Longmeadow Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility policy the facility failed to obtain weights according to Dietician recommendations for Resident #47. This affected one Resident (#47) out of three residents reviewed for nutrition. The facility census was 73. Findings included: Review of the medical record for Resident #47 revealed an admission date of 06/09/24 and her diagnoses included cerebral infarction due to embolism of right middle cerebral artery, diabetes, hypertension and presence of gastrostomy tube (tube inserted into the stomach to provide means of feeding and medication). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #47 had impaired cognition, and she had a feeding tube with weight loss that was not prescribed. Review of the care plan last revised 02/13/25 revealed Resident #47 was at risk for malnutrition related to underweight, dysphagia, nothing by mouth, feeding tube, pressure wounds, and significant weight change. Interventions included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of facility policy the facility did not ensure there was proper signage indicating oxygen was in use. This affected three Residents (#2, #18, and #26) out of four residents reviewed for oxygen use. This had the potential to affect 21 Residents (#6, #7, #12, #13, #17, #20 #26, #27, #29, #35, #44, #45, #51, #53, #54, #59, #62, #63, #229, #232, and #237) that were identified by the facility as having oxygen. The facility census was 73. Findings included: 1. Review of the medical records for Resident #2 revealed an admission date of 02/23/16 and diagnoses included bipolar disorder, diabetes, and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 had intact cognition and was not on oxygen. Review of the March 2025 physician orders for Resident #2 revealed he had no orders for oxygen. Observation on 03/24/25 at 11:30 A.M. revealed in Resident #2's room there was a Broda chair (a chair that reclines…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and facility policy review, the facility failed to ensure non-pharmacological interventions were attempted prior to administering as needed pain medication and failed to ensure parameters were in place for when to administer of Acetaminophen versus opioid pain medication. This affected two residents (#12 and #21) of five residents reviewed for unnecessary medications. The facility census was 73. Findings include: 1. Review of the medical record for Resident #12 revealed and admission date of 05/08/24. Diagnoses included respiratory failure, congestive heart failure, chronic obstructive pulmonary disease (COPD), kidney disease, sleep apnea, glaucoma and depression. Review the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was cognitively intact. She required setup help for eating, oral and personal hygiene, supervision for toileting and partial to moderate assistance for showering. Review of the physicians' orders from March 2025 revealed an order…

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

Based on record review, interview and facility policy review, the facility failed to ensure the physician was notified of laboratory results for Resident #12. This affected one resident (#12) of three residents reviewed for laboratory results. The facility census was 73. Findings include: Review of the medical record for Resident #12 revealed and admission date of 05/08/24. Diagnoses included respiratory failure, congestive heart failure, chronic obstructive pulmonary disease (COPD), kidney disease, sleep apnea, glaucoma and depression. Review of Resident #12's medical record revealed a urinalysis was obtained on 08/27/24 which showed evidence of nitrites, epithelial cells, bacteria, hyaline casts, mucous and white blood cell clumps. There was no evidence that the physician was notified of the results of the urinalysis. Interview on 03/26/25 at 9:21 A.M. with Licensed Practical Nurse (LPN) #322 confirmed there was no documented evidence the laboratory results were reported to the physician for Resident #12. Review of the facility policy titled Notification of Changes dated 01/01/25…

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, review of the Centers for Disease Control (CDC) nursing standard of practice for medication administration, and review of facility policy and procedure, the facility failed to ensure staff administered medications to Resident #7 and Resident #69 according to professional standards of practice. This affected two out of two residents observed for medication administration. The facility census was 72. Findings include: Resident # 7 was admitted on [DATE] with diagnoses including paroxysmal atrial fibrillation, gastroesophageal reflux disease, glaucoma, benign heart neoplasm, chronic obstructive pulmonary disease with pulmonary embolism, high blood pressure, transient ischemic attack (TIA), anemia, kidney disease, osteoarthritis, obesity, vitamin D deficiency, osteoporosis, and neuropathy. Resident #7's physician orders dated [DATE] to [DATE] indicated to administer the following medications upon rising: - Eliquis 2.5 mg tablet - furosemide 40 milligrams (mg) tablet - metoprolol 25…

