Three Meadows Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the medical record, staff interview, resident interview, family interview, and policy review revealed the facility failed to ensure medical documentation was complete and accurate. This affected two (#5, #51) of three residents reviewed for clinical documentation and had the potential to affect all residents. The facility census was 83. 1. Review of the medical record for Resident #05 revealed an admission date of 06/14/23. Diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus, Alzheimer's disease with late onset, dementia, hypertension, repeated falls, anemia, peripheral vascular disease, orthopedic aftercare following surgical amputation, Methicillin susceptible staphylococcus aureus infection, occlusion and stenosis of carotid artery, and unstageable pressure ulcer of sacral region, acquired absence of right leg above knee, and protein calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the medical record, staff interview, and policy review, the facility failed to ensure enhanced barrier precautions were maintained during wound care. This affected one (#05) of four residents reviewed for wound care. The facility identified 29 residents with enhanced barrier precautions. The facility census was 83. Review of the medical record for Resident #05 revealed an admission date of 06/14/23. Diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus, Alzheimer's disease with late onset, dementia, hypertension, repeated falls, anemia, peripheral vascular disease, orthopedic aftercare following surgical amputation, Methicillin susceptible staphylococcus aureus infection, occlusion and stenosis of carotid artery, and unstageable pressure ulcer of sacral region, acquired absence of right leg above knee, and protein calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #05 had severe cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to ensure call lights were within reach for one (#43) of four residents reviewed for call light accessibility. The census was 81. Findings include: Review of the medical record for Resident #43 revealed an admission date of 06/14/24. Diagnoses included venous insufficiency, multiple sclerosis, and osteoporosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was cognitively intact, dependent for toileting, showering/bathing, upper body dressing, lower body dressing, and required substantial/maximal assistance for personal hygiene. Observation on 05/12/25 at 10:26 A.M. revealed the call light laying on the floor beside Resident #43's bed. Interview with Certified Nurse Aide (CNA) #449 on 05/12/25 at 10:47 A.M. verified Resident #43's call light was lying on the floor out of the resident's reach. Observation on 05/12/25 at 10:48 A.M. revealed CNA #492 attached the call light to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident interview, and staff interview, the facility failed to maintain a clean environment. This affected two (6 and #49) of four residents reviewed for physical environment. The facility census was 81. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 04/14/25. Diagnoses included acute kidney failure, asthma, hypertensive heart and chronic kidney disease, type II diabetes, and anxiety. Review of the admission Minimum Data Set (MDS) assessment completed on 04/21/25 revealed Resident #6 was cognitively intact. Observation on 05/12/25 at 9:45 A.M. of Resident #6's room revealed a cup with popcorn coming out of it all over the floor. Observation and interview on 05/12/25 at 1:43 P.M. of Resident #6's room revealed the popcorn remained on the floor. Resident #6 stated the popcorn on the floor bothered her and she would like it to be cleaned up. Interview with Licensed Practical Nurse (LPN) Manager #475 on 05/12/25 at 1:52…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure residents who received psychotropic medications were monitored for behaviors, adverse effects, and efficacy. This affected one (#24) of five residents reviewed for psychotropic medications. The facility census was 81. Findings include: Review of the medical record revealed Resident #24 was admitted to the facility on [DATE]. Diagnoses included anxiety, depression, and hypertension. Review of the plan of care dated 03/24/25 revealed Resident #24 received antidepressant medication. Interventions included monitoring and documenting side effects and effectiveness. Review of the plan of care dated 03/24/25 revealed Resident #24 received antianxiety medication. Interventions included monitoring and documenting side effects and effectiveness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was cognitively intact. The resident received antianxiety and antidepressant 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, medical record review, and staff interview, the facility failed to provide ongoing assistance and coordination, with resident involvement, in developing discharge goals and plans for discharge. This affected one (#62) of one residents reviewed for discharges in a facility census of 81. Findings include: Review of the medical record revealed Resident #62 admitted to the facility on [DATE] with diagnoses including atrial fibrillation, venous insufficiency, segmental and somatic dysfunction of the lower extremity, major depressive disorder, hypertension, dysphagia, and right artificial hip joint. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was assessed with intact cognition, utilized a wheelchair for mobility, was independent with activities of daily living, was occasionally incontinent of bladder and was continent of bowel, and assessed at risk for pressure ulcer development with no skin breakdown. Review of Resident #62's social service admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy review, the facility failed to provide adequate staff assistance and implement fall interventions during care to prevent falls. This affected one (#19) of two residents reviewed for falls. The facility census was 81. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 02/26/24 with diagnoses of congestive heart failure, anxiety, and dementia, repeated falls. Resident #19 was under hospice care. Review of the modified quarterly Minimum Data Set (MDS) assessment, dated 10/31/24, revealed Resident #19 was dependent for toileting and required substantial/maximal assistance for bed mobility. Further review revealed Resident #19 did not have any falls since the previous assessment. Review of the current care plan, initiated 02/26/24, revealed Resident #19 was at risk for falls due to impaired balance, impaired mobility, and incontinence. Further review of the care plan revealed Resident #19 had an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the dialysis contract, the facility failed to ensure effective communication took place between the facility and the dialysis center. This affected one (#34) of one residents reviewed for dialysis. The facility census was 81. Findings include: Review of the medical record revealed Resident #34 was admitted to the facility on [DATE]. Diagnoses included end-stage renal disease, heart failure, type II diabetes mellitus, hypertension, and dependence on renal dialysis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact. The resident was assessed to receive dialysis. Review of Resident #34's active physician orders for May 2025 identified an order for dialysis on Mondays, Wednesdays, and Fridays. Review of Resident #34's dialysis communication forms for 03/01/25 through 05/08/25 revealed each form had three sections. The first section was to be completed by nursing staff prior to dialysis…

