Tuscany Gardens

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review the facility failed to ensure Resident #4 and Resident #99 had accurate Minimum Data Set (MDS) assessments. This affected two (Resident #4 and #99) of 34 medical records reviewed. The facility census was 99.Findings include:1. Review of the medical record for Resident #4 revealed an initial admission date of 12/13/23 with the latest readmission date of 06/22/25 with the diagnoses including but not limited to diabetes mellitus, neuromuscular dysfunction of bladder, hypertension, hyperlipidemia, hypothyroidism, depression, anxiety, congestive heart failure, cerebral infarct, pressure ulcer and chronic obstructive pulmonary disease. Review of the plan of care dated 06/16/25 revealed the resident had an alteration in skin integrity as evidenced by pressure ulcer to left buttocks. Interventions included assess area for size, color, drainage weekly and as needed, assess condition of skin/dressings as needed, assess for pain and provide treatment per physician order, body…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure timely follow-up for Resident #6's level II Preadmission Screening and Resident Review (PASARR) evaluation. This affected one (Resident #6) out of one resident reviewed for PASARRs. The facility census was 99.Findings include:Review of the medical record for Resident #6 revealed an admission date of 08/05/24 with diagnoses that included paraplegia, hereditary and idiopathic neuropathy, injury of urethra, schizoaffective disorder, and post-traumatic stress disorder.Review of the annual Minimum Data Set (MDS) 3.0 assessment for Resident #6 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.Review of the medical record chart for Resident #6 revealed the PASARR indicated the need for a level II evaluation, but there was no documented evaluation or attempt in the medical chart for the level II evaluation.Interview on 09/16/25 at 3:35 P.M. with Social Worker (SW) #583 verified that another staff member,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, and staff interview, the facility failed to develop and implement a comprehensive care plan addressing Resident #8's contractures. This affected one (Resident #8) out of nine residents reviewed for activities of daily living. The facility census was 99.Findings include:Review of the medical record chart for Resident #8 revealed an admission date of 01/22/22 with diagnoses that included type II diabetes, dementia, psychotic disturbance, mood disturbance, anxiety, secondary parkinsonism, stiffness of unspecified joint, and schizoaffective disorder.Review of the 5-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 09 out of 15, indicating impaired cognition. The assessment documented that the resident had impairments in both upper extremities and was maximally dependent for upper extremity dressing. The resident was also dependent on staff for rolling left and right in bed and required 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, record review, staff interview, and resident interview, the facility failed to provide appropriate Activities of daily living (ADL) care for resident's dependent on staff. This affected two (Residents #8 and #70) out of 9 residents reviewed for ADLs. The facility census was 99. Findings include: 1. Review of the medical record for Resident #8 revealed an admission date of 01/10/22 with diagnoses including urinary tract infection, chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, and morbid (severe) obesity due to excess calories. Review of the 5-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 09 out of 15, indicating impaired cognition. The assessment documented that the resident had impairments on both upper extremities, was dependent on staff for personal care tasks including eating, oral hygiene, toileting, bathing, and dressing, and was dependent for rolling and transfers. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, hospice record review and interview, the facility failed to ensure hospice information, including the hospice certification and plan of care for certification was up to date and available at the facility. This affected one resident (#44) of one resident reviewed for hospice services. The facility census was 99. Findings Include:Review of the medical record for Resident #44 revealed an initial admission date of [DATE] with the diagnoses including but not limited to chronic obstructive pulmonary disease, pulmonary embolism, congestive heart failure, hypertension, chronic kidney disease, hyperlipidemia, gastro-esophageal reflux disease, osteoarthritis, constipation, hypothyroidism, anxiety disorder and chronic respiratory failure. Review of the plan of care dated [DATE] revealed the resident received hospice services for end stage chronic respiratory failure with hypoxia. Interventions included follow physician's orders and Resident's advanced directives, hospice services as ordered,…

