Ayden Healthcare Of Rosemount Pavilion

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure smoking assessments were accurately completed for residents who smoked at the facility. This affected one resident (#39) out of the two residents reviewed for safe smoking practices during the annual survey. The facility identified 11 residents who were smokers. The facility census was 78. Findings include: Record review for Resident #39 revealed the resident was admitted to the facility on [DATE] and had diagnoses include pressure ulcer of the right heel, morbid obesity, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/20/25, revealed the resident was assessed to have intact cognition. Review of the care plan, initiated on 10/20/24, revealed the resident was at risk for injury related to smoking. Interventions included supervision at all times for smoking and smoking items to be kept at the nurses station. Review of the facility Smoking and Safety assessments,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure resident meals were as ordered by the physician. This effected one (Resident #20) of two residents reviewed for nutrition. The facility census was 78. Findings include: Review of the medical record for Resident #20 revealed an admission date of 08/04/19 with diagnoses including Alzheimer's disease, hypertension, protein calorie malnutrition, bipolar disorder, dementia, anxiety and hyperlipidemia. Review of a physician order dated 10/13/24 revealed Resident #20 was to receive a fortified foods diet, regular texture and thin liquids. Resident #20 also received a house supplement three times daily. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #20 was cognitively impaired with continuous inattention, disorganized thinking, had delusions and hallucinations and physical/verbal/other behavioral symptoms towards others. Resident #20 had impaired range of motion to bilateral lower extremities and was dependent…

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, interview and record review the facility failed to ensure Resident #20 family concerns of being overmedicated were timely and appropriately assessed. This effected one of one residents reviewed for opioid medication side effects. The facility census was 78. Findings include: Review of the medical record for Resident #20 revealed an admission date of 08/04/19 with diagnoses including Alzheimer's disease, hypertension, protein calorie malnutrition, bipolar disorder, dementia, anxiety and hyperlipidemia. Review of the physician orders dated 05/25 revealed Resident #20 was ordered the following medications: Tylenol eight hour extended release 650 milligrams (mg) by mouth every eight hours as needed for pain, tramadol hydrochloride 50 mg by mouth two times daily for pain, and attempt non pharmacological interventions as resident allows such as reposition for comfort, massage, diversion/guided imagery, music and relaxation techniques. Review of the Medication Administration Record (MAR) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review the facility failed to ensure blood pressure medications were held per the physician parameters. This effected one (Resident #69) of one reviewed for significant medication errors. The facility census was 78. Findings include: Review of the medical record for Resident #69 revealed an admission date of 03/03/25 with diagnoses including unspecified fracture of left lower extremity, generalized anxiety disorder, major depressive disorder, congestive heart failure, atrial fibrillation, diabetes mellitus type two, and hypertension. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #69 was cognitively intact with no mood symptoms or behaviors. Resident #69 had impaired range of motion to bilateral lower extremities. Resident #69 required substantial-maximum assistance from staff to complete activities of daily living. Resident #69 was incontinent of bowel and bladder. Resident #69 did not have any pain, falls or skin impairment. 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 record reviews and staff interviews, the facility failed to ensure laboratory testing was performed as ordered by the physician. This affected one resident (#39) out of the five residents reviewed for unnecessary medications during the annual survey. The facility census was 78. Findings include: Record review for Resident #39 revealed the resident was admitted to the facility on [DATE] and had diagnoses include pressure ulcer of the right heel, morbid obesity, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/20/25, revealed the resident was assessed to have intact cognition. Review of the active physicians order, dated 12/10/24, revealed the resident was to have a Complete Blood Count (CBC) with differential, and Basic Metabolic Panel (BMP), and a Hemoglobin(Hgb) A1C level drawn and resulted every three months in January, April, July, and October. Review of the laboratory results for Resident #39 from 10/11/24 through 05/14/25 revealed no CBC, BMP, or HgbA1C…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure indwelling foley catheter drainage bags were off the floor. This effected two residents (Resident #76 and #233) of three residents reviewed for indwelling foley catheters. The facility census was 78. Findings include: 1. Review of the medical record for Resident #76 revealed an admission date of 02/11/25 with diagnoses including dysarthria, neuromuscular dysfunction of bladder, transient ischemic attack (TIA), cirrhosis of liver, benign prostate hypertrophy (BPH), insomnia, viral Hepatitis B, hypertension and major depression. Review of the physician orders dated 05/25 revealed Resident #76 was ordered the following medications and treatments: 16 French indwelling foley catheter with 10 milliliter (ml) balloon to catheter bag drainage system related to neurogenic bladder, change indwelling foley catheter monthly and as needed, monitor urinary output related to foley catheter every shift, irrigate bladder three times per week with normal saline 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 staff interview and record review the facility failed to give residents the correct form when they were cut from therapy services and stayed in the facility. This affected two (Resident #12 and #35) of three residents reviewed for beneficiary notices. The facility census was 74. Findings include: 1. Record review of Resident #12 revealed an admission date of 09/19/22 and she was cut from therapy services on 07/03/23 and stayed in the facility and her pay source was Medicare part A. The resident had pertinent diagnoses including: stroke, hypertension and diabetes. Review of beneficiary notice date 06/29/23 revealed Resident #12 was being cut from therapy services on 07/03/23 and she did not receive CMS form 10055 that gives them the option to appeal, pay for it themselves, or agree to cut services. Interview with the Administrator on 08/09/23 at 2:00 P.M. verified there was no CMS form 10055 for Resident #12 given. 2. Record review of Resident #35 revealed an admission date of 04/18/23 and he was cut from therapy services on 05/04/23 and stayed in the facility and his pay…

