Piketon Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, staff interviews and facility policy, the facility failed to develop resident centered care plans for behavioral interventions for three (Residents #2, #28 and #30) of the eight residents reviewed. The facility census was 40. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 10/25/22. Diagnoses included: anxiety disorder, unspecified intellectual disabilities, unspecified mental disorder due to known physiological condition and schizoaffective disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident is rarely/never understood. This resident was assessed to require extensive assistance with one-person physical assist with bed mobility, dressing, and toileting and extensive assistance with two-persons physical assist with transfers. The resident received antianxiety medication seven days. Review of Resident #2's physician orders dated for 10/25/22 revealed this resident was receiving 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 facility interviews, record reviews and Medscape, the facility failed to obtain orders, and/or create care plans, conduct assessments and conduct communications for the appropriate care for three (Resident #25, #37, and # 295) out of twenty five residents reviewed. The facility census was 40. Findings include: 1. Review of the medical record for Resident # 295, revealed an admission date of 08/24/23. Diagnoses included: acute osteomyelitis, essential hypertension, and type 1 Diabetes Mellitus (DM). Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating intact cognition. This resident was assessed to require limited assistance with one-person physical assist for bed mobility, transfer, dressing and supervision with set up only for eating. Review of the physician's order dated 08/25/23 for Resident #295 revealed an order for an Omnipod 5 G6 Intro (Gen 5) Kit (Insulin Infusion Disposable Pump) 1 unit every…

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 record review the facility failed to ensure medication error rates were not greater than five percent when Resident #95 did not receive their dose of Eliquis (an anticoagulant blood thinner medication) and gave Resident #37 the wrong dose amount of Vitamin D3. This affected two (Resident #37, and #95) of four residents reviewed for medication administration. The facility had two errors out of 25 opportunities for a medication error rate of eight percent. The facility census was 40. Findings include: 1. Record review of Resident #95 revealed an admission date of 09/01/23 with pertinent diagnosis of: cellulitis, cirrhosis of liver, thrombocytopenia, atherosclerotic heart disease of native coronary artery, atrial fibrillation, type two diabetes mellitus, anemia, and congestive heart failure. Review of a Physicians Order dated 09/01/23 revealed to give apixaban (Eliquis) five milligrams one half tab by mouth every 12 hours. Observation on 09/06/23 at 7:54 A.M. revealed Registered Nurse (RN) #138 administering medications to Resident #95 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.

Based on observation, staff interview, record review, and policy review the facility failed to to provide a sanitary environment to prevent the spread and development of communicable disease and infections when they did not cleanse blood glucose monitoring machines appropriately after resident use for Resident #95. The facility identified three Residents (#5, #9, #11) on the 19-27 hallway who received blood glucose monitoring checks. The facility census was 40. Findings include: Record review of Resident #95 revealed an admission date of 09/01/23 with pertinent diagnosis of: cellulitis, cirrhosis of liver, thrombocytopenia, atherosclerotic heart disease of native coronary artery, atrial fibrillation, type two diabetes mellitus, anemia, and congestive heart failure. Review of a Physicians Order dated 09/03/23 revealed to inject novolog insulin per sliding scale before meals and at bedtime. Observation on 09/06/23 at 7:54 A.M. revealed Registered Nurse (RN) #138 used the glucometer to check Resident #95 blood sugar level. RN #138 cleaned the glucometer with alcohol after she was done.…