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, interview and facility policy review, the facility failed to comprehensively assess pressure ulcers/injury upon admission/readmission to the facility. This affected two residents (#2 and #4) of seven residents reviewed for pressure ulcers. The facility census was 99.Findings include:1. Review of the medical record for Resident #2 revealed an initial admission date of 02/02/24 with the latest readmission date of 06/30/25 with the diagnoses including but not limited to acute myocardial infarction, acute respiratory failure with hypoxia, diabetes mellitus, dysphagia, atrial fibrillation, congestive heart failure, anxiety disorder, depression, sleep apnea, pressure ulcer, sick sinus syndrome, obstructive and reflux uropathy and gastrostomy status. Review of the plan care dated 04/15/25 revealed the resident had an alteration in skin integrity as evidenced by a pressure ulcer to the coccyx. Interventions included assess area for size, color, drainage weekly and as needed,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interview, the facility failed to monitor and provide timely follow-up for Resident #8's bilateral wrist contractures. This affected one (Resident #8) out of two residents reviewed for mobility and range of motion. The facility census was 99.Findings include:Review of the medical record for Resident #8 revealed an admission date of 01/10/22 with diagnoses including type 2 diabetes mellitus without complications, dementia, psychotic disturbance, mood disturbance, anxiety, secondary parkinsonism, stiffness of joint, and schizoaffective disorder.Review of the 5-day Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 09 out of 15, reflecting impaired cognition. The MDS documented dependency on staff for personal care including eating, oral hygiene, toileting, bathing, and dressing, and full or partial dependence for transfers, rolling, and mobility. The resident's care plan did not address management of bilateral wrist…

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 interviews, medical record review to include hospital records, progress notes, and urology notes, and facility policy review, the facility failed to properly and safely maintain urinary catheters to include the timely address of urology recommendations for one resident's suprapubic catheter. This affected two residents (#60 and #81) of six residents reviewed for catheter care. The facility census was 99.Findings include:1.Review of the medical record for Resident #60 revealed an admission date of 09/04/24. Diagnoses included but not limited to sepsis, A-fib, paranoid schizophrenia, muscle weakness, need for assistance with personal care, dysphagia, mild cognitive impairment, depression, hypothyroidism, hyperlipidemia, acute respiratory failure, retention of urine, s/s concerning food and fluid intake, neuromuscular dysfunction of bladder, primary hypertension, abnormalities of gait and mobility. Review of the most recent Minimum Data Set (MDS) assessment, dated 09/03/25, 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 observation, medical record review and interview, the facility failed to ensure residents were provided adaptive equipment to promote independence with eating. Additionally, the facility failed to ensure food residents disliked were not served to residents. This affected one resident (#79) of four residents reviewed for nutrition. The facility census was 99.Findings Include:Review of the medical record for Resident #79 revealed an initial admission date of 10/16/19 with the latest readmission of 11/30/24 with the diagnoses including but not limited to cerebral palsy, chronic respiratory failure, chronic pain syndrome, protein calorie malnutrition, anemia, anxiety disorder, gastro-esophageal reflux disease and neuropathy. Review of the plan of care dated 10/25/19 revealed the resident had the potential for alteration in nutrition and hydration related to malnutrition, dysphagia, cerebral palsy, history of gastrointestinal bleed and anxiety. Interventions included adaptive equipment as ordered, honor food…

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, interviews and review of resident meal ticket, the facility failed to meet the nutritional needs of one resident. This affected one resident (#79) of four residents reviewed for nutrition. The facility census was 99.Findings Include:Review of the medical record for Resident #79 revealed an initial admission date of 10/16/19 with the latest readmission of 11/30/24 with the diagnoses including but not limited to cerebral palsy, chronic respiratory failure, chronic pain syndrome, protein calorie malnutrition, anemia, anxiety disorder, gastro-esophageal reflux disease and neuropathy. Review of the plan of care dated 10/25/19 revealed the resident had the potential for alteration in nutrition and hydration related to malnutrition, dysphagia, cerebral palsy, history of gastrointestinal bleed and anxiety. Interventions included adaptive equipment as ordered, honor food preferences as able, medications as ordered, monitor consistency of diet served, obtain food preferences,…

