Broadview Multi Care Center

Based on record review, observation and interview, the facility failed to provide a dignified dining experience for residents who required assistance with feeding. This affected one (Resident #21) of five residents observed for dining. Findings Include: Review of medical record for Resident #21 noted an admission date of 02/08/19. Diagnoses included multiple sclerosis, contracture to right and left elbow, right and left knee, and contracture of muscle, unspecified thigh. Review of the comprehensive Minimum Data Set assessment, dated 01/06/25, revealed Resident #21 had intact cognition and was dependent for eating. Review of the plan of care dated 02/11/19 noted Resident #21 had performance deficit related to multiple sclerosis and required assistance with feeding. Interventions included to provide extensive assistance with eating. Observations on 03/17/25 at 8:51 A.M. revealed Certified Nursing Assistant (CNA) #331 standing at the foot of the bed which was against the wall reaching over to feed Resident #21. Interview during the observations with CNA #331 revealed she was standing…

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 interviews and record review the facility failed to ensure resident concerns of missing items were addressed timely. This affected two of two residents reviewed for missing items (Resident #61 and #131). The facility census was 162. Findings Include: 1. Interview on 03/17/25 at 12:15 P.M. with Resident #61 revealed his licenses, social security card and birth certificate that he kept in a locked drawer were missing; he did not suspect theft. He reported the missing items to staff but nothing happened. Interview on 03/19/25 at 11:40 A.M. with Social Worker #411 revealed she was told by Resident #61 several months ago that he was missing his driver's license, social security card and birth certificate that he kept in a locked drawer. Social Worker #411 stated she filled out a concern form and told Resident #61 she would help him to get the items replaced and he declined. Interview on 03/19/25 at 3:50 P.M. with the Administrator revealed she had no knowledge of Resident #61 reporting missing items. The Administrator revealed upon receiving reports of missing items, staff 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, record review, staff interviews, and facility policy, the facility failed to ensure Resident #112 was placed on contact isolation precautions per the physician orders. This affected one resident (#112) out of four residents reviewed for isolation precautions and had the potential to affect all residents in facility. Total census was 162. Findings Include: Review of the medical record for Resident #112 revealed an admission date of 10/02/24 with diagnoses including paraplegia, protein calorie malnutrition, multiple pressure ulcers stage four, ureterostomy, neuromuscular dysfunction of bladder, and anxiety disorder. Observation on 03/18/25 at 4:30 P.M. revealed door signage of enhanced barrier precautions (EBP) in place for Resident #112. Review of medical record revealed an order for isolation was entered on 12/12/24 for contact precautions. Resident #112 was identified as a carrier for Acinetobacter baumannii (a highly resistant organism to antibiotics that can cause hospital-acquired infections as well as community infections in nursing homes). Interview 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.

Based on record review, observations, and interviews, the facility did not ensure food was served at palatable temperatures. This had the potential to affect 151 residents that received meals from the facility. Three residents (Resident #12, #48, and #116) out of 154 residents received nothing by mouth. The facility census was 154. Findings include: Interviews during the complaint investigation on 10/29/24, 10/30/24 and 10/31/24 during various hours from 7:45 A.M. through 4:00 P.M. with Residents #32, #119, #121, and #130 revealed that the food was cold and/or not palatable. Observation of tray line on 10/29/24 from 11:50 A.M. through 1:06 P.M. revealed food was above 165 degrees Fahrenheit (F) on the tray line. The food truck left the kitchen at 1:06 P.M. and arrived at the unit at 1:07 P.M. When the last tray on the truck was delivered on 10/29/24 at 1:15 P.M., the test tray was removed from the food cart and placed on a table where food temperatures were taken. The Corn flake crusted pork was 109 degrees Fahrenheit (F), and the cabbage was 116 degrees F. Registered Dietary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of a facility self- reported incident (SRI), review of facility investigation, review of facility policy, and staff interview, the facility failed to prevent the misappropriation of Resident #130's prescribed narcotics. This affected one resident (#130) of three residents reviewed for misappropriation. The facility census was 153. Findings include: Medical record review revealed Resident #130 was admitted to the facility on [DATE] with diagnoses to include but not limited to diabetes mellitus, bipolar disorder, anxiety disorder, and chronic pain. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/04/24, revealed Resident #130 had moderately impaired cognition, was on a pain regimen, and was dependent for activities of daily living. Review of Resident #130's plan of care dated 04/26/16 with a revision on 06/01/17 revealed Resident #130 was at risk for pain/discomfort related to a history of stroke, chronic colitis, chronic pain, and right hip pain. 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 observation, interview, and record review, the facility failed to provide residents with their preferences during meals. This affected two residents (#13 and #66) out of three residents (#13, #66, and #91) reviewed for diets and weight loss. The facility census was 154. Findings include: 1. Medical record review for Resident #13 revealed the resident was admitted to the facility on [DATE] with a readmit date of 07/25/23 and diagnoses including diabetes mellitus, chronic kidney disease and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/03/24, revealed the resident had intact cognition and required set up only for eating. Review of the October 2024 physician orders revealed that Resident #3 was ordered a regular diet with no restrictions and double portions of protein. Review of Resident #13's diet ticket revealed that he wanted triple portions of protein. Review of Resident #13's care plan dated 01/30/23 with a revision date of 01/31/24 revealed Resident…