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 staff interview, review of time punch cards, and review of direct care staff schedule revealed the facility failed to ensure the facility had Registered Nurse (RN) coverage for a consecutive eight hours. This had the potential to affect all 34 residents. Findings include: Review of the nursing staff schedule from 11/01/21 through 11/30/21 revealed the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were scheduled on 11/25/21 day shift. Review of the time punch cards for the DON revealed zero accumulated hours for 11/25/21. Review of the time punch for the ADON revealed zero accumulated hours for 11/25/21. Interview on 12/01/21 at 3:00 P.M. with the Administrator and the Regional Director of Clinical Operations #77 confirmed there was no RN coverage for the facility on 11/25/21.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interviews, group resident interview, review of Resident Council Meeting Minutes, and a test tray the facility failed to serve food that was palatable and at an acceptable temperature. This had the potential to affect 33 of 34 resident (Resident #15 receives nothing from the kitchen) and specifically affected Residents #26, #10, #22, #15, #18, #23, #26, #28, #29, and #31. Findings include: 1. Review of Resident Council meeting minutes revealed on 8/27/21 complaints of cold food, it was not the best food and the food was either over or under cooked. The 09/15/21 resident council minutes revealed the food was cold, the food tasted bad, the broccoli and cauliflower were overcooked, and served in big pieces. Interview of Resident #26 on 11/21/21 at 9:40 A.M. revealed sometimes the hot foods were served cold and were not good. Interview of Resident #10 on 11/21/21 10:30 A.M. revealed hot foods were served cold. Interview with Resident #22 on 11/21/21 at 10:53 A.M. revealed food was not served hot.…

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, resident group interview, resident council meeting minutes, and staff interview the facility failed to ensure accommodation of resident food preferences and failed to offer a food substitute when a resident did not like the food served. This affected 33 of 34 residents (except Resident #15 who received nothing from the kitchen) and specifically affected Residents #7, #18, #23, #28, #29, #30, and #31 . Findings include: Review of Resident Council meeting minutes revealed on 09/15/21 resident council minutes revealed staff never asked the resident's food preferences. The residents stated they never served what is on the menu, and the residents did not have a copy of the menu to ask for a substitution. Observation on 11/21/21 at 12:12 P. M. revealed Resident #18 did not eat her soup and State Tested Nursing Assistant (STNA) #16 did not offer Resident #18 a substitute for the food she did not like. Resident #31 did not eat her chips, sandwich, or fruit and ate 50% of her soup. STNA #16 did not offer Resident #31 an alternate for the food items…

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

Based on observation, interview and record review, the facility failed to maintain a sanitary kitchen and ensure safe storage of foods served to residents. This had the potential to affect 33 of the 34 residents (Resident #15 does not receive nutrition from the facility kitchen) and specifically affected Residents #29 and #30. Facility census was 34. Findings include: The kitchen was observed on 11/21/21 at 8:20 A.M. with food debris noted on the bottom shelf of the reach in freezer. The hand washing station had missing cove base, missing and loose caulking seal around the sink and a wall gouge measuring eight inches by 10 inches long. At the time of the observation, Diet Manager, (DM )#11 verified the findings and verified the surfaces were unable to be cleaned and sanitized. Observation on 11/29/21 at 10:45 A.M. of the kitchen revealed the wall behind the stove had green drippings which had a greasy consistency when touched. Observation on 11/29/21 at 11:45 A.M. during preparation of puree foods by [NAME] #15, the attic entry door in the ceiling above the food preparation area 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 observation, interview, policy review, and review of Centers for Disease Control information, and record reviews, the facility failed to implement transmission based precautions to prevent the spread of COVID-19. This had the potential to affect the 34 residents residing in the facility and specifically affected Resident #135. The facility census was 34. Findings include: Record review for Resident #135 revealed this resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction, dysphagia, restlessness and agitation, and history of falls. This resident had no known allergies. Review of the admission Minimum Data Set (MDS) assessment, dated 11/22/21, revealed this resident had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 04. This resident was assessed to require extensive assistance from two staff members for bed mobility and transfers and extensive assistance from one staff member for toileting. 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 and interview, the facility failed to maintain the call light system in working order. This had the potential to affect the 34 residents residing in the facility. The facility census was 34. Findings include: Observation on 11/29/21 at 12:43 P.M. revealed the call light system located at the nurses station was beeping and the light for room [ROOM NUMBER] was lit up but no lights outside resident rooms were lit up. Licensed Practical Nurse (LPN) #88 responded to room [ROOM NUMBER] and found the call light system had not been activated in the room. LPN #88 then began going from room to room searching for the activated call light. Interview with LPN #88 on 11/29/21 at 12:50 P.M. verified the call light system located at the nurses station was beeping and the indicator for room [ROOM NUMBER] was lighting up indicating the resident residing in that room had activated the call light system. LPN #88 then verified no call lights outside the resident rooms had been lit up and the call light 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 observation and interview, and review of facility policy, the facility failed to maintain tile flooring in a resident room in safe condition and to ensure residents and staff smoking area was free of fire hazards This had the potential to affect all 34 residents residing at the facility. Findings include: 1. Observation on 11/21/21 at 9:48 A.M. of room [ROOM NUMBER] revealed there were five tiles located in the center of the room which were cracked and had raised corners coming off of the floor. Observation on 11/29/21 at 3:11 P.M. of room [ROOM NUMBER] revealed there were five tiles located in the center of the room which were cracked and had raised corners coming off of the floor. Interview with Maintenance Supervisor #56 on 11/29/21 at 3:11 P.M. verified the five tiles located in the center of room [ROOM NUMBER] were cracked and had raised corners which needed to be replaced. 2. Observation on 11/30/21 between 4:15 P.M. and 4:22 P.M. State Tested Nursing Assistant (STNA) #18 entered the dining room…