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 interviews, record reviews, review of facility Self Reported Incident (SRI), review of facility investigation, and review of facility policy, the facility failed to prevent staff to resident abuse. This affected one resident (#14) out of the three residents reviewed for abuse during the annual survey. The facility census was 74. Findings include: Record review for Resident #14 revealed this resident was admitted to the facility on [DATE] and had diagnoses including unspecified convulsions, osteomyelitis, unspecified dementia, Alzheimer's disease, bipolar disorder, and altered mental status. Review of the significant change Minimum Data Set (MDS) assessment, dated 07/24/23, revealed this resident was rarely/never understood. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting and to require supervision with one person physical assistance for eating. Review of the facility SRI form, dated 07/03/23, revealed on 06/08/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, review of facility Self Reported Incident (SRI), review of facility investigation, and review of facility policy, the facility failed to ensure timely reporting of an allegation of abuse. This affected one resident (#14) out of the three residents reviewed for abuse during the annual survey. The facility census was 74. Findings include: Record review for Resident #14 revealed this resident was admitted to the facility on [DATE] and had diagnoses including unspecified convulsions, osteomyelitis, unspecified dementia, Alzheimer's disease, bipolar disorder, and altered mental status. Review of the significant change Minimum Data Set (MDS) assessment, dated 07/24/23, revealed this resident was rarely/never understood. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting and to require supervision with one person physical assistance for eating. Review of the facility SRI form, dated 07/03/23, revealed 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 interviews, record reviews, review of facility Self Reported Incident (SRI), review of facility investigation, and review of facility policy, the facility failed to ensure a timely and thorough investigation was completed following an allegation of abuse. This affected one resident (#14) out of the three residents reviewed for abuse during the annual survey. The facility census was 74. Findings include: Record review for Resident #14 revealed this resident was admitted to the facility on [DATE] and had diagnoses including unspecified convulsions, osteomyelitis, unspecified dementia, Alzheimer's disease, bipolar disorder, and altered mental status. Review of the significant change Minimum Data Set (MDS) assessment, dated 07/24/23, revealed this resident was rarely/never understood. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting and to require supervision with one person physical assistance for eating. Review of the facility SRI…

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 and record review, the facility failed to ensure a new Pre-admission Screen and Resident Review (PASARR) was completed following a new diagnosis of psychosis. This affected one resident (#16) out of the three residents reviewed for PASARR's during the annual survey. The facility census was 74. Findings include: Record review for Resident #16 revealed this resident was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, osteoarthritis, anxiety disorder, and difficulty walking. A new diagnosis of unspecified psychosis was added for the resident on 01/20/23. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/20/23, revealed this resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 12 out of 15. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting. Further record review for this resident revealed no evidence of…