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

Based on observation and interview the facility failed to provide a clean and sanitary environment. This affected five (#89, #110, #115, #134 and #180) residents and had the potential to affect all residents residing in the facility. The facility census was 178. Findings include: Observation on 06/17/24 at 6:38 A.M. revealed several dirty, moldy towels underneath an ice machine with puddles of water under the machine. Further observation revealed the floors around the ice machine were dirty with various debris. This was confirmed at time of observation with Licensed Practical Nurse (LPN) #465. Interview with LPN #465 at the time of the observation revealed she was aware of concerns related to housekeeping, especially on the weekends. On 06/17/24 at 6:44 A.M. a strong foul odor was noted outside of Resident #115's room. The origin of the odor was not determined; however, observation revealed a food tray on a wheelchair outside of Resident #134's room from the previous meal service. The floors in this area were dirty with various types of debris on them. The observations and odor 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure adequate and timely incontinence care. This affected two (#53 and #89) of four residents observed for incontinence care. The facility also failed to ensure adequate urinary catheter care. This affected two (#9 and #65) of two residents observed for urinary catheter care. The facility census was 178. Findings include: 1. Review of Resident #9's medical records revealed an admission date of 01/05/24. Diagnoses included neuromuscular bladder and stoke with left sided weakness. Review of Resident #9's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had intact cognition, was incontinent of bowel, and had a urinary catheter. Review of Resident #9's care plan dated 05/09/24 revealed Resident #9 was at risk for infection related to urinary catheter. Interventions included cleanse suprapubic catheter (catheter placed in the abdomen used to drain urine from the bladder) site with normal saline, apply mesalt (a dressing 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 interview, medical record review, and review of facility policy, the facility failed to ensure a restorative program was established for contracture management as recommended by therapy. This affected one (#110) of three residents reviewed for contracture management. The facility census was 178. Findings include: Review of the medical record for Resident #110 revealed diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, fibromyalgia, scoliosis, limitations of activities due to disability, and need for assistance with personal care. Review of physician's order dated 04/10/24 revealed apply left wrist brace at bedtime and remove in the morning for contracture prevention. Review of the Medicare Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #110 had severe cognitive impairment and was dependent on staff assistance for toilet hygiene, bathing, dressing, personal hygiene, and transfers. Review of the Nurse Practitioner…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure proper infection control techniques were used for residents on isolation precautions. This affected one (#146) of three residents observed for isolation precautions. The facility census was 178. Findings include: Review of Resident #146's medical records revealed an admission date of 06/05/24. Diagnoses included stoke with right sided weakness, need for personal care assistance and cognitive deficits. Review of Resident #146's care plan dated 06/05/24 revealed Resident #146 was incontinent of bowel and bladder. Interventions included check resident for incontinence and provide care as needed. Review of Resident #146's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #146 had impaired cognition. Resident #146 was incontinent of bowel and bladder. Review of Resident #146's progress note dated 06/19/24 revealed a stool sample was obtained to test for Clostridioides difficile (C-diff), a bacterial infection. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure sufficient staffing to timely transfer residents who required two person Hoyer lift assistance. This affected Resident #22 and had the potential to affect all eleven residents (Resident's #5, #22, #45, #69, #71, #76, #78, #87, #103, #143, #167) residing on the nursing unit who required a mechanical lift for transfers. Findings include: Review of Resident #22's medical record revealed an admission date of 10/23/23 and diagnoses included hydronephrosis with renal and ureteral calculous obstruction, type two diabetes mellitus with diabetic neuropathy, muscle weakness, and difficulty in walking. Review of Resident #22's care plan dated 10/03/23 included Resident #22 had an ADL (Activity of Daily Living) self-care deficit related to weakness, impaired mobility. Resident #22 would improve current functional status related to ADL's. Interventions included to provide total