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 3. Record review for Resident #26 revealed this resident was admitted to the facility on [DATE] with diagnoses including non-displaced transverse fracture of right fibula, falls, muscle weakness, urinary tract infection, anxiety, morbid obesity, chronic pain, acute kidney failure, hypertension, bimalleolar fracture, and hyperlipidemia. This resident had no known drug allergies. Review of Resident #26's quarterly Minimum Data Set (MDS) assessment, dated 11/19/21, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. Resident #26 was admitted to the facility with a diagnosis of bilateral leg fractures and is currently in bed with a urinary catheter in place. Review of Resident #26's Physician Orders revealed an order was obtained on 11/03/21 for a urinary catheter due to recent acute kidney failure, resident request, and immobility. Order was obtained for 16 French urinary catheter with 10 ml balloon. Resident was explained risks and benefits.…

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 and interview the facility failed to ensure Witnessed Authorization Forms were completed and available for residents whose personal funds were being managed by the facility. This affected two (Resident #4, and #5) of the four residents reviewed for personal funds. The facility census was 34. Findings include: Review of the resident personal funds account record for Resident #4 revealed the facility was managing a personal funds account for Resident #4, and failed to have a Witnessed Authorization Form on record for personal funds to be managed by the facility. Review of the resident personal funds account record for Resident #5 revealed the facility was managing a personal funds account for Resident #5, and failed to have a Witnessed Authorization Form on record for personal funds to be managed by the facility. Interview on 11/29/21 at 11:30 A.M. with Business Office Manager #76 confirmed Resident #4, and #5 did not have a Witnessed Authorization Form on record.

Based on record review and interview the facility failed to provide receipts and/or book keeping records for all personal account activity. This affected three (Resident #4, #5, and #11) of the (4) four residents reviewed for personal funds. The facility census was 34. Findings include: Review of the resident personal funds revealed the facility failed to keep or provide records and/or receipts for purchases or withdrawals from resident personal funds accounts for Resident #4, #5, and #11 who were noted to have personal funds being managed by the facility. Interview on 11/29/21 at 11:30 A.M. with Business Office Manager #76 confirmed she was not able to locate any receipts for any purchases or cash withdrawals for Resident #4, #5, and #11.