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

Based on staff interview, observation, and record review the facility failed to have a care plan for Resident #30's skin condition and failed to have an accurate care plan for Resident #47's dialysis port site. This affected two of 17 residents reviewed for care plans. The facility census was 74. Findings include: 1. Record review of Resident # 30 revealed an admission date of 06/09/23 with pertinent diagnoses of: non pressure chronic ulcer of skin, anxiety disorder, hypertension, and cellulitis of abdominal wall. Review of the 06/16/23 admission Minimum Data Set (MDS) assessment revealed the resident was cognitively intact and was at risk for pressure ulcers and had two arterial or venous ulcers. The MDS triggered in section V for a skin/pressure ulcer care plan to be out in place. Review of the medical record on 08/09/23 revealed the resident had a wound to her abdominal area since admission. Review of the medical record on 08/09/23 revealed there was no care plan for pressure ulcer or skin alterations developed. Interview on 08/10/23 at 10:15 A.M. with the Administrator verified…

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 interviews, record reviews, and review of facility policy, the facility failed to ensure appropriate pain management was provided for a residents complaints of pain. This affected one resident (#14) out of the two residents reviewed for pain management during the annual survey. The facility census was 74. Findings include: Record review for Resident #14 revealed this resident was admitted to the facility on [DATE] and had diagnoses including unspecified convulsions, osteomyelitis, unspecified dementia, Alzheimer's disease, bipolar disorder, and altered mental status. Review of the significant change Minimum Data Set (MDS) assessment, dated 07/24/23, revealed this resident was rarely/never understood. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting and to require supervision with one person physical assistance for eating. This resident was assessed to exhibit nonverbal indicators of pain daily over past 5 days. 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 staff interview, observation, resident interview, and record review the facility failed to provide dialysis care with professional standards when they failed to document checks of the dialysis port. This affected one (Resident #47) of one resident who was receiving dialysis services. The facility census was 74. Findings include: Record review of Resident # 47 revealed an admission date of 01/10/23 with pertinent diagnoses of: end stage renal disease, type two diabetes mellitus, morbid obesity, lymphedema, atrial fibrillation and hypertension. Review of the 07/07/23 quarterly Minimum Data Set (MDS) assessment revealed the resident was moderately cognitively impaired and was receiving dialysis services. Review of the care plan dated 01/11/23 revealed Resident #47 has renal failure related to end stage disease and the goal is the resident will be free from infection through the review date. Review of Resident #47's medical record on 08/10/23 revealed there was no documented evidence that the dialysis site was checked for infection, bleeding, bruit or thrill, or patency.…

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 interviews, record reviews, and review of facility policy, the facility failed to ensure pain levels and interventions for pain were monitored and documented when pain medication was administered. This affected two residents (#14 and #18) out of the two residents reviewed for pain management during the annual survey. The facility census was 74. Findings include: 1. Record review for Resident #14 revealed this resident was admitted to the facility on [DATE] and had diagnoses including unspecified convulsions, osteomyelitis, unspecified dementia, Alzheimer's disease, bipolar disorder, and altered mental status. Review of the significant change Minimum Data Set (MDS) assessment, dated 07/24/23, revealed this resident was rarely/never understood. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting and to require supervision with one person physical assistance for eating. Review of the care plan, dated 04/25/23, revealed this 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 record review and interview the facility failed to provide an appropriate diagnosis for the use of an antipsychotic medication. This affected two residents (Resident #34 and Resident #74) out of five residents reviewed for unnecessary medications. The facility census was 74. 1. Record Review of Resident #34 on 08/09/23 at 07:41 A.M. revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: acute kidney failure, Schizoaffective disorder, osteomyelitis, left femur fracture, abdominal wall abscess, chronic ulcers, congestive heart failure, adult failure to thrive, Alzheimer's disease, anxiety, depression, and dementia. Review of the Minimum Data Set (MDS) assessment completed on 05/02/23 revealed this resident has severe cognitive impairment. Review of physician orders revealed this resident is receiving the following medication: Seroquel 25 milligrams (mg) 1 tablet by mouth daily at bedtime for agitation. Review of current resident diagnoses revealed this resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, resident interview, and observation the facility failed to ensure residents received necessary care and treatment for application of hand protectors and hospice services. This affected two of 22 sampled residents (Residents #56 and #66). Findings include: 1. Review of Resident #66's medical record revealed she was admitted on [DATE] with diagnoses that included: dysphagia, muscle weakness, abnormal posture, essential hypertension, hemiplegia right side, cerebrovascular disease, and cerebral edema. Review of Resident # 66's admission Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #66's speech was clear, she makes herself understood, she understands others, her cognition was intact, and she had minimal depression. Resident #66 had verbal and other behavioral symptoms not directed toward others one to three days during the assessment period, that did not impact the resident or other residents, and she did not reject care. Resident #66 required…