assist with transfer (chair to bed to chair transfer, shower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy the facility failed to ensure sufficient staffing to meet the behavioral health needs of the residents. This affected Resident's #76 and #101 and had the potential to affect all 31 residents residing on their nursing unit. The census was 175. Findings include: 1. Review of Resident #101's medical record revealed an admission date of 01/05/24 and diagnoses included vascular dementia, hemplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting left non-dominant side, and schizophrenia. Resident #101 resided on Rosepointe B unit. Review of Resident #101's care plan revised 04/09/24 included Resident #101 demonstrated socially inappropriate behaviors, verbally inappropriate towards staff, observed Resident #101 placing self on floor, crawling on floor, and was hard to redirect. Resident #101's dignity would be honored AEB (as evidenced by) Resident #101's needs would be honored daily by next review date.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #22 was assisted into bed timely after returning from an appointment. This affected one resident (Resident #22) and had the potential to affect eleven residents (Resident's #5, #22, #45, #69, #71, #76, #78, #87, #103, #143, #167 residing on the nursing unit who required a mechanical lift for transfers. The facility census was 175. Findings include: Review of Resident #22's medical record revealed an admission date of 10/23/23 and diagnoses included hydronephrosis with renal and ureteral calculous obstruction, type two diabetes mellitus with diabetic neuropathy, muscle weakness, and difficulty in walking. Review of Resident #22's care plan dated 10/03/23 included Resident #22 had an ADL (Activity of Daily Living) self-care deficit related to weakness, impaired mobility. Resident #22 would improve current functional status related to ADL's. Interventions included to provide total assist 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 interview, record review and review of facility policy the facility failed to ensure Resident #176's physician orders were followed for treatments to her left above the knee amputation stump. This affected one resident (Resident #176) out of three residents reviewed for treatments. The facility census was 175. Findings include: Review of Resident #176's medical record revealed an admission date of 03/22/24 and diagnoses included encounter for orthopedic aftercare following surgical amputation, dehiscence of amputation stump, acquired absence of left leg above knee, and encounter for surgical aftercare following surgery on the skin and subcutaneous tissue. Resident #176 was discharged from the facility on 04/08/24. Review of Resident #176's hospital After Visit Summary discharge instructions revealed she had a hospital admission from 03/14/24 through 03/22/24. Resident #176's principal diagnosis was incision and drainage abscess, thigh or knee region. Resident #176 had an amputation stump infection.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of facility policy, the facility failed to ensure Resident #47's urine culture result report was reported timely to the physician, and failed to ensure Resident #10 and Resident #47 received appropriate incontinence care timely. This affected two residents (Resident #10 and #47) out of three reviewed for incontinence. The facility census was 175. Findings include: 1. Review of Resident #47's medical record revealed an admission date of 11/09/22 and diagnoses included chronic respiratory failure with hypoxia, metabolic encephalopathy, and acute pancreatitis without necrosis or infection. Review of Resident #47's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #47 was cognitively intact. Resident #47 was always incontinent of urine and bowel. Review of Resident #47's progress notes dated 04/10/24 through 04/24/24 did not reveal evidence Resident #47 requested two incontinence briefs or an incontinence brief and a liner, or the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of the facility policy and review of hospital records the facility failed to ensure Resident #142 received incontinence care timely, failed to ensure Resident #9 received services to care for his suprapubic catheter, and failed to ensure Resident's #76 and #93 received appropriate incontinence care. This affected three residents (Resident's #76, #93, #142) out of five residents reviewed for incontinence care and one resident (Resident #9) out of three residents reviewed for catheter care. The facility census was 170. Findings include: 1. Review of Resident #142's medical record revealed an admission date of 01/15/23 and diagnoses included congestive heart failure, drug-induced systemic lupus erythematosus, and schizophrenia. Review of Resident #142's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #142 had moderate cognitive impairment. Resident #142 was dependent on staff for toileting, bathing and personal hygiene. Resident…