Based on observation, resident interview, group resident interview, staff interview, and policy review the facility failed to provide an adequate dining space that was clean, comfortable, and homelike. This affected 11 residents who routinely ate in the common area by the nurses station (Resident #6, Resident #8, Resident #18, Resident #23, Resident #31, Resident #24, Resident #29, Resident #13, Resident #7, Resident #3, and Resident #26) and one resident ( Resident #12) who was observed eating in the common area. The facility census was 34 residents. Findings include: Observation on 11/21/21 at 8:15 A.M. revealed a large dining room with the doors closed. The room was brightly lit, had seven tables of differing sizes, and other dining room furnishings (sideboards, china cabinets, etc.). At the time of the observation, Dietary Manager (DM) #11 confirmed it was the resident dining room, but it was closed to the residents and she did not know why. DM #11 revealed the residents had not used the dining room since June 2021. Observation on 11/21/21 at 11:49 A.M. revealed residents eating…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a therapeutic diet for three residents, (Residents #6, #12 and #30,) and accurately monitor weights for one resident (Resident #24), as ordered by the physician for 21 residents reviewed for nutritional status. The facility census was 34. Findings include: 1. Review of the medical record and face sheet revealed Resident #30 was admitted to the facility on [DATE] with the diagnoses of chronic obstructive pulmonary disease, (COPD), dementia, SOB, gastritis, peripheral vascular disease, depressive disorder, nausea, reflux disease, fatigue, and muscle weakness. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 was moderately cognitively impaired, received a mechanically altered diet, was edentulous without pain., and had no depression. Review of plan of care updated on 09/15/21, addressed Resident #30's nutritional risk due to dementia, COPD, and edentulous assessment. Interventions included provide 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 3. Review of Resident #24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, hypertension, schizoaffective disorder (10/26/2021). Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #24 used oxygen and on hospice. Review of Resident #24's monthly physician orders for November 2021 revealed oxygen at two liters per minute as needed for dyspnea and to change the oxygen tubing every week and as needed. Review of Resident #24's treatment administration record for November 2021 revealed oxygen ordered at two liters for per minute and to change the tubing every week. There was no evidence Resident #24's oxygen tubing was changed. Observation on 11/21/21 at 9:48 A.M. of Resident #24's room revealed an oxygen concentrator with tubing next to Resident #24's bed. The tubing attached to the concentrator was not dated. Observation of Resident #24's oxygen concentrator on 11/29/21 at 10:00 A.M. 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, staff interview, and personnel file review, the facility failed to ensure direct care staff were provided dementia education. This affected one resident (Resident #24) of 11 residents with a dementia diagnosis. The facility census was 34. Findings include: Review of Resident # 24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, hypertension, schizoaffective disorder. Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #24 had short-term and long-term memory problems, no recall and her decision making was severely impaired. Resident #24 had no behaviors, she rejected care one to three days. Resident #24 was dependent on two staff for bed mobility, required extensive assistance of two staff to transfer, did not walk, no locomotion, required extensive assistance of two staff for dressing, was dependent on one staff to eat, for toilet use, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and observation the facility failed to provide personal materials of the resident's choice as requested. This affected one resident(Resident #28) out of two residents reviewed for personal choices. The facility census was 34. Findings include: Record review for Resident #28 revealed this resident was admitted to the facility on [DATE] with diagnoses including diabetes mellitis type II, myositis, muscle weakness, hypertension, anxiety, osteoarthritis, urinary tract infection, dyspnea, depression, cardiac arrhythmias, bipolar disorder, muscle spasms, pain, constipation, Vitamin D deficiency, hyperlipidemia, thyroid disorders, hyperlipidemia, depression, atherosclerotic heart disease, atrial fibrillation, chronic obstructive pulmonary disease, pain syndrome, and cystocele. This resident had allergies to Ibuprofen. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/03/21, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status…

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 ensure residents who formulated an advance directive had the directive honored. This affected two of five sampled residents (Resident #15 and Resident #24) reviewed for advance directives. Findings include: 1. Review of Resident #15's medical record revealed she was admitted on [DATE] with diagnoses that included: chronic obstructive pulmonary disease, heart failure, urinary incontinence, anxiety, hemiplegia and hemiparesis of right side, and psychosis. Resident #15 requested a do not resuscitate-comfort care (DNR-CC) order on 09/26/19. Review of Resident #15's quarterly Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #15's speech was clear, she was understood by others, understands others, her vision was adequate with no correction, and her cognition was intact. Resident #15 had a life expectancy of six months or less and she received hospice services. Review of Resident #15's signed October 2021 and November 2021…