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

Based on observation, policy review, and staff interview the facility failed to ensure medications were stored appropriately when the facility had numerous expired medications and undated insulin. This affected three Residents (#8, #59, and #67) and affected two of four medication carts observed for med storage. The facility census was 84. Findings include: Observation on 08/12/21 at 10:43 A.M. of the 100 hall medication cart revealed the following expired over the counter medications: cetrizine 10 milligrams (mgs) expired 07/21, Vitamin B-12 100 micrograms expired 07/21, and multi vitamin with iron expired 12/20. Interview with Licensed Practical Nurse (LPN) #408 on 08/12/21 at 10:43 A.M. verified the medications were all expired and should have been discarded and not used. Observation on 08/12/21 at 10:54 A.M. of the 400 hall medication cart revealed Resident #67 insulin Lispro vial was not marked when opened and was received from pharmacy on 03/01/21. Resident #8 Lantus insulin vial was not marked when opened and was received from pharmacy on 05/25/21. Resident #59 had a Basaglar…

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, staff interview, review of facility policy for Notices of Transmission Based Precautions, Wound Care, and review of the Center for Disease Center guidance on Respirators on/Respirators off, the facility failed to ensure infection control safety measures were followed for residents who were in quarantine for COVID-19 and being an unvaccinated new admission, resident on contact isolation, and for residents during a wound dressing change. This affected five residents (Resident #9, #19, #274, #275, and #285) of the 22 residents reviewed during this annual survey. The facility census was 84. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 12/26/18. Diagnoses included pressure ulcer to the coccyx, muscle weakness, and hemiplegia affecting unspecified side. Review of Resident #19's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/17/21, revealed the resident's cognition was not assessed. No behaviors were noted. Resident #19 was noted to require extensive assistance from two staff members…

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 resident bathroom floors were clean. This affected three (Residents #278, #279 and #284) of three residents reviewed for environment. The facility census was 84. Findings include: 1. Observation on 08/10/21 at 8:58 A.M. revealed built-up dust and additional unidentified debris on the floor in the corners and the floor was visibly dirty inside Residents #284 and #279's bathroom. Interview on 08/10/21 at 8:58 A.M., Resident #279 stated the housekeeping staff mop his room most days but they do not sweep. Resident #279 further stated the dust and unidentified debris in the corners had been that way since he admitted last month (07/21/21). Observation on 08/16/21 at 11:03 A.M. revealed built-up dust and additional unidentified debris remained on the floor in the corners and dirty floor inside Resident #284 and #279's bathroom. Interview on 08/16/21 at 11:09 A.M., Housekeeping Assistant (HA) #350 stated all resident rooms are cleaned daily. HA #350 verified there was dust and unidentified debris…