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 and staff interview, the facility failed to ensure adequate bath linens were available as needed for resident care. This had the potential to affect 48 (#2, #3, #7, #8, #12, #13, #14, #15, #19, #22, #23, #24, #29, #32, #33, #35, #37, #39, #41, #42, #43, #44, #47, #51, #52, #53, #54, #61, #65, #69, #70, #72, #74, #75, #79, #82, #87, #88, #89, #91, #95, #96, #99, #100, #101, #105, #107, and #108) residents residing on the 400 and 500 units of 110 total residents in the facility. The census was 110.Findings Include:Observations on 07/23/25 from 8:00 A.M. to 12:30 P.M. revealed the following there were no washcloths available for resident care in either of the clean linen closets on the 400 unit and there were only five (5) towels available for resident care on the 500 unit.Interview with Laundry/Housekeeping Supervisor (LHS) #107 on 07/23/25 at approximately 9:00 A.M. confirmed the 400 unit had no washcloths and stated there should always be washcloths and towels in the clean linen closet for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of an incident report, staff interview, and facility policy review, the facility failed to complete a thorough investigation to determine potential neglect of a resident. This affected one (#114) of three residents reviewed for neglect. The census was 110.Findings Include:Review of the medical record revealed Resident #114 was admitted to the facility on [DATE]. Diagnoses included urinary tract infection, enterocolitis, pulmonary fibrosis, muscle weakness, difficulty walking, cognitive communication deficit, morbid obesity, obstructive sleep apnea, major depressive disorder, hereditary and idiopathic neuropathy, repeated falls, hypocalcemia, hyperkalemia, acute kidney failure, hypertension, obstructive and reflux uropathy, chronic obstructive pulmonary disease, atherosclerotic heart disease, and lymphedema. Review of Resident #114's Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident was cognitively intact.Review of Resident #114 progress notes dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to complete the physician order for a urine culture in an appropriate timeframe for one (#27) of three residents reviewed for orders for urine cultures. The facility census was 110. Findings include:Record review for Resident #27 revealed the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia, hemiparesis, chronic pulmonary obstructive disease (COPD), history of urinary tract infections (UTIs), and pyonephrosis.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. The resident was assessed to require staff assistance with bathing, dressing and grooming.Review of the care plan dated 06/24/25 revealed Resident #27 was at risk for infection related to a history of UTIs. Interventions included completing laboratory values as ordered and notifying the provider of abnormal results.Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and resident interview,the facility failed to protect the resident from abuse by staff. This affected one (Resident #54) of four resident records reviewed for abuse. The census was 105. Findings include: Review of Resident #54's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, morbid obesity, major depression, peripheral vascular disease, anxiety, reduced mobility and anxiety. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed her cognition was intact. She required set up or clean up assistance with oral hygiene, she is dependent for toileting, and requires substantial/maximal assistance for shower/bathing, dressing, personal hygiene and turning and repositioning. She is always incontinent of urine and frequently incontinent of bowel. Review of the plan of care she experiences alteration in mood and/or behavior as evidenced by resident has diagnoses of…

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

Based on medical record review, resident interview, and staff interview, the facility failed to ensure residents were provided with necessary transportation to attend outside appointments as scheduled. This affected one (Resident #150) of three residents reviewed for transportation to outside appointments. The facility census was 112 residents. Findings include: Review of the medical record for Resident #150 revealed an admission date of 09/17/20 and a readmission date of 11/30/22 with diagnoses including unspecified injury at T2-T6 level of thoracic spinal cord, morbid obesity due to excess calories, bipolar disorder, anxiety disorder, paraplegia, unspecified mood (affective) disorder, and depression. Review of the care plan for Resident #150 initiated 11/30/22 revealed the care plan did not address the resident's need for transportation to outside appointments. Review of the Minimum Data Set (MDS) assessment for Resident #150 dated 10/09/24 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs). Interview on 12/12/24 at 4:23…

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 medical record review the facility failed to report an allegation of resident-to-resident sexual abuse. This affected one (Resident #12) of three residents reviewed for abuse. The facility census was 112. Findings include: Review of the medical record for Resident #12 revealed an admission date of 01/24/2021. Diagnoses included dementia, unspecified sequelae of cerebral infarction, and moderate protein calorie malnutrition. Review of Resident #12's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had a memory problem and had severe cognitive impairment. Review of Resident #12's nursing progress noted from 04/2024 revealed nothing related to inappropriate resident contact. Review of Resident #16's medical record revealed an admission date 07/01/23. Diagnoses included dementia, hypertension, and primary open-angled glaucoma. His April 2024 orders revealed an order for a Wandergaurd to is right ankle. Review of his quarterly MDS assessment dated [DATE] revealed a moderate…