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

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure medications were provided as ordered by the physician and within prescribed time frames. This resulted in 12 of 28 medications being administered in error with an error rate of 42.86 percent (%). This affected three (#53, #16, and #74) of four residents observed for medication administration in a facility census of 81. Findings include: 1. Observation on 05/13/25 at 10:21 A.M. noted Registered Nurse (RN) #482 preparing medications for Resident #53. The medications included the medication to treat symptoms of Parkinson's disease Carbidopa-Levodopa 25-100 milligrams (mg), the anticonvulsant medication divalproex delayed release 125 mg, the heart failure medication Sacubitril-Valsartan 24-26 mg, the antihypertensive medication Hydralazine 25 mg, and the pain medication Tylenol eight (8)-hour extended release 650 mg two tablets. Continued observation at 10:31 A.M., revealed RN #482 administered the medications to Resident #53 one-by-one using a spoon. 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.

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure medications were administered as ordered, and within ordered time frames, to prevent significant medication errors. This affected three (#53, #16, #74) of four residents observed for the administration of medications in a facility census of 81. Findings include: 1. Observation on 05/13/25 at 10:21 A.M. noted Registered Nurse (RN) #482 preparing medications for Resident #53. The medications included the medication to treat symptoms of Parkinson's disease Carbidopa-Levodopa 25-100 milligrams (mg), the anticonvulsant medication divalproex delayed release 125 mg, the heart failure medication Sacubitril-Valsartan 24-26 mg, and the antihypertensive medication Hydralazine 25 mg. Continued observation at 10:31 A.M., revealed RN #482 administered the medications to Resident #53 one-by-one using a spoon. Review of the medical record noted Resident #53's physician orders and prescribed time frames listed on the medication administration record (MAR) noted the following; 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, staff interview, and review of the diet manual guidance, the facility failed to ensure pureed food items had an appropriate texture. This had the potential to affect two (#51 and #231) of two residents on a pureed diet. The facility census was 81. Findings include: 1. Review of the medical record for Resident #51 revealed an admission date of 11/24/21 with diagnoses of dysphagia and anorexia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had severely impaired cognition and was able to feed himself with setup or clean-up assistance and received a mechanically altered diet. Review of the physician order dated 02/20/25 revealed Resident #51 received a regular diet with pureed consistency and thin liquids. 2. Review of the medical record for Resident #231 revealed an admission date of 05/12/25 with diagnosis of Alzheimer's disease. Review of the nursing admission evaluation, dated 05/12/25, revealed Resident #231 was in a coma/persistent vegetative…

