pulmonary disease, urge incontinence, essential hypertension, heart failure, personal history of malignant neoplasm of bladder, atherosclerotic heart disease of native coronary artery without angina pectoris and cognitive communication deficit. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure medications were administered per physician orders. This affected one (#38) of five residents reviewed for unnecessary medications. The facility census was 53. Findings include: Review of Resident #38's medical record revealed an admission date of 09/29/20. Diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease, dementia with behavioral disturbance, hypertension, and congestive heart failure. Review of Resident #38's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of Resident #38's care plan listed the resident as having impaired cognitive function related to dementia and Alzheimer's disease. Interventions included to administer medications as ordered. Review of Resident #38's physician order dated 09/29/20 revealed an order for Exelon patch 4.6 milligrams (mg's) per hour, apply one patch transdermally every 24 hours…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure resident pharmacy recommendations were addressed in a timely manner by the physician. This affected two (#18 and #13) of five residents reviewed for unnecessary medications. The facility census was 53. Findings include: 1. Review of Resident #13's medical record revealed an admission date of 02/19/21. Diagnoses included Alzheimer's disease, cognitive communication deficit, dysphagia, major depressive disorder, insomnia, anxiety disorder, and dementia. Review of Resident #13's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of eight out of 15 indicating Resident #13 was moderately cognitively impaired. Resident #13 required extensive assistance with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. Review of Resident #13's care plan revised 07/10/21 revealed supports and interventions for risk for wandering/elopement, risk for decrease…

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 residents were free from unnecessary medications when the facility failed to ensure as needed (PRN) psychotropic medications were limited to 14 days and renewal evaluation forms were completed for the continuation of use. In addition, the facility failed to ensure supporting diagnosis were included for the use of psychotropic medications. This affected three (#18, #49 and #13) of five residents reviewed for psychotropic medications. The facility census was 53. Findings Include: 1. Review of Resident #13's medical record revealed an admission date of 02/19/21. Diagnoses included Alzheimer's disease, cognitive communication deficit, dysphagia, major depressive disorder, insomnia, anxiety disorder, and dementia. Review of Resident #13's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of eight indicating Resident #13 was moderately cognitively impaired. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and resident and staff interview, the facility failed to ensure resident meal preferences were honored and alternates were offered. This affected two (#24 and #48) of eight residents reviewed for food concerns. The facility census was 53. Findings include: 1. Review of Resident #24's medical record revealed an admission date of 02/19/21. Diagnoses included chronic respiratory failure, major depressive disorder, chronic obstructive pulmonary disease, morbid obesity, and sleep apnea. Review of Resident #24's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating Resident #24 was cognitively intact. Resident #24 required extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. Resident #24 displayed no behaviors during the review period. Review of Resident #24's care plan revised 08/16/21 revealed Resident #24 was at risk for malnutrition and dehydration. Interventions…

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 maintain accurate medical records documentation regarding residents falls and/or transfer to the hospital. This affected two (#1 and #49) of five sampled residents reviewed for falls. The facility census was 53. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 01/30/21. Diagnoses included multiple fractures of ribs, right side, subsequent encounter for fracture with routine healing, anxiety disorder, muscle weakness, gastro-esophageal reflux, overactive bladder, atrial fibrillation, major depressive disorder, essential hypertension and weakness. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had moderate cognitive impairment with a BIMS of nine out of 15. Resident #1 required extensive assist with one person assist for bed mobility, transfers, walking in room and corridor, toilet use, personal hygiene was total dependence for bathing with one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and review of facility policy, the facility failed to offer influenza vaccination to residents. This affected one (#53) of five residents reviewed for immunizations. The facility census was 53. Findings include: Review of Resident #18's medical record revealed an admission date of 11/09/20. Diagnoses included Alzheimer's disease, unspecified; malignant neoplasm of unspecified site of left female breast; unspecified atrial fibrillation; acute kidney failure; and pulmonary hypertension. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #18 was moderately cognitively impaired. The MDS indicated Resident #18 was not offered the influenza vaccine. Review of Resident #18's immunizations in her electronic medical record (EMR) was silent for influenza vaccination. Interview on 09/01/21 at 10:29 A.M. with the Director of Nursing (DON), verified the facility did not have documentation Resident #18 was offered the influenza vaccination upon…

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.