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, interview, and facility policy review, the facility failed to ensure a resident being discharged from a Medicare covered Part A stay with benefit days remaining was provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form, and a Notice of Medicare Non-Coverage-Forms, Center for Medicare and Medicaid Services (CMS) 10123-(NOMNC) form. This affected one resident of the three residents reviewed for Beneficiary Notifications (Resident #13). The facility census was 34. Findings include: Review of the medical record for Resident #13 revealed an admission date of 09/24/20. Diagnoses included Parkinson's disease, acute and chronic respiratory failure, and drug induced acute dystonia (involuntary muscle contractions that cause repetitive or twisting movements). Review of Resident #13's Significant Change of Condition, Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 experienced long and short term memory problems and 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, staff interview, and observation the facility failed to assess a resident's use of a specialty chair and failed to assure the resident's chair was not positioned to prevent the resident for getting out of the chair. This affected one of one residents (Resident #24) reviewed for restraints. Findings include: Review of Resident #24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, and hypertension. Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #24's speech was clear, Resident #24 was rarely understood, rarely understands, she had short-term and long-term memory problems, no recall and her decision making was severely impaired. Resident #24 had no behaviors, she rejected care one to three days. Resident #24 was dependent on two staff for bed mobility, required extensive assistance of two staff to transfer, did not walk, and had no locomotion. Resident #24…

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 Review of resident medical record and staff interview, the facility failed to document a discharge for a resident returning to the community. This affected one (Resident #34) of the two residents reviewed for discharging from the facility. The facility census was 34. Findings include: Review of the closed medical record for Resident #34 revealed an admission date on 02/24/21 and a discharge date of 08/31/21. Diagnoses included, dementia without behavioral disturbances, hypertension, and muscle weakness. Review of the Resident #34's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 07 indicating a severely impaired cognition for daily decision making abilities. Resident #34 required limited assistance from one staff member for bed mobility, transfers, ambulation, dressing, toilet use, and personal hygiene, and supervision with set up help only for eating. Review of Resident #34's MDS revealed Discharge, return not anticipated, dated 08/31/21. 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 record review, observation, and interview the facility failed to provide appropriate dental and nutritional assessments to appropriately represent the residents health status. This affected two residents (Resident #4 and Resident #20) of 21 residents reviewed for accurate assessments. The facility census was 34. Findings include: 1. Record review for Resident #4 revealed this resident was admitted to the facility on [DATE] with diagnoses including Huntington's disease, lack of coordination, muscle weakness, dementia, dysphagia, abnormal posture, peripheral vascular disease, delusional disorders, depression, unspecified psychosis, paranoid personality disorder, Vitamin D deficiency, and shortness of breath. This resident had no known allergies. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/17/21, revealed this resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 8. Review of Annual Minimum Data Set Assessment Section…

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 refer a resident for a level II pre-admission screening and resident review (PASRR) when the resident was newly diagnosed with a mental illness. This affected one of three sampled residents (Resident #24) reviewed for PASRR. Findings include: Review of Resident #24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, hypertension, schizoaffective disorder (10/26/21). Review of Resident #24's PASRR dated 03/17/21 revealed Resident #24 did not have any mental illness. Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident # 24 did not have a level II PASRR completed. There was no level II PASRR conducted after Resident #24 was newly diagnosed with a mental illness, schizoaffective disorder. Interview of Regional Director of Clinical Operations (RDCO) #77 on 11/30/21 at 11:16 A.M. confirmed no level II PASRR was conducted…