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 staff interview, the facility failed to ensure resident meal trays were served in a sanitary manner. This affected one (#62) of seven residents observed during dining services. The facility census was 81. Findings include: Review of the medical record for Resident #62 revealed an admission date of 11/06/23 with diagnoses of anxiety, repeated falls, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/14/25, revealed Resident #62 had intact cognition and was able to eat independently. Observation on 05/12/25 at 11:43 A.M. revealed Certified Nurse Aide (CNA) #550 was passing the noon meals trays. CNA #550 entered Resident #62's room and placed a meal tray on the resident's overbed table. Also present on the overbed table was a urinal with urine in it. Interview on 05/12/25 at 11:44 A.M. with CNA #550 confirmed Resident #62's urinal, containing urine, was on the overbed table and CNA #550 placed a meal tray on the same table. CNA #550 stated she did not realize the urinal was on the table. Subsequent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility policy review, the facility failed to properly store medications. This affected one resident (#78) reviewed for medications left at bedside. The facility census was 81. Findings include: Review of the medical record for Resident #78 revealed she was admitted on [DATE] with diagnoses of hyperlipidemia, polyneuropathy, and history of urinary tract infection (UTI). Review of the current physician orders dated 08/24 for Resident #78 revealed she was prescribed Cranberry 300 milligrams (mg) (used for UTI prevention), Atorvastatin 40 mg (used to control high cholesterol), and Gabapentin 600 mg (used for nerve pain). Review of Resident #78's medication administration record (MAR) reveaeld Cranberry 300 mg was scheduled to be administered at 9:00 A.M., 1:00 P.M., and 9:00 P.M. daily, Atorvastatin 40 mg was scheduled to be administered at 9:00 P.M. daily and Gabapentin 600 mg was scheduled to be administered at 9:00 A.M., 1:00 P.M., and 9:00 P.M. daily. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and hospice staff interviews, review of medication information from Medscape and facility medication administration policy, the facility failed to ensure blood pressure medication was administered in accordance with physician orders. This resulted in a significant medication error when one resident received an anti-hypertensive blood pressure medication outside of physician prescribed administration parameters. This affected one (#1) of five sampled residents reviewed for the administration of medications. The facility census of 85. Findings include: Resident #1 admitted to the facility on [DATE] with the diagnosis including, cardiomyopathy, congestive heart failure, atrial fibrillation, coronary artery disease, ventricular tachycardia, cardiac pacemaker, seizure disorder, pulmonary hypertension, pleural effusion, left clavical fracture, and cerebral vascular accident affecting left non-dominant side with hemiplegia and hemiparesis. According to the minimum data set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, review of the medical record, and review of a facility policy, the facility failed to ensure a resident was safely transferred using a mechanical lift per the care plan and facility policy. This affected one (#48) of one residents observed for a mechanical lift transfer. The facility census was 79. Findings include: Review of the medical record for Resident #48 revealed an admission date of 06/30/22. Diagnoses included quadriplegia, polyneuropathy, epilepsy, and contractures. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact and was dependent on staff for transfers. Review of the care plan dated 03/06/24 revealed Resident #48 had an activities of daily living (ADLs) self-care deficit with an intervention including mechanical transfers with the assistance of two staff. Continuous observation on 04/02/24 from 10:50 A.M. to 10:55 A.M. revealed State Tested Nurse Aide (STNA) #90 wheeled Resident #48…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff and resident interview, and review of a facility policy, the facility failed to ensure a dependent resident received timely incontinence care. This affected one (#41) of three residents reviewed for bowel and bladder incontinence. The census was 79. Findings include: Review of Resident #41's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis affecting the right side (dominant) after a cerebral infarct, compression of the brain, aphasia, rheumatoid arthritis, dementia, ulcerative colitis, and hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was assessed with severely impaired cognition, dependent on staff for activities of daily living (ADLs) including transfers and repositioning. Resident #41 utilized a wheelchair propelled by staff for mobility, was incontinent of bowel and bladder, and was at risk for pressure ulcer development. 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, medical record review, staff and resident interview, and review of a facility policy, the facility failed to ensure the facility was adequately staffed to ensure a dependent resident received timely incontinence care. This affected one (#41) of three residents reviewed for bowel and bladder incontinence. The census was 79. Findings include: Review of Resident #41's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis affecting the right side (dominant) after a cerebral infarct, compression of the brain, aphasia, rheumatoid arthritis, dementia, ulcerative colitis, and hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was assessed with severely impaired cognition, dependent on staff for activities of daily living (ADLs) including transfers and repositioning. Resident #41 utilized a wheelchair propelled by staff for mobility, was incontinent of bowel and bladder, and was at risk…

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 staff interview, record review, and policy review, the facility failed to notify the physician of medication being unavailable from the pharmacy for administration. This affected one (Resident #76) of three reviewed for medications. The facility census was 70. Findings include: Review of the medical record for Resident #76 revealed an admission date of 12/29/22 with diagnoses including but not limited to chronic kidney disease, hypertensive heart disease, congestive heart failure, type two diabetes, chronic obstructive pulmonary disease (COPD), and asthma. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #76 revealed the resident was cognitively intact and required extensive assistance for activities of daily living. Review of the care plan dated 11/15/22 for Resident #76 revealed the resident had altered respiratory status/difficulty breathing related to COPD. Interventions included administer medications as ordered. Review of physician orders for Resident #76 revealed an order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to ensure medications were administered per physician orders. This affected one Resident (#76) of three residents reviewed for medications. The facility census was 70. Findings include: Review of the medical record for Resident #76 revealed an admission date of 12/29/22 with diagnoses including but not limited to chronic kidney disease, hypertensive heart disease, congestive heart failure, type two diabetes, chronic obstructive pulmonary disease (COPD), and asthma. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #76 revealed the resident was cognitively intact and required extensive assistance for activities of daily living. Review of the care plan dated 11/15/22 for Resident #76 revealed the resident had altered respiratory status/difficulty breathing related to COPD. Interventions included administer medications as ordered. Review of physician orders for Resident #76 revealed an order for Dupixent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, staff interview, and policy review, the facility failed to ensure an admission skin assessment was completed, and failed to ensure wound treatments were entered into the electronic medical record and completed per physician orders. This affected one (Resident #79) of three residents reviewed for pressure ulcers. The facility census was 78. Findings include: Review of the medical record for Resident #79 revealed an admission date of 09/23/23 and a discharge date of 10/15/23. Diagnoses included sepsis, encephalitis and encephalomyelitis, enterocolitis due to clostridium difficile, acute kidney failure, type two diabetes mellitus, chronic systolic heart failure, chronic kidney disease stage three, atrial fibrillation, and atherosclerosis of coronary artery bypass graft. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 had intact cognition. The resident required the extensive assistance of two staff for bed mobility, transfers, and…