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 and record review the facility failed to notify the ombudsman when residents were admitted to the hospital. This affected one (Resident #9) of three reviewed for hospitalization. The facility census was 84. Findings include: Record review of Resident #9 revealed an admission date of 06/27/18 with pertinent diagnoses of: chronic respiratory failure, chronic obstructive pulmonary disease, dementia, cerebrovascular disease, seizures, hypertension, arteriosclerotic heart disease, type two diabetes mellitus, major depressive disorder, dysphagia, hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage, benign prostatic hyperplasia, glaucoma, chronic kidney disease, and insomnia. Review of the 07/23/21 quarterly Minimum Data Set (MDS) assessment revealed Resident #9 was moderately cognitively impaired and required total dependence for bed mobility, eating, bathing, and toilet use. The Resident was always incontinent of bowel and bladder. Record review of Progress Notes dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the Resident Assessment Instrument (RAI) the facility failed to ensure resident assessments were completed accurately in the areas of nutrition, skin integrity, and opiod use. This affected three (Residents #40, #41, and #279) of 22 residents reviewed for assessments. The facility census was 84. Findings Include: 1. Review of the medical record for Resident #40 revealed an admission date of 12/16/20. Diagnoses included unspecified displaced fracture of surgical neck of left humerus, 4-part fracture of surgical neck of left humerus, non-displaced fracture of right tibial spine, essential hypertension, unspecified dementia, and hypokalemia. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. Resident #40 weighed 99 pounds. Review of Resident #40's weights revealed, on 07/08/21, Resident #40 weighed 100.4 pounds. On 06/01/21, Resident #40 weighed 98.8 pounds. On 05/04/21, Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and staff interview, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) (a screen to check for a serious mental illness prior to admission into a facility) for residents with a qualifying diagnosis of bipolar disorder and failed to include a qualifying diagnosis when completing a level one PASRR for a resident. This affected two (Residents #59 and #63) of the two residents reviewed for PASRRs. The facility census was 84. Findings include: 1. Review of the medical record for Resident #59 revealed an admission date of 06/08/21. Diagnosis included bipolar disorder with current episode depression, heart failure, and hypertension. Review of Resident #59's quarterly Minimum Data Set (MDS) 3.0 assessment completed on 07/09/21 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating an intact cognition for daily decision making ability. Resident #59 was noted to express feeling down, depressed or hopeless, have trouble falling asleep, or…

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 develop comprehensive care plans for residents in the areas of refusal of treatment, smoking, and activities. This affected two (Resident #71 and #279) of 22 sampled resident's whose care plans were reviewed. Findings include: 1. Review of Resident #71's medical record revealed she was admitted on [DATE] with diagnoses that included: hypertensive urgency, asthma, chronic pain, osteoarthritis, pleural effusion, insomnia, dementia without behaviors, gastro-esophageal reflux disease, constipation, and cognitive communication deficit. Review of Resident #71's admission Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #71's speech was clear, she made herself understood, she understands others, and her cognition was moderately impaired. Resident #71 had moderately severe depression, she had no psychosis, did not refuse care, and had no behaviors. It was somewhat important for Resident #71 to have reading material,…