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 ensure staff donned appropriate personal protective equipment when providing direct care for Resident #60. This affected one out of three residents reviewed for pressure ulcers. The facility census was 72. Findings include: Review of Resident #60's medical record revealed the resident was admitted on [DATE] with diagnoses including stroke, coronary artery disease, cancer, heart failure, high blood pressure, diabetes mellitus, and high cholesterol. Review of Resident #60's plan of care revised 12/13/24 indicated a potential for complications related to the use of an indwelling urinary catheter. Intervention on the plan of care indicated to implement enhanced barrier precautions. Review of Resident #60's Minimum Data Set (MDS) assessment dated [DATE] indicated the presence of a stage three pressure ulcer (Full thickness tissue loss. Subcutaneous visible but bone, tendon or muscle is not fat may be exposed. Slough may be present but does 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.

Based on record review, observation, and interview the facility failed to maintain safe and comfortable water temperatures for residents. This had the potential to affect nine residents (Resident #1, Resident #3, Resident #9, Resident #24, Resident #36, Resident #48, Resident #49, Resident #56 and Resident #61) residing on [NAME] Hall. The census was 71. Findings include: Observation on 01/07/25 at 11:16 A.M. of the water temperature in the shower room on [NAME] Hall revealed a shower temperature of 90.4 degrees Fahrenheit (F) after the water was running for seven minutes. The water temperature of the sink started at 101 degrees F but went down to 99 degrees F after running for 3 minutes. Interview on 01/07/25 at 11:16 A.M. with Maintenance Director #225 revealed the temperature should be between 110 to 120 degrees F. He stated he had to adjust it weekly based on colder or hotter weather temperatures. Review of a list of residents residing on [NAME] Hall revealed Resident #1, Resident #3, Resident #9, Resident #24, Resident #36, Resident #48, Resident #49, Resident #56 and 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 interview, record review, and review of the facility policy, the facility failed to deliver all resident mail and personal packages to them unopened. This affected two residents reviewed (Resident #1 and #24) and had the potential to affect all residents. The facility census was 78. Findings include: 1. Record review for Resident #1 revealed an admission date of 07/20/23 and a transfer to hospital date of 08/08/24. Diagnosis included respiratory failure with hypoxia, morbid severe obesity due to excessive calories, atrial fibrillation, and dependence on respirator (ventilator) status. Review of the annual Minimum Data Set (MDS) dated [DATE] for Resident #1 revealed Resident # #1 was cognitively intact. Resident #1 used a wheelchair for mobility. Phone interview on 08/19/24 at 2:22 P.M. with Resident #1 revealed while she was at the facility, she received mail and packages delivered by the staff that were opened without her permission prior to her receiving them. Interview on 08/19/24 at 2:34 P.M. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility policy, the facility failed to assure one resident, Resident #5 received routine showers/baths per the resident preference and the facility schedule. This affected one resident (Resident #5) of three residents reviewed for bathing. The facility census was 78. Findings include: Record review for Resident #5 revealed an admission date of 01/02/24. Diagnosis included autistic disorder, morbid obesity, and malignant neuroleptic syndrome. Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #5 was moderately cognitively impaired. Resident #5 had no impairment of the upper or lower extremities, used a wheelchair for mobility, required set up or clean up assist for meals and was dependent for showers. Review of the care plan dated 01/22/24 for Resident #5 revealed assistance needed for activities of daily living (ADL) related to cognitive impairment, impaired mobility, Autism, and intellectual disability. The resident required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to timely report and address a Resident #21's change in skin condition. This affected one resident (Resident #21) of three residents reviewed for change in condition. Findings include: Record review for Resident #21 revealed an admission date of 10/31/19. Diagnosis included schizoaffective disorder, HIV, and Alzheimer's disease. Review of the physician orders for Resident #21 revealed an order dated 10/17/22 to apply zinc oxide cream to bilateral buttocks every shift and as needed for skin integrity. Review of the quarterly Minimum Data set (MDS) dated [DATE] revealed Resident #21 was rarely or never understood. Resident #21 had no impairment in functional limitations in range of motion to the upper or lower extremities, Resident #21 was dependent for personal hygiene. Resident #21 was always incontinent of bowel and bladder. Resident # received applications of ointments. Resident #21 required supervision or touch assist with walking 10…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure Resident #21, who had a history of Alzheimer's disease, had proper interventions in place to prevent consumption of poisonous substances. This affected one resident (Resident #21) of one resident reviewed for dementia care. The facility census was 78. Findings include: Record review for Resident #21 revealed an admission date of 10/31/19. Diagnosis included schizoaffective disorder and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #21 was rarely or never understood. Resident #21 had no impairment in functional limitations in range of motion to the upper or lower extremities, Resident #21 required set up or clean up assist with eating and was dependent for personal hygiene. Resident #21 was always incontinent of bowel and bladder. Resident #21 received applications of ointments. Resident #21 required supervision or touch assist with walking 10 feet.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility policy, the facility failed to ensure Resident #1 was free from significant medication error. This affected one resident (Resident #1) of three residents reviewed for medication administration. The facility census was 78. Findings include: Record review for Resident #1 revealed an admission date of 07/20/23 and a transfer to hospital date of 08/08/24. Diagnosis included respiratory failure with hypoxia and atrial fibrillation. Review of the annual Minimum Data Set (MDS) dated [DATE] for Resident #1 revealed Resident #1 was cognitively intact. Review of the physician orders for Resident #1 dated 07/08/24 revealed an order for Midodrine (used to increase blood pressure) hcl 10 milligrams (mg) one tablet by mouth three times a day for blood pressure, hold if systolic blood pressure (SBP) above 120. Review of the Medication Administration Record (MAR) for Resident #1 for 07/08/24 through 08/07/24 revealed Resident #1's blood pressure was monitored prior…