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

Based on observation and staff interview, the facility failed to ensure the menu was reviewed by the facility's dietitian. The had the potential to affect all residents who received food from the kitchen. The facility identified three residents who did not receive food from the kitchen (Resident #41, Resident #50, and Resident #189). The facility census was 85. Findings include: Observation of the menus on 11/29/22 at 10:32 A.M. revealed no dietitian's signature. Interview on 11/29/22 at approximately 1:31 P.M. with the Food Service Director (FSD) #272 revealed the menu was created by the previous Food Service Director and was not the menu provided by the corporation. Interview on 11/29/22 at 3:43 P.M. with the Registered Dietitian (RD) #333 revealed the previous Food Service Director modified the men, and the current menu was not reviewed by the RD #333.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure the dishwashing machine was hot enough to sanitize the dishes. The had the potential to affect all residents who received food from the kitchen. The facility identified three residents who did not receive food from the kitchen (Resident #41, Resident #50, and Resident #189). The facility census was 85. Findings include: Observation on 11/29/22 at 1:29 P.M. revealed Dietary Aide #221 washing noon meal dishes. Observation of the dishwasher rinse temperature revealed it reached 115 degrees Fahrenheit (F). Interview on 11/29/22 at approximately 1:31 P.M. with the Food Service Director (FSD) #272 confirmed the dishwasher rinse temperature was 115 degrees F and was an inadequate temperature to sanitize the dishes properly. He stated the rinse temperature should be at least 180 degrees F. Further interview revealed the heat booster was turned off, and FSD #272 subsequently turned it back on. The FSD #272 was unable to specify how long the heat booster was turned off, stating it had to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interview, review of pharmacy receipts and review of facility policies, the facility failed to ensure medications were administered per physician order. This affected four (#13, #63, #133, and #193) of 23 residents reviewed for medication administration. The facility census was 85. Findings include: 1. Review of Resident #193's medical record revealed an admission date of 11/23/22. Diagnoses included urinary tract infection, type II diabetes, muscle wasting and atrophy, anemia, hypertension and chronic lymphocytic leukemia of B-cell type not having achieved remission. Review of the admission Evaluation dated 11/23/22 revealed Resident #193 was alert and oriented. Review of a plan of care focus area initiated 11/25/22 revealed Resident #193 had a bowel elimination alteration of diarrhea. Interventions included administer medications as ordered. Review of physician orders revealed Resident #193 had orders Nystatin external cream 100000 unit/gram (gm) apply 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, resident interview and staff interview, the facility failed to ensure call lights were within reach of residents. This affected two (#184 and #188) of two residents reviewed for call lights. The facility census was 85. Findings include: 1. Review of Resident #184's medical record revealed an admission date of 08/06/22 and a readmission date of 11/15/22. Diagnoses included hypo-osmolality, generalized anxiety disorder, sarcopenia, atrial fibrillation, hypertension, type II diabetes and major depressive disorder. Review of the admission Evaluation dated 11/15/22 revealed Resident #184 was alert and oriented. Observation on 11/28/22 at 10:06 A.M. revealed Resident #184 sitting in a chair, positioned to the right at the foot of the bed. The call light was clipped to the sheet on the left side of the bed near the head of the bed. Interview at the time of the observation with Resident #184 revealed she needed assistance reaching her walker, which was folded and leaning against the wall to her left. Resident #184 stated she was unable to reach her call light to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, staff interview, review of activity participation records, observation, and review of activity schedules, the facility failed to ensure residents choices were honored to be out of bed when desired and to attend activities of choice. This affected one (Resident #36) of two residents reviewed for choices. The facility census was 85. Findings include: Review of the medical record revealed Resident #36 was admitted to the facility on [DATE]. Diagnoses included diabetes mellitus type II, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarct affecting the left side, asthma, morbid obesity, major depressive disorder, atrial fibrillation, bipolar disorder, insomnia, chronic obstructive pulmonary disease, hypokalemia, pulmonary hypertension, post traumatic stress disorder, gastro-esophageal reflux disease, osteoarthritis, diverticulosis, and sarcopenia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/04/22, 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 resident interview, staff interview, review of facility records and review of the facility policy, the facility failed to ensure residents had access to personal funds. This affected one (#7) of four residents reviewed for resident trust accounts. The facility census was 85. Findings include: Review of the medical record for Resident #7 revealed an admission date of 02/12/19 and a readmission date of 11/09/20. Diagnoses included of hemiplegia affecting right dominant side, obstructive sleep apnea, and anxiety. Review of the quarterly Minimum Data Set assessment, dated 10/03/22, revealed Resident #7 had intact cognition, Review of facility records revealed Resident #7 had a Resident Trust account. Interview on 11/27/22 at 11:56 A.M. with Resident #7 revealed the facility did not have money available for him when he requested it to purchase a pizza. Further interview revealed he was familiar with the hours during which money should be available. Interview on 11/30/22 at 1:57 P.M. with Receptionist #233 confirmed residents come to her to withdraw money from their accounts. She…