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 medical record review the facility failed to thoroughly investigate an allegation of resident-to-resident sexual abuse. This affected one (Resident #12) of three residents reviewed for abuse. The facility census was 112. Findings include: Review of the medical record for Resident #12 revealed admission date of 01/24/2021. Diagnoses include dementia, unspecified sequelae of cerebral infarction, and moderate protein calorie malnutrition. Review of Resident #12's quarterly Minimum Data Set assessment dated [DATE] revealed she had a memory problem and had severe cognitive impairment. Review of Resident #12's nursing progress noted from 04/2024 revealed nothing related to inappropriate resident contact. Review of Resident #16's medical record revealed an admission date 07/01/23. Diagnoses included dementia, hypertension, and primary open-angled glaucoma. His April 2024 orders revealed an order for a Wandergaurd to is right ankle. Review of his quarterly MDS assessment dated [DATE] revealed 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 interview and record review the facility failed to ensure an investigation and appropriate corrective action was implemented after staff used a mechanical lift incorrectly. This affected one (Resident #13) of three residents reviewed for accidents. The facility census was 112. Findings include: Review of the medical record for Resident #13 revealed an admission date of 11/05/2022. Diagnosis included hemiplegia and hemiparesis following a cerebral infarction, stiffness of the left hip, ataxia, and Moyamoya. Review of Resident #13's physician orders revealed an order dated 02/28/23 that stated the facility may utilize Hoyer lift for transfers as needed for weakness/difficulty transferring. Review of Resident #13's progress notes from 03/01/24 through 03/31/24 revealed no notes related to the incident. A note on 03/11/2024 at 10:18 P.M. revealed that neurological (Neuro) checks continue as ordered. Review of her Quarterly Minimum Data Set (MDS) dated [DATE] revealed she has intact cognition and required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of manufacture guidelines the facility failed to remove five expired tuberculin (TB) solution vials from circulation. This had the potential to affect all 108 residents residing in the facility. The facility census was 108. Findings Include: Observation on [DATE] at 1:20 P.M. of unit 400 medication storage refrigerator revealed an opened Aplisol tuberculin (TB) solution vial received from pharmacy on [DATE] with an opened date of [DATE]. Registered Nurse (RN) #212 confirmed the expired opened Aplisol TB solution vial. Observation on [DATE] at 1:30 P.M. of unit 200 medication storage refrigerator revealed an opened Aplisol TB solution vial received from the pharmacy on [DATE] with no opened date. Further observation revealed another opened Aplisol TB solution vial received from the pharmacy on [DATE] with no opened date. Registered Nurse (RN) #282 confirmed the two opened expired Aplisol TB solution vials. Observation on [DATE] at 1:42 P.M. of unit 300 medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to implement infection control measures for the cleaning of glucometers (blood sugar meters) and proper hand hygiene during wound dressing change procedures. This affected two residents (Residents #26 and #108) out of eleven residents requiring blood sugar checks on Units 200 and 300, and one resident (Resident #6) out of three residents reviewed for skin pressure injuries. The facility census was 108. Findings Include: 1. Review of Resident #108's medical record revealed Resident #108 was admitted to the facility on [DATE] with the admitting diagnoses including Diabetes Mellitus type two, high blood pressure, hypothyroidism, and weakness. Resident #108 required limited assistance from staff for activities of daily living (ADL) tasks. Review of Resident #108 signed physician orders revealed an order dated 11/01/23 for Novolog Insulin 100 unit per milliliter administered four times daily per blood sugar check results.…

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, observation of wound care, and facility policy review, the facility failed to ensure resident room door and window blind was closed during wound care. This affected one (Resident #6) of one resident reviewed for privacy during wound care. The facility census was 108. Findings include: Review of the medical record review for Resident #6 revealed an admission date of 05/19/23. Diagnoses included heart failure, peripheral vascular disease (PVD), and primary osteoarthritis. Review of Resident #6's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 06 out of 15 indicating the resident had a severely impaired cognition for daily decision making abilities. Resident #6 was noted to have one unstageable pressure ulcer, one stage II pressure ulcer, and three venous and arterial ulcers. Review of Resident #6's treatment orders dated 01/07/24 revealed the following treatment to be completed, Right upper…

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, resident representative and staff interviews, review of laboratory test results, and facility policy review, the facility failed to notify one resident's representative (Resident #7) of laboratory test results. The facility also failed to notify one resident's (Resident #7) physician/nurse practitioner/physician assistant or resident representative a lab was not completed as ordered. This affected one (Resident #7) of one reviewed for notification of change. The facility census was 108. Findings Include: Review of the medical record for Resident #7 revealed an admission date on 11/16/21. Medical diagnoses included spinal stenosis, chronic obstructive pulmonary disease (COPD), chronic kidney disease Stage 3, and dysphagia (difficulty swallowing) oropharyngeal phase. Review of the emergency contacts for Resident #7 revealed the resident's daughter (Daughter #301) was the resident's primary emergency contact and the resident's Durable Power of Attorney (DPOA). Review of the annual Minimum Data Set (MDS) 3.0 assessment revealed Resident #7 had impaired cognition…

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 facility policy review, the facility failed to implement preventative skin interventions to prevent repeated skin infections for Resident #85. Additionally, the facility failed to timely assess a bruise for one resident (Resident #4) and failed to implement physician order for a back brace for one resident (Resident #96). This affected two residents (Resident #4 and #85) out of four residents reviewed for skin integrity and one resident (Resident #96) out of three residents reviewed for positioning devices. The facility census was 108. Findings Include: 1. Review of the medical record for Resident #85 revealed Resident #85 was admitted to the facility on [DATE] with admitting diagnoses including Huntington's Disease, depressive disorder, disorders of the bladder, overactive bladder, impaired communication, and anxiety. Resident #85 required assistance from staff for activities of daily living (ADL) tasks. Review of Resident #85's quarterly [NAME] Data Set (MDS)…