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 interview, record review and review of facility policy the facility failed to ensure Resident #70 had physician's orders and parameters for continuous oxygen administration via nasal cannula. This affected one resident (Resident #70) out of three residents reviewed for oxygen administration. The facility census was 68. Findings include: Review of Resident #70's medical record revealed an admission date of 02/08/23 and a discharge date of 02/10/23. Resident #70's diagnoses included hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the right dominant side, obstructive sleep apnea and type two diabetes mellitus. Review of Resident #70's admission Assessment with Baseline Care Plan dated 02/08/23 included Resident #70 was admitted from the hospital, had the cognitive ability to be oriented to his room, surroundings and was oriented to room, call bell, bed controls and side rails. Resident #70 was alert to person and situation and had clear verbal communication. Resident #70 was non ambulatory. Review of Resident #70's physician orders 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.

Based on interview, record review and review of the facility policy ,the facility failed to ensure Resident #70 was free from significant medication errors. This affected one resident (Resident #70) out of three residents reviewed for medication administration. The facility census was 68. Findings include: Review of Resident #70's medical record revealed an admission date of 02/08/23 and a discharge date of 02/10/23. Resident #70's diagnoses included hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the right dominant side, obstructive sleep apnea and type two diabetes mellitus. Review of Resident #70's Gold Form Provider Orders dated 02/08/23 included an admitting diagnosis of intracerebral hemorrhage (stroke) and additional diagnoses included calf DVT (deep venous thrombosis), and presence of inferior vena cava filter. Review of Resident #70's hospital information Patient Care Summary for Transfer dated 02/08/23 at 10:51 A.M. included Heparin Sodium 5000 units subcutaneous every 8 hours was given at on 02/08/23 at 6:17 A.M. and the next dose 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 interview and record review the facility failed to provide adequate supervision to ensure Resident #60 did not leave the facility unattended. This affected one resident (#60) of three reviewed for supervision. The facility census was 68. Findings include: Review of Resident #60's medical records revealed an admission date of 08/16/21. Diagnoses included dementia and cognitive impairment. Review of Resident #60's care plan dated 08/17/22 revealed the resident had an episode of anxiety related to being on the secured unit and was noted to have been beating on the door and was exit seeking. Exit seeking behaviors were also noted to have occurred when the resident believed it was time to smoke. Interventions included place a clock in resident's room to remind him of the smoking times. The care plan also indicated Resident #60 had a diagnosis of dementia that required resident to be placed on the secured unit. Interventions included review on a quarterly basis for continued placement on the secured unit.…