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 staff interview, the facility failed to ensure a code status was accurately portrayed in the resident's medical record. This affected one (Resident #2) of 28 residents reviewed. The facility census was 85. Findings include: Review of the medical record for Resident #2 revealed an admission date of 10/20/21 with a readmission date of 10/29/21. Diagnoses included end stage renal disease, anemia, sarcopenia, venous insufficiency, obstructive sleep apnea, and insomnia, generalized anxiety disorder. Review of the comprehensive Minimum Data Set assessment, dated 10/24/22,revealed Resident #2 had intact cognition. Review of the current physician orders for Resident #2 revealed an order dated 04/21/22 for Full Code status. Review of the current care plan for Resident #2 revealed she had a Full Code status. Observation of the paper chart on 11/28/22 at 2:01 P.M. revealed Resident #2 had a red Do Not Resuscitate, Comfort Care-Arrest (DNRCCA) sign in her chart along with a Do Not Resuscitate (DNR) form signed by the nurse practitioner on 04/07/22.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and review of facility policy, the facility failed to notify the physician when ordered medications were unavailable. This affected one (#193) of one resident reviewed for notification of change. The facility census was 85. Findings include: Review of Resident #193's medical record revealed and admission date of 11/23/22. Diagnoses included type II diabetes, muscle wasting and atrophy, anemia, hypertension and chronic lymphocytic leukemia of B-cell type not having achieved remission. Review of the admission Evaluation dated 11/23/22 revealed Resident #193 was alert and oriented. Review of the plan of care initiated 11/23/22 revealed Resident #193 had had insulin dependent diabetes. Interventions included administer medication per physician orders. Review of physician orders revealed Resident #193 had orders for the insulin Lyumjev KwikPen Subcutaneous Solution Pen-Injector 100 unit/milliliter (ml) inject 4 units subcutaneously two times daily only if sugar was over…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the resident census, resident interview, staff interview and review of the facility admission packet, the facility failed to provide written bed hold notification to a resident upon transfer to the hospital. This affected one (#61) of two residents reviewed for hospitalization. The facility census was 85. Findings include: Review of Resident #61's medical record revealed an admission date of 05/24/22 and a readmission date of 11/15/22. Diagnoses included sepsis, muscle wasting and atrophy, altered mental status, osteoporosis, dysphagia, chronic obstructive pulmonary disease (COPD), asthma, morbid obesity, type II diabetes, congestive heart failure and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 was cognitively intact. Review of Resident #61's census revealed the resident was transferred to the hospital on [DATE]. Further review of Resident #61's medical record revealed no documentation the 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 medical record review, observation, resident and staff interview, the facility failed to ensure residents that required assistance with shaving were provided adequate care and services and further the facility failed to provide personal hygiene for a resident with dry skin. This affected two residents (#55 and #56) of six residents reviewed for activities of daily living. The census was 85. Findings include: 1. Review of Resident #55's medical record revealed an admission date of 01/22/20. Diagnoses included cerebral infarct due to a thrombosis of the right vertebral artery, contracture's left and right hands, pain in joints, memory deficit, dysphagia, pharyngeal phase, sarcopenia, hemiplegia and hemiparesis affecting left (non dominant), diabetes mellitus type II, major depressive disorder, anxiety disorder, hypertension and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/14/22, revealed Resident #55 was cognitively intact, active and able to make decisions about care. Resident #55 required two person physical assistance with part 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.

Based on observation, resident and staff interview, medical record review, and policy review, the facility failed to ensure splint devices were applied as ordered by the physician. This affected one (#56) of one residents reviewed for range of motion. The facility identified Resident #56 as the only resident in the facility with orders for a splint. The census was 85. Findings include: Review of Resident #56's medical record revealed an admission date of 07/17/20. Diagnoses included cerebral infarction, cognitive communication deficit, heart failure, muscle wasting and atrophy, diabetes mellitus type II, essential hypertension, hyperlipidemia, and need for assistance with personal care. Review of the Minimum Data Set (MDS) assessment completed 09/06/22 revealed Resident #56 was assessed with intact cognition, required extensive one person physical assistance with personal hygiene and dressing, and was assessed with functional limited range of motion affecting one side of Resident #56's upper extremities. Review of a physician order dated 08/11/22 revealed Resident #56 was ordered 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.

Based on observation, staff interview, medical record review, review of drug manufacturer's instructions, and review of facility policies, the facility failed to ensure medications were administered as ordered. This resulted in three medication errors of 28 total opportunities for a medication error rate of 10.71%. This affected one (#133) of three residents observed during medication administration. The census was 85. Findings include: Review of Resident #133's medical record revealed an admission date of 11/25/22. Diagnoses included major depressive disorder, anxiety disorder, muscle wasting and atrophy, peripheral vascular disease, and diabetes mellitus type II. Review of a physician order dated 11/25/22 revealed Resident #133 was ordered the anti-anxiety medication Buspar 10 milligrams (mg) by mouth twice daily for anxiety. Review of a physician order dated 11/25/22 revealed Resident #133 was ordered insulin Glargine 56 units subcutaneously (SQ) every morning and at bedtime. Review of a physician order dated 11/25/22 revealed Resident #133 was ordered the supplement Vitamin D3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, review of drug manufacturer's instructions, and review of facility policies, the facility failed to ensure insulin was administered as ordered. This affected one (#133) of three residents observed during medication administration and one (#193) of one residents reviewed for insulin usage. The facility identified 25 residents in the facility with orders for insulin. The census was 85. Findings include: 1. Review of Resident #133's medical record revealed an admission date of 11/25/22. Diagnoses included major depressive disorder, anxiety disorder, muscle wasting and atrophy, peripheral vascular disease, and diabetes mellitus type II. Review of a physician order dated 11/25/22 revealed Resident #133 was ordered insulin Glargine 56 units subcutaneously (SQ) every morning and at bedtime. Observation on 11/29/22 at 8:37 A.M. revealed Licensed Practical Nurse (LPN) #288 prepared to administer Resident #133 her morning medications. LPN #288 removed 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, staff interview, medical record review, and review of drug manufacturer's instructions, the facility failed to ensure insulin was stored in a safe manner. This affected two (#28 and #40) of eight residents who had insulin stored in the North One, South Two, and Subacute Two medication carts. The facility identified 25 residents in the facility with orders for insulin. The census was 85. Findings include: 1. Review of Resident #28's medical record revealed an admission date of 03/26/22. Diagnoses included end stage renal disease, diabetes mellitus type II, peripheral vascular disease, anemia, sarcopenia, major depression, and anxiety. Review of a physician order dated 07/17/22 revealed Resident #28 was ordered insulin Lispro via sliding scale subcutaneously (SQ) before meals and at bedtime. Observation of the North One medication cart on 12/01/22 at 10:44 A.M., with Licensed Practical Nurse (LPN) #288, revealed an insulin Lispro administration pen with no resident name or open date written on the pen. LPN #288 identified the insulin Lispro administration pen…