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, observations, and facility's fall policy, the facility failed to ensure ordered fall interventions were in place. This affected one (Resident #86) of the eight residents reviewed for falls. The facility census was 108. Findings include: Review of the medical record for Resident #86 revealed an admission date of 04/06/21. Diagnoses included Parkinson, hypokalemia, aphasia, seizures, vitamin B 12 deficiency anemia, and hypertension. Review of the plan of care dated 04/22/21 and revised 05/02/23 revealed Resident #86 was at risk for falls due to unsteady gait, Parkinson's, seizures, the use of psychotropic medication, incontinence, needing assistance with activities of daily living (ADL)'s. Interventions include to educate the resident on the use of the call light, keep call light is in reach, extend strips to the shower floor, commonly used articles in reach, keep trash can within reach, non-skid material to top of chair, to toilet, chair near window closet door,…

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, observations, and facility policy review, the facility failed to assist residents with eating and implementing nutritional interventions with a noted significant weight loss. This affected two (Resident #2 and #70) of the three residents reviewed for nutritional support. The facility census was 108. Findings include: 1. Review of the medical record for Resident #70 revealed an admission date of 11/09/22. Diagnoses included dementia, metabolic encephalopathy, encounter for palliative care, and dysphasia. Review of Resident #70's documented weights revealed on 04/06/23 resident weighed 155.4 pounds and then on 04/25/23 the resident weighted 138.4 pounds. This is a noted loss of 17 pounds in less than 30 days. Continued weights after 04/25/23 revealed weights at 138.4 or less. Review of Resident #70's dietary charting revealed no documentation noted to address the sudden 17 pound weigh loss or implementation of interventions to prevent further weight loss. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and observation the facility failed to post safety signs indicating the use of oxygen outside of oxygen-dependent residents' rooms as required. This affected one resident (Resident #20) who receives oxygen. The facility census was 108. Findings Include: Review of the medical record for Resident #20 revealed the resident was admitted on [DATE] for Urinary Tract Infection, Respiratory disorder, and Acute Respiratory Failure. Review of the Care Plan dated 12/23/23 for Resident #20 indicated the resident receives oxygen therapy. Resident #20 suffers from respiratory deficits caused by a history of Coronavirus disease 19, which includes persistent shortness of breath, pneumonia, and respiratory failure. Review of Resident #20 orders dated 12/24/23 revealed resident is to receive oxygen continuous per nasal cannula to maintain saturation above 90% every shift for hypoxia. Observation on 01/22/24 at 2:47 P.M. revealed the absence of safety signs indicating the use of oxygen outside of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to administer blood pressure medication according to the physician's order for one resident (Resident #75). This affected one (Resident #75) of five reviewed for unnecessary medications. The facility census was 108. Findings Include: Review of the medical record for Resident #75 revealed an initial admission date on 03/03/20 and a readmission date on 03/30/23. Medical diagnoses included cerebral palsy, chronic atrial fibrillation, presence of cardiac pacemaker, and hypotension (low blood pressure). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #75 had mildly impaired cognition and scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #75 was independent with completing bed mobility, toileting, and dressing and required supervision or set up help from staff to complete transfers, hygiene, showering/bathing, and eating tasks. Review of…

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

Based on record review, staff interviews, and facility policy review, the facility failed to obtain a laboratory test as ordered by a physician for one resident (Resident #7). This affected one (Resident #7) of one reviewed for laboratory tests. The facility census was 108. Findings Include: Review of the medical record for Resident #7 revealed an admission date on 11/16/21. Medical diagnoses included spinal stenosis, chronic obstructive pulmonary disease (COPD), chronic kidney disease Stage 3, and dysphagia (difficulty swallowing) oropharyngeal phase. Review of the annual Minimum Data Set (MDS) 3.0 assessment revealed Resident #7 had impaired cognition and scored a 7 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #7 required assistance ranging from partial assistance to dependence on staff to complete Activities of Daily Living (ADLs). Review of the Medication Administration Record (MAR) dated November 2023 revealed an order for Resident #7 to check Basic Metabolic Panel (BMP), check potassium level one time only for two days was dated 11/28/23 at…