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 notify the state mental health authority promptly after an significant change in a resident mental health, a resident with a newly diagnosed mental illness. This affected one of three sampled residents (Resident #24) reviewed for pre-admission screening and resident review (PASRR). Findings include: Review of Resident #24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, hypertension, schizoaffective disorder (10/26/21). Resident #24 received a new mental health diagnoses of schizoaffective disorder on 10/26/21. Resident #24 had no mental illness diagnoses identified prior. Interview of Regional Director of Clinical Operations (RDCO) #77 on 11/30/21 at 11:16 A.M. confirmed the state mental health authority was not notified of Resident #24's significant change in mental health.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Review of resident medical record and staff interview, the facility failed to complete a discharge summary for a resident returning to the community. This affected one (Resident #34) of the two residents reviewed for discharge from the facility. The facility census was 34. Findings include: Review of the medical record for Resident #34 revealed an admission date on 02/24/21 and a discharge date of 08/31/21. Diagnoses included, dementia without behavioral disturbances, hypertension, and muscle weakness. Review of the Resident #34's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 07 indicating a severely impaired cognition for daily decision making abilities. Resident #34 required limited assistance from one staff member for bed mobility, transfers, ambulation, dressing, toilet use, and personal hygiene, and supervision with set up help only for eating. Review of Resident #34's MDS revealed Discharge, return not anticipated, dated 08/31/21. 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 observations, interviews, and record reviews, the facility failed to ensure residents were provided with the necessary assistance to help maintain abilities in the area of eating and ambulation. This affected four of 22 residents (#7, #8, #12, and #24) reviewed for meal assistance. The facility census was 34. Findings include: 1. Record review for Resident #12 revealed this resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, hypertension, tremors, anxiety, depression, hypothyroidism, and malignant neoplasm of the breast. This resident had no known allergies. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 10/05/21, revealed this resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 06. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting, and set-up assistance with supervision for eating. This resident 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 observation, interview and record review, the facility failed to provide Activities of Daily Living (ADL) assistance and care for one dependent resident (Residents #11) of 21 residents reviewed for ADL assistance. The facility census was 34. Findings include: Review of the medical record and face sheet revealed Resident #11 was admitted to the facility on [DATE] with the diagnosis of chronic kidney disease, difficulty walking, hemiplegia following cerebral vascular accident, dysphagia, peripheral vascular disease, and aphasia. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 was cognitively intact and was able to make needs known. Resident #11 required extensive assistance of one person assistance for personal hygiene care, including shaving and supervision for bathing. Review of the plan of care, revised on 10/07/21, identified Resident #11's need for extensive assistance of one staff with grooming. Interventions included explaining procedures prior to starting and providing…

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, resident group meeting, and resident council minute review the facility failed to provide residents with a meaningful, varied activity program, and ongoing activities program that was tailored to the wants and needs of the residents living in the facility. This affected three of three sampled residents (Resident #6, Resident #20, and Resident #24) and five of five residents (Resident #18, Resident #31, Resident #23, Resident #28, and Resident #29) who attended the resident group meeting. Findings include: 1. Review of Resident #20's medical record revealed she was admitted on [DATE] with diagnoses that include: non displaced fracture of the right femur, cerebral palsy, paraplegia, contracture of left ankle, contracture of muscle multiple sites, postsurgical malabsorption, edema, anxiety disorder, disorder of psychological development, epilepsy, and constipation. Review of Resident #20's annual Minimum Data Set (MDS) dated [DATE] revealed 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 resident interview, medical record review, and staff interview the facility failed to assess and provide vision services and devices as needed. This affected one of one residents reviewed for vision (Resident #15). Findings include: Review of Resident #15's medical record revealed she was admitted on [DATE] with diagnoses that included: chronic obstructive pulmonary disease, heart failure, urinary incontinence, anxiety, hemiplegia and hemiparesis right side, and psychosis. Review of Resident #15's annual minimum Data Set (MDS) dated [DATE] revealed the following. Resident #15's speech was clear, she understood others, her vision was adequate with no correction, and her cognition was intact. Resident #15 had no behaviors and did not reject care. Resident #15 required extensive assistance of two staff for bed mobility and to transfer. Review of Resident # 15's quarterly MDS dated [DATE] revealed the following changes: rejected care one to three days, and for locomotion she required set up help with staff…

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 complete fall investigations and assessments of residents after falls with head injuries. This affected one of three residents reviewed for falls and after fall assessments (Resident #384). Findings Include: Review of the closed medical record for Resident #384 revealed an initial admission date of 10/09/13, re-entry date on 11/01/13, and a discharge date on 05/19/21. Diagnoses included difficulty in walking, unsteadiness on feet, repeated falls, muscle weakness, abnormal posture, stiffness of the knees, transient ischemic attack (TIA), concussion without loss of consciousness, injury of the head, and contusion of the scalp. Review of Resident #384's quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating a moderately impaired cognition for daily decision making abilities. Resident #384 was noted to experience or express no behaviors. Resident #384 required extensive…