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

Based on observation, staff interview, medical record review, and review of the facility policy, the facility failed to ensure pureed foods were prepared in a manner to maintain the nutritive value and ensure proper portion size. This had the potential to affect two residents (#18 and #68) who were identified on a pureed diet. The facility census was 85. Findings include: Review of the medical record for Resident #18 revealed an admission date of 09/13/19 with medical diagnoses of or phase dysphagia and anorexia. Review of a physician order dated 04/14/22 revealed Resident #18 was on a pureed diet. Review of the medical record for Resident #68 revealed an admission date of 11/09/21 with diagnoses of weakness and type 2 diabetes mellitus. Review of the physician order dated 11/11/21 revealed Resident #68 received a pureed diet. Observations on 11/29/22 at 1:29 P.M. revealed [NAME] #285 preparing pureed ham in the food processor. Initial observation revealed [NAME] #285 placed an unmeasured quantity of ham in the food processor and blended it. [NAME] #285 added an unmeasured quantity…

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 staff interview, record review, review of the pharmacy recommendations, and review of the facility policy, the facility failed to follow up on pharmacy recommendations regarding the use of prophylactic antibiotics and physician recommendations for infectious disease consult. This affected one resident (#19) of three reviewed for prophylactic antibiotics. The facility census was 85. Findings include: Review of the medical record for Resident #19 revealed an admission date of 11/21/19. Diagnoses included multiple sclerosis, quadriplegia, reduced mobility, neuralgia and neuritis, and constipation. Review of the quarterly Minimum Data Set assessment, dated 08/17/22, revealed Resident #19 had intact cognition. Further review revealed he received an antibiotic. Review of Resident #19's current physician orders revealed an order dated 11/27/19 for the antibiotic cephalexin capsule 500 milligrams twice daily for prophylaxis. Review of Resident #19's current care plan revealed he received a prophylactic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and medical record review, the facility failed to ensure resident call systems in the bathroom were maintained in working order. This affected one (#15) of 23 sampled resident's bathrooms observed for functioning call lights. The census was 85. Findings include: Review of Resident #15's medical record revealed an admission date of 02/23/19. Diagnoses included personal history of traumatic brain injury, mood affect disorder, unspecified psychosis, major depression, anxiety, pain, depression, and unspecified intracranial injury without loss of consciousness. Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was assessed with intact cognition. Review of an activities of daily living (ADLs) self-care deficit care plan dated 02/25/19 revealed an intervention that Resident #15 required one person limited assistance with a gait belt for transfers. Observation on 11/28/22 at 2:46 P.M. revealed Resident #15 was in a bedroom…

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

Based on record review, observation and staff interview, the facility failed to ensure a clean environment. This affected one (#26) of seven residents reviewed for environment. The facility census was 85. Findings include: Review of the medical record for Resident #26 revealed an admission date of 06/21/22 with medical diagnoses of heart failure, need for assistance with personal care, and type 2 diabetes mellitus. Observation on 11/28/22 at 9:57 A.M. revealed a cola can on the floor and a brown dried stain around it, approximately 18 inches in diameter next to Resident #26's bed. Observation on 11/28/22 at 1:55 P.M. revealed the cola can and dried brown stain remained on the floor next to Resident #26's bed. Observation on 11/29/22 at 11:19 A.M. revealed the brown stain remained on Resident #26's floor. Interview at that time with Licensed Practical Nurse (LPN) #299 confirmed the dried stain on the floor that appeared to be cola. Observation on 11/29/22 at 4:25 P.M. revealed the brown stain remained on Resident #26's floor next to her bed. Interview at that time with LPN #295…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to provide a bed hold notification to the resident, and or the resident's representative. This affected three Residents (#11, #45, #56) of four reviewed for hospitalization. The facility census was 114. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 09/25/18. The resident was noted to have been transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. The resident was transferred to the hospital again on 12/29/19 due to chest pain, and was readmitted to the facility on [DATE]. There was no evidence Resident #11, or her representative was given a bed hold notification, or any information on the bed hold policy regarding her two hospitalizations dated 11/13/19 and 12/29/19. Interview on 01/06/20 at 2:20 P.M. with Resident #11 revealed she was not given a bed hold notification either time she was transferred to the hospital.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review the facility failed to ensure safe and effective medication administration assistance when medications were left at the bedside for one Resident (#68) of one observed for medications unattended. The facility further failed to appropriately store medications safely. This had the potential to effect 15 residents (#53, #52, #89, #24, #4, #68, #22, #66, #13, #36, #02, #12, #15, #63, and #70) who the facility identified as cognitively impaired and independently mobile on the second floor. The facility census was 114. Findings include: 1. Medical record review for the Resident # 68 revealed an admission date of 03/01/19. Diagnosis included cerebral infarction (stroke), acute kidney failure, anemia, muscle weakness and atrial fibrillation. Review of the Minimum Data Safety Set (MDS) assessment, dated 12/06/19 revealed the resident had impaired cognition. Observation on 01/06/20 at 10:24 A.M. revealed the Resident #68 in his room, sitting in his wheelchair, 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, staff interview, and review of facility policy, the facility failed to cover food during transportation and distribution to residents. This had the potential to affect all 100 residents who received trays off the hall carts. Resident #93, #19, #4, #31, #42, #23, #68, #106, #29, #13, #33, and #46 received food in the main dining room and Resident #61 and #82 received no food by mouth. The facility census was 114. Findings include: Observation on 01/07/20 at 11:24 A.M. of the lunch meal service revealed Dietary Staff (DS) #401, DS #402 and DS #400 plating food and adding the trays to the meal service cart. DS #400 was adding diced fruit in bowls and spice cake dessert to the meal trays. It was noted the spice cake and diced fruit were not covered. Observation on 01/07/20 at 11:31 A.M. of the second floor delivery of meal trays revealed staff were removing the lunch trays from the food cart and transporting the spice cake and diced fruit uncovered down the halls to the residents. Resident #15 received an uncovered spice cake and Resident #62 received an uncovered…