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

Based on observation, record review, review of email, review of facility policy the facility failed to ensure Resident's #104, #124 and #149 were provided milk that is palatable. This is affected three residents (Resident's #104, #124 and #149) and had the potential to affect all 166 residents who dined in the facility. The facility census was 170. Findings include: Review of Resident #149's medical record revealed an admission date of 07/01/21 and diagnoses include quadriplegia, chronic respiratory failure with hypoxia or hypercapnia, and type two diabetes mellitus. Review of Resident #149's physician orders dated 02/03/24 revealed regular diet, regular texture, thin consistency. Review of Resident #149's Quarterly Minimum Data Set (MDS) 3.0 assessment revealed Resident #149 was cognitively intact. Review of Resident #104's medical record revealed an admission date of 04/27/23 and diagnoses included heart failure, antiphospholipid syndrome and moderate protein-calorie malnutrition. Review of Resident #124's medical record revealed an admission date of 12/20/23 and diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of the facility policy the facility failed to ensure Resident #93's resident representative was notified of a change of condition. This affected one resident (Resident #93) out of three residents reviewed for resident representative notification. The facility census was 170. Findings include: Review of Resident #93's medical record revealed an admission date of 11/21/23 and diagnoses included end stage renal disease, dependence on renal dialysis, and encephalopathy. Resident #93 was transported to the hospital on [DATE] and passed away at the hospital on [DATE]. Review of Resident #93's medical record profile notes dated 11/21/23 revealed Resident #93's Emergency Contact Number One (EC1) #533 was her friend. Review of Resident #93's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #93 had moderate cognitive impairment. Resident #93 required supervision or touching assistance with Activity of Daily Livings's and required partial to…

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

Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident's #104 and #124 had a clean, sanitary and homelike environment. This affected two residents (Resident's #104 and #124) out of three reviewed for clean, sanitary environment. The facility census was 170. Findings include: Review of Resident #149's medical record revealed an admission date of 07/01/21 and diagnoses include quadriplegia, chronic respiratory failure with hypoxia or hypercapnia, and type two diabetes mellitus. Review of Resident #149's Quarterly Minimum Data Set (MDS) 3.0 assessment revealed Resident #149 was cognitively intact. Review of Resident #104's medical record revealed an admission date of 04/27/23 and diagnoses included heart failure, antiphospholipid syndrome and moderate protein-calorie malnutrition. Interview on 03/26/24 at 4:57 P.M. with Resident #149 revealed the room he shared with Resident #104 was not very clean. Interview on 03/26/24 at 5:00 P.M. with Resident #104 revealed he was very unhappy the room was dirty and needed cleaned.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, review of hospital records and review of the facility policy the facility failed to ensure Resident #93's central venous catheter dressing was changed and failed to ensure physician orders were obtained for the care of Resident #93's central venous catheter. This affected one resident (Resident #93) out of three residents reviewed for dressing changes. The facility census was 170. Findings include: Review of Resident #93's medical record revealed an admission date of 11/21/23 and diagnoses included end stage renal disease, dependence on renal dialysis, and encephalopathy. Resident #93 was transported to the hospital on [DATE] and passed away at the hospital on [DATE]. Review of Resident #93's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #93 had moderate cognitive impairment. Resident #93 required supervision or touching assistance with Activity of Daily Livings's and required partial to moderate assistance with bathing. Resident #93 was always…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of the facility policy the facility failed to thoroughly assess Resident #93's condition prior to dialysis treatment and failed to ensure Resident #93 was transported to the hospital timely when her dialysis catheter was not functioning and she could not receive renal dialysis. This affected one (Resident #93) of three residents reviewed for dialysis. The facility census was 170. Findings include: Review of Resident #93's medical record revealed an admission date of 11/21/23 and diagnoses included end stage renal disease, dependence on renal dialysis, and encephalopathy. Resident #93 was transported to the hospital on [DATE] and passed away at the hospital. Review of Resident #93's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #93 had moderate cognitive impairment. Resident #93 required supervision or touching assistance with Activity of Daily Livings's and required partial to moderate assistance with bathing. Resident #93 was always…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to ensure physician's orders were followed for Resident #187. This affected one resident (#187) of three residents reviewed for admission and discharge procedures. The facility census was 187. Findings include: Review of the medical record for Resident #187 revealed an admission date of 11/11/23 and a discharge date of 11/22/23. Diagnoses included dementia, chronic kidney disease, heart failure, fracture of the right shoulder, depression, and arthritis. Review of the comprehensive Minimum Data Set (MDS)assessment dated [DATE] revealed Resident #187 was cognitively intact. She required some substantial/maximum assistance for eating and oral hygiene and was dependent for toileting, showering, hygiene, and upper and lower body dressing. She had an impairment to her upper extremity on one side. Review of the hospital discharge instructions provided to the facility dated 11/11/23 revealed Resident #187 had an appointment on 11/13/23 to…