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 timely incontinence care had been provided. This affected three residents (#37, #49 and #52) of four observed for incontinence care. The facility identified 44 incontinent residents. The facility census was 68. Findings include: Review of Resident #37's medical records revealed an admission date of 07/20/21. Diagnoses included muscle weakness, falls, and difficulty walking. Review of Resident #37's care plan dated 09/12/22 revealed the resident was incontinent of bowel and bladder. Interventions included provide incontinence care every two hours and as needed. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had impaired cognition, required extensive assistance with toileting, and was incontinent of bowel and bladder. Review of Resident #49's medical records revealed an admission date of 11/18/21. Diagnoses included cognitive deficits, dementia and aphasia (difficulty speaking). Review of MDS assessment 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 record review and interview, the facility failed to ensure supplements were administered as ordered. This affected two (Residents #5 and #62) of four residents reviewed for nutrition and weight loss. Findings include: 1. Review of Resident #5's medical record revealed he was admitted on [DATE] with diagnoses including multiple sclerosis, difficulty in walking and dysphagia. Review of Resident #5's physician orders revealed an order dated 09/23/22 for Boost plus eight ounces three times a day for nutrition support and wound healing. Review of Resident #5's medication administration records (MARS) from 10/28/22 to 11/02/22 revealed the Boost plus was not administered on 10/28/22 for lunch, 10/28/22 for dinner, 10/29/22 for breakfast, 10/29/22 for lunch, 10/30/22 for breakfast, 10/30/22 for lunch, 10/31/22 for lunch and 10/31/22 for dinner. Interview on 11/02/22 at 7:35 A.M. with Licensed Practical Nurse (LPN)/Assistant Director of Nursing (ADON) #818 revealed the facility ran out of Boost plus on 08/28/22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review the facility failed to ensure adequate staffing on the memory care unit. This affected three residents (#37, #49 and #52) residing on the memory care unit. The memory care census was 10. Findings include: Review of Resident #37's medical records revealed an admission date of 07/20/21. Diagnoses included muscle weakness, falls, and difficulty walking. Review of Resident #37's care plan dated 09/12/22 revealed the resident was incontinent of bowel and bladder. Interventions included provide incontinence care every two hours and as needed. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had impaired cognition, required extensive assistance with toileting, and was incontinent of bowel and bladder. Review of Resident #49's medical records revealed an admission date of 11/18/21. Diagnoses included cognitive deficits, dementia and aphasia (difficulty speaking). Review of the MDS assessment dated [DATE] revealed Resident #49 had impaired…

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 policy review, the facility failed to store food in the dry storage room and in the walk-in freezer in a sanitary manner. The facility also failed to store pans and pitchers in a sanitary manner. This had the potential to affect all 66 residents who currently resided in the facility and ate food prepared in the kitchen. Finding include: On 08/05/19 the following observations were made in the facility kitchen: At 9:10 A.M., the [NAME] Beach stainless steel blender was observed on a food preparation counter across from the steam table. Upon removal of the lid, the blender pitcher had water in the pitcher. The dietary manager (DM) stated the blender had been used the evening before to puree desserts. When asked if the blender pitcher was supposed to be stored wet, the DM stated, No. At 9:13 A.M., in the dry storage room, a bag of bleached flour was observed to be open and exposed. The DM stated, It should be sealed. Also, a bag of crispy onions was open and exposed. When shown…