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 staff interview, the facility failed to serve residents lunch at the same time who were sitting at the same table together. This affected one Resident (#36) of four observed during the lunch meal. The facility census was 114. Findings include: Observation on 01/07/20 at 12:02 P.M. revealed three residents (#9, #36, and #89) were seated at a table in the dining room for lunch. Resident #9 was served at 12:02 P.M., and was finished eating at 12:16 P.M. Resident #89 was served at 12:20 P.M. At 12:22 P.M. Resident #63 arrived to the table and was served immediately. Resident #36 still did not have lunch served. Resident #36 began eating Resident #63's pureed food. At 12:30 P.M. Resident #36 received a meal, 28 minutes after being seated at the table Interview on 01/07/20 at 12:30 P.M. with Activities Coordinator #405 verified Resident #36 had waited a long time while other residents at the table ate, and the resident ate some of Resident #63's food.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, and facility policy review, the facility failed to implement their abuse policy to report and investigate when a resident reported her cell phone was missing. This affected one Resident (#37) of four reviewed for misappropriation. The facility census 114. Findings include: Medical record review for Resident #37 revealed an admission date of 02/01/12 with diagnoses including, multiple sclerosis (MS), paraplegia, and type two diabetes. Review of Resident #37's Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed the resident was cognitively intact. Interview on 01/06/20 at 2:44 P.M. with Resident #37 revealed her cell phone had been missing for three to four weeks, and she had informed the facility. The resident revealed staff did look in her room, however no further action was taken to her knowledge. Interview on 01/07/19 at 03:56 P.M. with the Licensed Social Worker (LSW) #409 revealed she was aware Resident #37's cell phone was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, and facility policy review, the facility failed to report an allegation of missing property. This affected one Resident (#37) of four reviewed for misappropriation. The facility census 114. Findings include: Medical record review for Resident #37 revealed an admission date of 02/01/12 with diagnoses including, multiple sclerosis (MS), paraplegia, and type two diabetes. Review of Resident #37's Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed the resident was cognitively intact. Interview on 01/06/20 at 2:44 P.M. with Resident #37 revealed her cell phone had been missing for three to four weeks, and she had informed the facility. The resident revealed staff did look in her room, however no further action was taken to her knowledge. Interview on 01/07/19 at 03:56 P.M. with the Licensed Social Worker (LSW) #409 revealed she was aware Resident #37's cell phone was missing. The LSW #409 revealed a hospice nurse had informed her the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, and facility policy review, the facility failed to fully investigate an allegation of missing property. This affected one Resident (#37) of four reviewed for misappropriation. The facility census 114. Findings include: Medical record review for Resident #37 revealed an admission date of 02/01/12 with diagnoses including, multiple sclerosis (MS), paraplegia, and type two diabetes. Review of Resident #37's Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed the resident was cognitively intact. Interview on 01/06/20 at 2:44 P.M. with Resident #37 revealed her cell phone had been missing for three to four weeks, and she had informed the facility. The resident revealed staff did look in her room, however no further action was taken to her knowledge. Interview on 01/07/19 at 03:56 P.M. with the Licensed Social Worker (LSW) #409 revealed she was aware Resident #37's cell phone was missing. The LSW #409 revealed a hospice nurse had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, and staff interview, the facility failed to offer quarterly care plan conferences for one Resident (#74) of one reviewed for care conferences. The facility census was 114. Findings include: Review of Resident #74's medical record revealed an initial admission date of 12/06/18 and readmission on [DATE]. Diagnoses included gangrene, multiple sclerosis (MS, and heart failure. Review of Resident #74's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #74's progress notes revealed a care conference was held on 12/19/18 with the resident present. Review of Resident #74's progress notes revealed a care conference was held on 03/12/19 and the resident declined to attend. Interview on 01/06/20 at 11:06 A.M. with Resident #74 revealed he had not been to a care conference in a year. Interview on 01/09/20 at 9:41 A.M. with Licensed Social Worker (LSW) #409 verified Resident #74 had not had a care conference…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, family interview, staff interview, and review of facility nursing procedure, the facility failed to ensure a dependent resident was provided with activities of daily living (ADLs). This affected one Resident (#82) of six reviewed for ADLs. The census was 114. Findings include: Review of Resident #82's medical record revealed an initial admission date of 03/02/17 and readmission on [DATE]. Diagnoses included hemiplegia affecting left nondominant side, muscle weakness, and contracture of muscle left lower leg. Review of Resident #82's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Resident #82 was noted to require a one person assistance with personal hygiene. Review of Resident #82's care plan revealed an ADL care deficit related to physical limitations/history of contractures. The ADL care plan revealed to assist the resident with daily hygiene and grooming. Observation on 01/06/20 at 2:28 P.M. of Resident #82…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interviews, and facility policy review, the facility failed to complete treatments as ordered and failed to complete a minimum of weekly non-pressure and pressure wound assessments for two Residents (#57 and #69) of five reviewed for pressure ulcers. The facility census was 114. Findings include: 1. Review of the medial record for Resident #57 revealed an admission date of 11/21/19 with diagnoses of chronic atrial fibrillation (irregular heartbeat), and acute hematogenous osteomyelitis (bone infection) left ankle and foot. Resident #57 was noted with two non-pressure wounds present upon admission to the facility. The first was noted as a left lateral foot surgical wound, and the second was noted as a left lateral foot open lesion. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was admitted to the facility with one Stage III pressure wound and a surgical wound. Review of Resident #57's Plan of Care revealed three…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure a resident with a colostomy received care and treatments as ordered. This affected one Resident (#8) of one reviewed for colostomy care. The facility census was 114. Findings include: Review of Resident #8's medical record revealed an admission date of 10/01/19 with diagnoses included myocardial infarction (heart attack), end stage renal disease, and colostomy. Review of Resident #8's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired. Resident #8 was noted with an abdominal feeding tube, and an colostomy. Review of Resident #8's physician's orders revealed an order dated 10/01/19 for colostomy care to be completed every three days, on day shift. Review of Resident #8's Treatment Administration Record (TAR) for November 2019, December 2019 and January 2020 revealed Resident #8's colostomy care was not completed as ordered on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, staff interview, and review of facility pain flow sheet, the facility failed to ensure a resident's pain medications was administered in a timely manner. This affected one Resident (#50) of one reviewed for pain management. The facility census was 114. Findings include: Review of Resident #50's medical record revealed an admission date of 11/11/19. Diagnoses included muscle wasting, fibromyalgia (muscle pain), and insomnia. Review of Resident #50's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #50's physician orders revealed an order dated 12/21/19 for Oxycodone (narcotic) 5 milligrams (mg every four hours for pain. Review of Resident #50's care plan revised 01/03/19 revealed supports and interventions for pain. Supports and interventions included administer medications as ordered, and non-pharmacological pain interventions. Review of Resident #50's Medication Administration Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview and review of facility policy, the facility failed to ensure residents who received hemodialysis had their fistulas monitored as ordered. This affected one Resident (#8) of one reviewed for dialysis. The facility census was 114. Findings include: Review of Resident #8's medical record revealed an admission date of 10/01/19. Diagnoses included myocardial infarction, type II diabetes, end stage renal disease, and dependence on renal dialysis. Review of Resident #8's physician's orders revealed an order dated 10/02/19 for Resident #8's arteriovenous (AV) fistula to be checked every day on day shift for thrill and bruit. Review of Resident #8's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired. The resident was noted to be receiving dialysis, had an abdominal feeding tube, and ostomy at the time of the review. Review of Resident #8's Treatment Administration Record (TAR) for November 2019,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, and facility policy review, the facility failed to administer multiple doses of intravenous (IV) antibiotics per the physician orders for one resident (#57) of one reviewed for infections. The facility census was 114. Findings include: Review of the medial record for Resident #57 revealed an admission date of 11/21/19 with diagnoses of chronic atrial fibrillation (irregular heartbeat), and acute hematogenous osteomyelitis (bone infection), left ankle and foot. Resident #57 was admitted to the facility with a physician order for Cefepime (an antibiotic) two grams IV, three times a day for osteomyelitis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was admitted to the facility with physician orders for IV antibiotics. Review of the Medication Administration Record (MAR) for November 2019 revealed the IV antibiotic was not administered as scheduled on 11/22/19 at 6:00 A.M. The antibiotic order was renewed on 11/26/19…

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

Based on observation, staff interview, and facility policy review, the facility failed to ensure a medication was disposed of to prevent a potential infection control incident. This affected one Resident (#65) of two residents reviewed for medication administration. The census was 114. Findings include: Observation on 01/08/20 at 8:21 A.M. of medication administration administration with Licensed Practical Nurse (LPN) #421 for Resident #65 revealed the LPN dropped an Amlodipine tablet on the medication cart, and then picked it up with bare hands and put the tablet in the medication cup. Interview with the LPN at the time of the observation revealed she always picked up medications that drop on the medication cart with bare hands. She further revealed it was normal practice for her, and she saw no issue regarding infection control. Observation on 01/08/20 at 8:27 A.M. revealed LPN 421 administered the dropped Amlodipine to Resident #65. Review of a facility policy titled Medication Disposal/Destruction, and dated 08/2018 revealed wasted medications are defined as a medication that is…

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.