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

Based on review of facility infection control logs and infection control documentation, staff training records and interview the facility failed to develop and implement a comprehensive and effective infection control program to timely identify and implement corrective measures when trends and increased numbers of infection were identified to prevent the spread of infection including COVID-19. This had the potential to affect all 105 residents residing in the facility. Findings include Review of the infection control log for November 2021 revealed 34 of the 102 residents in the facility were on antibiotics (33%) during the month. This included 13 residents treated for urinary tract infections (UTIs), 12 residents with skin or wound infections, six residents with respiratory infections and six residents with eye infections, C Diff, or other infections. Review of the infection control log for December 2021 revealed 32 of the 107 residents in the facility were on antibiotics (30%). This included 12 residents treated for UTIs, six residents with skin or wound infections, eight residents…

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, facility policy and procedure review and interview the facility failed to obtain written authorization to manage personal funds and failed to ensure funds were maintained in an interest-bearing account for a Medicaid recipient. This affected one resident (#38) of nine residents reviewed for resident funds. Findings include: Review of the medical record for Resident #38 revealed an admission date of 03/02/21 with diagnoses including diabetes, diabetic neuropathy, right left below knee amputation and urine retention. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 03/23/22 revealed Resident #38 was cognitively intact with a Brief Interview for Mental Score (BIMS) of 14. The assessment revealed the resident required extensive assistance with staff for transfers and mobility. On 04/14/22 at 10:20 A.M. interview with Business Office Manager (BOM) #228 revealed Resident #38 provided the business office manager an envelope of money. BOM #228 revealed the envelope initially had $450.00. BOM #228 counted out the remaining money in the envelope 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, record review, facility policy and procedure review and interview the facility failed to establish a system that assures the full, complete and separate accounting, according to generally accepted accounting principles related to funds being held by the facility for Resident #38. This affected one resident (#38) of nine residents reviewed for resident funds. Findings include: Review of the medical record for Resident #38 revealed an admission date of 03/02/21 with diagnoses including diabetes, diabetic neuropathy, right left below knee amputation and urine retention. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 03/23/22 revealed Resident #38 was cognitively intact with a Brief Interview for Mental Score (BIMS) of 14. The assessment revealed the resident required extensive assistance with staff for transfers and mobility. On 04/14/22 at 10:20 A.M. interview with Business Office Manager (BOM) #228 revealed Resident #38 provided the business office manager an envelope of money. BOM #228 revealed the envelope initially had $450.00. BOM #228…

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, resident interview, and staff interview, the facility failed to ensure a resident was provided with personal privacy. This affected one resident (#17) of one resident reviewed for privacy. Findings include: Review of the medical record for Resident #17 revealed an admission date of 01/20/22. She had resided in the same room since admission. A Minimum Data Set assessment completed on 01/27/22 stated the resident required extensive assistance from staff with transfers and locomotion. Interview with Resident #17 on 04/12/22 at 9:43 A.M. revealed the sliding door to the bathroom in her room does not close all the way. (room [ROOM NUMBER]). She stated that if the main door to her room does not get shut by staff, she feels like the people in the hallway can see her using the bathroom. (The bathroom is located right beside the main door to the room). She stated sometimes she does not like to go to the bathroom because of this. She stated the door had been this way since she was admitted .…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to update and submit Preadmission Screening and Resident Reviews (PASARR) for Resident #95 and Resident #104 to include all mental health diagnoses. The affected two residents (#95 and #104) of four residents reviewed for PASARR screenings. Findings Include: 1. Review of the medical record for Resident #104 revealed an original admission date on 02/20/18 and a recent readmission date on 02/20/22. Medical mental health diagnoses included generalized anxiety disorder (04/30/18), schizoaffective disorder (09/14/18), major depressive disorder (03/02/18), and unspecified psychosis not due to a substance or known physiological condition (02/20/18). Review of the PASARR screening for Resident #104 dated 03/15/18 revealed mood disorder and psychotic disorder were included on the PASARR. The resident received new mental health diagnoses on 04/30/18 and 09/14/18. There were no updated PASARR screenings included in Resident #104's medical record that included…

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

Based on observation, record review and interview facility failed to ensure Resident #36's plan of care was implemented and updated to reflect the resident's dental care needs. This affected one resident (#36) of 27 residents whose care plans were reviewed. Findings include: Review of the medical record for Resident #36 revealed an admission date of 02/10/21. Resident #36 had diagnoses including cerebral infarction, diabetes mellitus type two, respiratory disorder, hemiplegia, seizure disorder, hypertension, anxiety, depression, atrial fibrillation, chronic pain and polyneuropathy. Review of the plan of care, dated 09/20/21 revealed Resident #36 had impaired dentition and was at risk for oral problems including pain, chewing and swallowing difficulty and had upper and lower dentures. Interventions on the care plan included if dentures were ill fitting, contact social services to make arrangements to get dentures examined for repairs, complete an oral assessment per schedule, dentures to be worn for meals, monitor and report to the physician any reports of pain or poor fitting…