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

Based on observation and interview the facility failed to provide a clean and sanitary environment. This had the potential to affect all residents residing in the facility. The facility census was 171. Findings include: Observation on 11/20/23 at 8:04 A.M. revealed Resident #162 was in a wheelchair in her room. Observation of the room revealed various debris and a pile of dirty linen on the floor. Resident #162 was not interviewable. Observation on 11/20/23 at 8:20 A.M. revealed Residents #15 and #49 were sleeping in bed. Observation of the room revealed various debris on the floor. Interview on 11/20/23 at 9:03 A.M. with the Administrator revealed the previous housekeeping supervisor had recently walked out of the facility and she promoted a staff member to the housekeeping supervisor position. Observation of Resident #111's room on 11/20/23 at 10:07 A.M. revealed a large red splatter on the wall and the bathroom door. Interview with Resident #111 at time of observation revealed she had rolled over a ketchup packet a few weeks ago and it splattered on the door and wall. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure medications were administered with an error rate of less than five percent. A total of four errors out of 25 opportunities for error were observed resulting in a 16 percent medication error rate. This affected one resident (#117) of two (#104 and #117) observed for medication administration. The facility census was 171. Findings include: Review of Resident #117's medical records revealed an admission date of 11/18/18. Diagnoses included convulsions, stroke with right sided weakness and aphasia (difficulty speaking). Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #117 had intact cognition. Resident #117 required extensive assistance with bed mobility, personal hygiene and toileting. Review of the current physician orders for November 2023 revealed Resident #117 was ordered levetiracetam (seizure medication) extended release 500 milligrams (mg) two times a day, amantadine (seizure medication) 100 mg once a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure medications were not left unattended at the residents bedside. This affected one resident (#149) of three (#104, #117 and #149) observed for unattended medications. The facility census was 171. Findings include: Review of Resident #149's medical records revealed an admission date of 08/30/21. Diagnoses included chronic pain, high blood pressure and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #149 had intact cognition. Resident #149 required partial assistance with toileting, bathing and personal hygiene. Observation on 11/20/23 at 10:33 A.M. revealed Resident #149 was asleep in bed with his blanket pulled up over his head. Further observation revealed a medication cup that contained nine unidentified medications on Resident #149's breakfast tray. The observation was confirmed by Licensed Practical Nurse (LPN) #336 who stated medications should not be left unattended in resident rooms. LPN #336 awakened…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of the facility policy the facility failed to ensure Resident #190's significant weight gain was evaluated timely, the facility failed to ensure Resident #190 was administered medication for loose watery stools per physician order and the facility failed to ensure Resident #190's abdominal circumference measurements were addressed. This affected one resident (Resident #190) out of three residents reviewed for quality of care. The facility census was 166. Findings include: Review of Resident #190's medical record revealed an admission date of 06/11/23 and diagnoses included unspecified diastolic (congestive) heart failure, Parkinson's Disease, unspecified atrial fibrillation, dehydration and type two diabetes mellitus. Resident #190 was transported to the local hospital and discharged from the facility on 07/09/23. Review of Resident #190's care plan dated 06/14/23 included Resident #190 was at risk for fluid imbalance related to altered oral intake, acute kidney…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy the facility failed to ensure a medication error rate of less than five percent during Resident #102's medication administration observation. This affected one resident (Resident #102) out of five residents reviewed for medication administration. There were 31 opportunities for error, administered by two nurses, two errors were made, and the medication error rate was 6.45 percent. The facility census was 166. Findings include: Review of Resident #102's medical record revealed an admission date of 03/18/22 and diagnoses included heart failure, type two diabetes mellitus, and irritable bowel syndrome. Review of Resident #102's physician orders dated 06/03/23 revealed Humalog Injection Solution 100 units per milliliter (ml), inject subcutaneously before meals and bedtime for diabetes. Review of Resident #102's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #102 was cognitively intact. Resident #102…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure Resident #190's medical record had accurate and thorough documentation regarding physician ordered lab work. This affected one resident (Resident #190) out of three residents reviewed for documentation in the medical record. The facility census was 166. Findings include: Review of Resident #190's medical record revealed an admission date of 06/11/23 and diagnoses included unspecified diastolic (congestive) heart failure, Parkinson's Disease, unspecified atrial fibrillation, dehydration and type two diabetes mellitus. Resident #190 was transported to the local hospital and discharged from the facility on 07/09/23. Review of Resident #190's care plan dated 06/14/23 included Resident #190 was at risk for fluid imbalance related to altered oral intake, acute kidney failure and congestive heart failure. Resident #190 would remain free of signs and symptoms of fluid overload as evidenced by and including a decrease in or absence of edema, anxiety,…