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 facility policy review the facility failed to ensure all staff, including medical providers, treated two residents (Resitens #5, and #9) with dignity when entering their rooms and during care. This affected two of 14 residents reviewed for dignity. Findings include: 1. On 08/05/19 at 9:50 A.M. a physician (who was later identified as the Medical Director) was observed entering the room of Resident #5, which had the door closed, without knocking or announcing himself. Two state tested nursing assistants (STNA) were observed in the room providing personal care to the resident. The physician did not ask permission to enter upon opening the door. During an interview on 08/05/19 at 10:00 A.M., Resident #5 stated the physician never knocks on our door, he just walks in and further stated other staff in the building do knock before they come in. On 08/05/19 at 11:30 A.M. the Medical Director approached the surveyor and stated, I have never been instructed by the former director [administrator] at the facility about knocking on doors and that he had 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.

Based on observation, interview and facility policy review the facility failed to ensure physical examinations and discussion of private health information for two residents (Residents #7 and #9) were conducted privately. This affected two of 14 residents reviewed for privacy. Findings include: 1. Observation revealed, on 08/05/19 at 10:12 A.M. a male, who was later identified as the Medical Director, walked in Resident #9's room while the resident was speaking with the surveyor. The gentleman walked in without knocking or asking permission to enter, interrupting the surveyor interview with Resident #9. The gentleman then began to discuss Resident #9's care in front of the surveyor and leaned down and placed a stethoscope on the resident's chest, to listen to her heart and lungs. The surveyor exited the room at that time. Brief interview with the Administrator at 10:30 A.M. on 08/05/19 revealed the gentleman was the Medical Director and one of three attending physicians seeing residents in the facility. On 08/06/19 at 9:35 A.M. an interview with Resident #9, about the previous day…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure urinary output was tracked as ordered for one resident (Resident #37) with an indwelling urinary catheter. This affected one of two residents reviewed for urinary catheters. The facility census was 66. Findings include: Review of Resident #37's admission Minimum Data Set (MDS) Assessment, (an assessment tool completed by the facility staff used to identify resident care problems and assist with care planning) with an Assessment Reference Date (ARD), the end-point of the evaluation period, of 01/10/19, revealed the facility admitted the resident on 01/03/19 with diagnoses of spina bifida, generalized muscle weakness, neuro muscular dysfunction of the bladder, essential (primary) hypertension, and three pressure ulcers. In addition, the MDS Assessment indicated under Section V Care Area Assessment section, the resident was admitted with urinary incontinence and an indwelling catheter/urinary ostomy.…

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 that residents were free from medications used without adequate indication, for one resident (Resident #6). This affected one of of 17 sampled residents. The facility census was 66. Findings include: According to the facility Face Sheet (undated), Resident #6 was admitted to the facility on [DATE]. The face sheet revealed diagnoses of unspecified dementia without behavioral disturbance, overactive bladder, and generalized muscle weakness. No diagnosis of a history of urinary tract infections (UTI) was found in the clinical record. No documentation was found that Resident #6 had a urology consult or was seen by a urologist. According to the quarterly Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD), the end-point of the evaluation period, of 05/10/19, revealed Resident #6, in Section C, which assessed the resident's cognitive status, had a Brief Interview for Mental Status (BIMS) score of 5. A score of 5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility's policy, the facility failed to maintain accurate and complete medical records for one (Resident #9) regarding diagnoses that were actually associated with another resident in the facility. This affected one of 19 sampled resident whose records were reviewed. Findings include: Review of Resident #9's Face Sheet, from the Demographics Tab in the electronic medical record (EMR), revealed she was admitted on [DATE]. Her Diagnosis Report, from the Diagnoses tab of the EMR revealed admitting diagnoses included diabetes, chronic obstructive pulmonary disease (COPD), major depressive disorder (recurrent), and sleep apnea. Diagnoses of schizophrenia and cerebral palsy were added to the diagnosis list on 03/30/18. On 01/22/18 her attending physician, who was also the Medical Director, wrote two Physician Progress Notes, in the Progress Note tab of the EMR. The notes timed at 2305 (11:05 P.M.) documented Resident #9 had a Past Medical History…

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.