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 closed record review, facility policy and procedure review and interview facility failed to provide a safe discharge for Resident #111. This affected one resident (#111) of one resident reviewed for discharge. Findings include Review of the medical record for the Resident #111 revealed an admission date of 01/28/22 with discharge date of 02/12/22. Resident #111 had diagnoses including dementia without behaviors, diabetes type one, asthma legal blindness, heart failure, peripheral vascular disease, and history of falls. Review of the Minimum Data Set (MDS) assessment, dated 02/04/22 revealed Resident #111 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and required extensive assistance of two staff members for bed mobility and extensive assist of one staff for transfers. Review of the progress notes dated 02/12/22 at 5:20 P.M. revealed resident left facility with family and all belongings. The nurse was unsuccessful in contacting listed phone numbers on resident's profile. The nurse left message for resident's wife and attempted to contact…

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, facility policy and procedure review and interview the facility failed to ensure residents dependent on staff received assistance with hygiene including shaving, and nail care. This affected one resident (#15) of the four residents reviewed for activities of daily living (ADL) care. Findings include: Review of the medical record for Resident #15 revealed an admission date of [DATE]. Diagnosis included fracture of part of the neck of the right femur, orthopedic aftercare, non-displaced type II dens fracture (dens is also known as the odontoid bone, an upward extension of the Cervical 2 (C2) vertebrae up into the C1), trochanteric fracture of the left femur, abnormalities of gait and mobility, and legal blindness as defined in the United States. Review of Resident #15's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #15's cognition had not been assessed. Resident #15 was noted to required extensive assistance from two staff members for bed…

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, facility policy and procedure review and interview the facility failed to ensure all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and/or the residents' choices. The facility failed to ensure Hospice communication documentation was kept readily available for review at the facility or in the resident's medical record for Resident #16 and failed to ensure the Hospice provider was notified timely of changes in the resident's condition. The facility failed to monitor bruising following a fall for Resident #47. The facility failed to schedule and complete an ordered Magnetic Resonance Image (MRI) timely for Resident #104. This affected three residents (Residents #16, #47 and #104) of four residents reviewed for quality of care. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date on [DATE] with diagnoses including moderate protein-calorie…

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 Resident #38, who developed a pressure ulcer in the facility received the necessary treatment and services to promote healing and prevent new ulcers from developing. This affected one resident (#38) of five residents reviewed for pressure ulcers. Findings include: Review of the medical record for Resident #38 revealed an admission date of 03/02/21 with diagnoses including diabetes with neuropathy and right below the knee amputation. The resident was admitted with an unstageable pressure ulcer to the bottom of his left foot. On 03/02/21 the resident was assessed as not being at risk for pressure ulcers with a score of 19. The rating system used by the facility was a score of 15-18 was at risk, 13-14 moderate risk, 10-12 high risk, 9 or below very high risk. A Minimum Data Set (MDS) 3.0 assessment, dated 03/09/21 indicated the resident had an unstageable pressure ulcer on admission. An MDS 3.0 assessment, dated 02/11/22 indicated 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.

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure fall interventions were in place for residents at risk for falls and/or with history of falling. This affected two residents (#16 and #73) of four residents reviewed for accidents. Findings include: 1. Review of the medical record for Resident #73 revealed an admission date of 08/21/20 with diagnoses including insomnia, recurrent major depressive disorder and heart failure. Review of the plan of care, dated 01/05/21 revealed Resident #73 was at risk for falls due to a history of a cerebral vascular accident (CVA), impaired balance and personal history of falls. Interventions included to ensure brakes to wheelchair were fixed, encourage and remind to ask for assistance, ensure call light was within reach, ensure environment was free of clutter, commonly used articles were in reach, pull tab alarm was attached to bed and wheelchair, non-skid strips to the right side of the bed and visual reminders on bathroom wall to ask for help. A plan of care, dated 07/07/21…

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 laboratory testing to rule out a possible urinary tract infection was completed timely and as ordered for Resident #362 who had a history of urinary tract infections. This affected one resident (#362) of four residents reviewed for quality of care. Findings include: Review of the medical record for Resident #362 revealed an admission date of 03/29/22 with diagnoses including unspecified fracture of shaft of humerus in right arm, Type II diabetes mellitus, urinary tract infection (UTI) and unspecified atrial fibrillation. Review of the admission Bowel and Bladder Assessment, dated 03/29/22 revealed Resident #362 had an indwelling catheter at the time of admission. The remaining sections of the assessment were not completed. Review of the plan of care, dated 03/29/22 revealed Resident #362 had an alteration in elimination related to recently having recently having a Foley catheter. Interventions included to monitor for signs and symptoms of UTI…