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

Based on observation, record review and interview the facility failed to maintain Resident #146's wheelchair in good repair. This affected one resident (#146) of seven sampled residents requiring the use of a wheelchair. Findings include: Review of Resident #146's Minimum Data Set (MDS) 3.0 assessment, dated 07/03/19 revealed the resident had mild cognitive impairment and was alert to self and others with periods of forgetfulness, confusion and disorientation. Resident #146 was assessed to have functional impairment of both upper and lower extremities related to Parkinson's disease and required the total assistance of one to two staff for transfers and locomotion on and off the unit. Observation of Resident #146 on 07/29/19 at 11:40 A.M. revealed the resident was seated in a tilt in space wheelchair with her feet propped on pillows on top of a foot stool. The right-side foot rest was not attached to the wheelchair and the area where the foot rest attached appeared to have been sheared off. An interview with State tested nursing assistant (STNA) #811 on 07/29/19 at 11:45 A.M.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure one resident (Resident #172) was provided adequate assistance with meals as recommended by therapy staff. This affected one (#172) of six residents reviewed for assistance with nutrition. Findings include: Review of Resident #172's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including heart failure, unspecified dementia without behavioral disturbance and unspecified glaucoma. Review of Resident #172's current nutritional care plan revealed an intervention initiated 02/07/13 for staff to assist the resident at meals as needed. Review of Resident #172's current activities of daily living (ADL) care plan revealed an intervention initiated 07/13/15 for meals to be in the dining room with an overbed table related to positioning. Review of the Occupational Therapy (OT) Evaluation and Plan of Treatment form, dated 06/27/19 revealed the current referral indicated the resident was referred to OT…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure Resident #93, who was dependent on staff for activities of daily living received timely and adequate showers per the resident's choice and the facility shower schedule. This affected one resident (93) of three residents reviewed for choices. Findings include: Review of Resident #93's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, contracture of the left hand, hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side. Review of Resident #93's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition and was totally dependent with one person physical assist for bathing. Review of nurse aide documentation revealed Resident #93 was scheduled for showers Wednesday and Saturday on the 3:00 P.M. to 11:00 P.M. shift. Review of Resident #93's medical record, shower…

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

Based on observation, record review and interview the facility failed to ensure Resident #62's oxygen tubing was maintained in a clean manner. This affected one resident (#62) of two residents reviewed with oxygen therapy. Findings include: Review of Resident #62's medical record revealed an initial admission date of 04/05/18 with diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure, interstitial pulmonary disease. The annual Minimum Data Set (MDS) 3.0 assessment, dated 06/01/19 revealed the resident had impaired cognition and required extensive assistance of two staff for bed mobility, total dependence of two staff for transfers, and supervision of one staff for eating. Review of the July 2019 physician orders revealed a respiratory order for Airvo2 high flow system every shift related to chronic obstructive pulmonary disease and chronic respiratory failure. Observation on 07/29/19 at 3:15 P.M. of Resident #62 revealed the resident laying in bed with a nasal cannula in his nose and the length of the oxygen tubing connected to the oxygen…

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

Based on observation, record review and interview the facility failed to use appropriate hand washing and change gloves during medication administration for Resident #93 to prevent the spread of infection. This affected one resident (#93) of two residents sampled during medication administration. Findings include: During an observation of medication administration on 07/30/19 at 7:36 A.M., Licensed Practical Nurse (LPN) #809 was observed to enter Resident #93's room with artificial tears eye drops, and prepared oral medications. LPN #809 performed hand washing, placed gloves on both hands and placed one drop of artificial tears into each of Resident #93's eyes. Following the administration, LPN #809 offered a tissue to the resident, elevated the head of Resident #93's bed using the bed remote and then administered Resident #93's oral medications. With the same gloved hands, LPN #809 then obtained an enteral tube syringe, removed Resident #93's gastrostomy tube (G-tube) from under the blanket, checked the G-tube for placement, obtained water from the sink in a cup, gravity flushed…

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.