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 resident interview, medical record review, and staff interview the facility failed to assess and provide treatment and care to treat a resident's incontinence. This affected one of one residents reviewed for bladder function (Resident #15). Findings include: Review of Resident #15's medical record revealed she was admitted on [DATE] with diagnoses that included: chronic obstructive pulmonary disease, heart failure, urinary incontinence, anxiety, hemiplegia and hemiparesis right side, and psychosis. Review of Resident #15 annual minimum Data Set (MDS) dated [DATE] revealed the following. Resident #15's speech was clear, she understood others, and her cognition was intact. Resident #15 had no behaviors and did not reject care. Resident #15 required extensive assistance of two staff for bed mobility and to transfer. Resident #15 was not on a toileting program and was always incontinent of bladder, There was no comprehensive assessment of Resident #15's bladder function or bladder retraining potential.…

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 pharmacy recommendations, and staff interview the facility failed to review a resident's drug regimen and make recommendations regarding drug irregularities. This affected one of six sampled residents (Resident #24) reviewed for unnecessary medications. Findings include: Review of Resident #24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, and hypertension. On 10/26/21 a diagnosis of schizoaffective disorder was added. Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #24 received an antipsychotic medication, an antidepressant medication, and an anticoagulant, 6 of 7 day assessment period and there was no dose reduction of the antipsychotic medication. Review of Resident #24's monthly physician orders revealed on admission an order for an antipsychotic medication (Risperdal) one milligram (mg) at bedtime. Review of Resident #24's July 2021,…

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 ensure a resident did not receive an antipsychotic medication without an indication for its use. This affected one of six sampled residents (Resident #24) reviewed for unnecessary medications. Findings include: Review of Resident #24's medical record revealed she was admitted on [DATE] with diagnoses that included: seizures, dementia, diabetes, and hypertension. On 10/26/21 a diagnosis of schizoaffective disorder was added. Review of Resident #24's significant change Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #24 received an antipsychotic medication, an antidepressant medication, and an anticoagulant 6 of 7 day assessment period. There was no dose reduction of the antipsychotic medication. Review of Resident #24's monthly physician orders revealed on admission an order for an antipsychotic medication (Risperdal) one milligram (mg) at bedtime. Review of Resident #24's medical record revealed the resident did not…

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 interview the facility failed to provide routine dental services for two residents. This affected two residents (Resident #4 and Resident #15) of four residents reviewed for routine dental services. The facility census was 34. Findings include: 1. Record review for Resident #4 revealed this resident was admitted to the facility on [DATE] with diagnoses including Huntington's disease, lack of coordination, muscle weakness, dementia, dysphagia, abnormal posture, peripheral vascular disease, delusional disorders, depression, unspecified psychosis, paranoid personality disorder, Vitamin D deficiency, and shortness of breath. This resident had no known allergies. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/17/21, revealed this resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 8. Review of Annual Minimum Data Set Assessment Section L 0200 completed on 05/07/21 revealed the resident 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, observation, and staff interview, the facility failed to ensure resident medical records reflected an accurate code status and enteral nutrition orders. This affected two residents (Resident #383, and #20) of the 23 resident records reviewed. The facility census was 34. Findings include: 1. Review of the closed medical record for Resident #383 revealed an admission date of [DATE], and a discharge date of [DATE]. Diagnoses include chronic kidney disease stage 3, hypokalemia, and heart disease. Review of Resident #383's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating an intact cognition for daily decision abilities. Resident #383 required supervision with no set up for bed mobility, transfers, locomotion, dressing, and personal hygiene. Resident #383 required supervision with set up assist for eating and toilet use. Review of Resident #383's physician orders for [DATE] revealed Resident #383's…

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.