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 observation, the facility failed to identify a resident's need for an audiology consult who was experiencing signs of being hard of hearing. This affected one (Resident #27) of one resident reviewed for vision/hearing needs. The facility census is 84. Findings included: Review of the medical record for Resident #27 revealed an initial admission date of 12/28/20 and a re-entry date of 03/29/21. Diagnoses included acquired absence of the left leg below the knee, hypothyroidism, and anxiety disorder. Review of Resident #27's quarterly Minimum Date Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating a moderately impaired cognition for daily decision making ability. Resident #27 was noted to require extensive assistance from one staff member for bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #27 was noted to have adequate hearing with no assistive devices. 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 staff interview, medical record review, resident interview, and observation the facility failed to provide an ongoing activities program that was of interest to the resident. This affected one (Resident #71) two sampled residents reviewed for activities. Findings include: Review of Resident #71's medical record revealed she was admitted on [DATE] with diagnoses that included: hypertensive urgency, asthma, chronic pain, osteoarthritis, pleural effusion, insomnia, dementia without behaviors, gastro-esophageal reflux disease, constipation, and cognitive communication deficit. Review of Resident #71's admission Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #71's speech was clear, she made herself understood, she understands others, and her cognition was moderately impaired. Resident #71 had moderately severe depression, she had no psychosis, did not refuse care, and had no behaviors. It was somewhat important for Resident #71 to have reading material, to listen to music she liked, 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 observation, staff interview, resident interview, and medical record review the facility failed to ensure residents received the nutritional interventions to maintain body weight and to ensure nutritionally adequate diets were provided. This affected two of four sampled residents reviewed for nutrition (Resident #71 and #41). Findings include: 1. Review of Resident #71's medical record revealed she was admitted on [DATE] with diagnoses that included: hypertensive urgency, asthma, chronic pain, osteoarthritis, pleural effusion, insomnia, dementia without behaviors, gastro-esophageal reflux disease, constipation, and cognitive communication deficit. Review of Resident #71's admission Minimum Data Set (MDS) dated [DATE] revealed the following. Resident # 71's speech was clear, she made herself understood, she understands others, and her cognition was moderately impaired. Resident #71 had moderately severe depression, she had no psychosis, did not refuse care, and had no behaviors. Resident #71 required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to ensure oxygen tubing was changed per the physician's order. This affected one (Resident #41) of one residents reviewed for respiratory care. The facility identified nine residents who receive respiratory treatments. The facility census was 84. Findings include: Review of the medical record for Resident #41 revealed an admission date of 07/01/21. Diagnoses included heart failure, chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus without complications, unspecified cirrhosis of liver, anxiety disorder, major depressive disorder, chronic atrial fibrillation, and end stage renal disease. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident required extensive assistance of two staff for bed mobility, transfers, and toileting. Review of the physician orders revealed orders dated 07/02/21 for oxygen via nasal cannula at 3 liters per…

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 received antipsychotic medication had an adequate indication for use and had target behaviors identified. This affected one of five sampled residents and one resident reviewed for hospice (Resident #56 and #63). Findings include: 1. Review of Resident #63's medical record revealed she was admitted on [DATE] with osteoarthritis of knee, dementia with behavioral disturbance, generalized anxiety, and schizoaffective disorder bipolar disorder. Review of Resident #63's admission Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #63 did not have a serious mental illness and/or intellectual disability. Resident #63 received an antipsychotic medication. Review of Resident #63's physician orders revealed an antidepressant medication (Zoloft) 50 milligrams (mg) daily, an antianxiety medication (Ativan) 0.5 mg once daily at bed time, and antipsychotic medication (Seroquel) 25 mg twice daily. Review of 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 staff interview, observation and record review the facility failed to ensure medications error rates were less than 5% when they administered the wrong medication and wrong dosage amount for Resident #47. The facility had 29 medication administration opportunities with two errors for a medication error rate of 6.9%. The facility census was 84. Findings include: Record review of Resident #47 revealed an admission date of 09/11/15 with pertinent diagnoses of: type two diabetes mellitus, hypothyroidism, schizoaffective disorder, dementia, vitamin D deficiency, and gastro-esophageal reflux disease. Review of Resident #47's Physician Orders on 08/11/21 revealed an order dated 02/09/21 for heartburn relief 10 mg tablet give two tablets orally one time a day for gastro-esophageal reflux disease. Review of Resident #47's Physician Orders on 08/11/21 revealed an order dated 01/26/21 for Vitamin D3 2000 unit tablet give one tablet orally one time a day for supplement. Observation of a medication pass on 08/11/21 at 9:15 A.M. with Registered Nurse (RN) #835 revealed she administered…

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 menu review, resident interview, staff interview, and medical record review the facility failed to have a vegetarian menu prepared in advance. This affected one of four sampled residents reviewed for nutrition (Resident #71). Findings include: Review of Resident #71's medical record revealed she was admitted on [DATE] with diagnoses that included: hypertensive urgency, asthma, chronic pain, osteoarthritis, pleural effusion, insomnia, dementia without behaviors, gastro-esophageal reflux disease, constipation, and cognitive communication deficit. Review of Resident #71's admission Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #71's speech was clear, she made herself understood, she understands others, and her cognition was moderately impaired. Resident #71 had moderately severe depression, she had no psychosis, did not refuse care, and had no behaviors. Resident #71 required extensive assistance of two staff for bed mobility, did not transfer, walk, or use locomotion, supervision 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.