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, facility policy and procedure review and interview the facility failed to ensure adequate monitoring was completed related to the administration of cardiac medication for Resident #36 to ensure the medication was necessary and administered at the most effective dosage. The facility also failed to ensure adequate justification for the use of Tagamet prescribed to treat sexual behaviors for Resident #100 and failed to ensure staff documented and monitored for target behaviors to ensure the justification of the continued use of the medication. This affected two residents (#36 and #100) of four residents reviewed for unnecessary medication use. Findings include: 1. Review of the medical record for Resident #36 revealed an admission date of 02/10/21. Resident #36 had diagnoses including cerebral infarction, diabetes mellitus type two, respiratory disorder, hemiplegia, seizure disorder, hypertension, anxiety, depression, atrial fibrillation, chronic pain and polyneuropathy. Review of the care plan, dated 09/20/21 revealed resident had cardiac symptoms 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.

Based on observation, record review, facility policy and procedure review and interview the facility failed to obtain or provide timely dental services to meet the needs of each resident. This affected two residents (#36 and #55) of four residents reviewed for dental services. Findings include: 1. Review of the medical record for Resident #55 revealed an admission date of 12/05/21. Record review revealed the resident had a physician's order for a low concentrated sweets diet (no texture modifications). An oral assessment, dated 12/05/21 revealed the resident was edentulous (no teeth) and had no dentures. Review of an admission Minimum Data Set (MDS) 3.0 assessment, completed 12/12/21 revealed the resident was edentulous. The MDS care area assessment (CAA) dental status revealed the resident was noted with impaired dentition. It did not mention if the resident had dentures. An oral assessment, dated 03/30/22 indicated the resident was edentulous with no dentures. A quarterly MDS 3.0 assessment, completed 04/03/22 did not indicate any issues related to dental status. The MDS indicated…

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, facility policy and procedure review and interview the facility failed to ensure Resident #36's medical record was maintained in a complete and accurate manner. This affected one resident (#36) of 27 residents whose medical records were reviewed. Findings include: Review of the medical record for Resident #36 revealed an admission date of 02/10/21. Resident #36 had diagnoses including cerebral infarction, diabetes mellitus type two, respiratory disorder, hemiplegia, seizure disorder, hypertension, anxiety, depression, atrial fibrillation, chronic pain and polyneuropathy. Review of the plan of care, dated 09/20/21 revealed Resident #36 had impaired dentition and was at risk for oral problems including pain, chewing and swallowing difficulty and had upper and lower dentures. Interventions on the care plan included if dentures were ill fitting, contact social services to make arrangements to get dentures examined for repairs, complete an oral assessment per schedule, dentures to be worn for meals, monitor and report to the physician any reports of…

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

Based on record review, facility policy and procedure review and interview the facility failed to implement an effective antibiotic stewardship program to ensure the appropriate use of antibiotics to reduce the development of antibiotic-resistant infections/organisms. This affected one resident (#38) of five residents reviewed for urinary tract infections. Findings include: Review of the medical record for Resident #38 revealed an admission date of 03/02/21 and a diagnosis of urinary retention. Record review revealed Resident #38 had a physician's order for an indwelling urinary catheter. Review of a nurse's progress note, dated 11/01/21 at 1:13 P.M. revealed a new order was obtained to complete a urinalysis and culture and sensitivity related to Resident #38 being febrile. Review of temperature records revealed on 10/31/21 at 12:53 P.M. a temperature of 101.1 degrees Fahrenheit (F). On 10/31/21 at 3:45 P.M. his temperature was 100.1 degrees F. On 11/01/21 at 12:07 A.M. his temperature was 99.8 degrees F. On 11/01/21 at 7:32 A.M. his temperature was 98.8 degrees F. and at 1:47 P.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 record review, facility policy and procedure review and interview facility failed to ensure the flu vaccine was offered and provided to Resident #72. This affected one resident (#72) of five residents reviewed for vaccines. Findings include Review of the medical record for the Resident #72 revealed an admission date of 09/30/21 with diagnoses including Waldenstrom macroglobulinemia, depression, psychosis, dementia with behavioral disturbances, constipation and anxiety. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 03/11/22 revealed Resident #72 was cognitively intact with a Brief Interview for Mental Status Score (BIMS) of 8. Review of Section O of the MDS assessment, revealed the flu vaccine was not offered or provided. Review of Resident #72's hard chart medical record contained a flu vaccination consent form that only contained the resident's name printed at the top and the date of admission [DATE]). The form did not have a selection marked regarding the vaccination and consent…

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.