Tranquility Of Richmond Heights

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure Resident #100 received assistance as needed and failed to recognize a change in Resident #100's condition. This affected one (#100) of six residents reviewed for the provision of care and services. The facility census was 49. Findings Include: Resident #100 was admitted to the facility on [DATE] with diagnoses including breast cancer to the left breast, dementia without behavioral disturbance, multiple sclerosis, high blood pressure, left mastectomy, and psychotic disorder with delusions. Review of the quarterly comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 08/06/24 revealed Resident #100 was moderately cognitively impaired, needed set up for eating, and supervision for toileting and bathing. Review of the progress notes revealed on 08/22/24 timed 2:06 P.M. revealed Resident #100 had an appointment scheduled for 10:00 A.M. but was unable to make it due to the resident being incontinent of a large amount of stool. It…

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 policy review, the facility failed to ensure appropriate and accurate medical record documentation for one (#100) of six residents reviewed for change in condition. The facility census was 49. Findings Include: Resident #100 was admitted to the facility on [DATE] with diagnoses including breast cancer to the left breast, dementia without behavioral disturbance, multiple sclerosis, high blood pressure, left mastectomy, and psychotic disorder with delusions. Review of the quarterly comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 08/06/24 revealed the Resident #100 was moderately cognitively impaired and needed supervision for all care. Review of the progress note dated 08/22/24 timed 2:06 P.M. revealed Resident #100 had an appointment scheduled for 10:00 A.M. but was unable to make the appointment because the resident had been incontinent of a large amount of stool and it took a long time to clean the resident up. The resident's daughter contacted the doctor'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure Resident #115, who had cognitive and neurological impairments, a diagnosis of dementia, and was at risk for falls, was not left unattended in the facility van with no air conditioning and the door open for an extended period of time. This affected one resident (#115) of three residents reviewed for transportation to outside appointments. The facility census was 67. Findings include: Resident #115 was admitted to the facility on [DATE] with diagnoses including left breast wound, left breast cancer, dementia, multiple sclerosis, heart disease, chronic kidney disease, depression, anxiety, and psychosis with delusions. Review of the admission MDS (Minimum Data Set) Version 3.0 Assessment Tool dated 05/17/24, Resident #115 had a BIMS (Brief Interview for Mental Status) of 10/15 indicating moderate cognitive impairment. Review of Resident #115's care plan initiated on 05/11/24 indicated Resident #115 had impaired thought processes related to cognitive…

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

Based on record review, observations, and interview the facility failed to provide activities as scheduled and to support the residents' mental and psychosocial wellbeing. This affected three (#2, #45, #47) of 13 residents interviewed and had the potential to affect nine (#1, #2, #12, #17, #24, #26, #30, #34, and #36) of 48 residents observed for participation in activities. Findings include: Review of the activity calendar for April 2024 revealed on 04/18/24 the facility would provide room visits at 10:00 A.M., exercise at 11:30 A.M., brain teasers at 11:45 A.M., and a scenic ride with ice cream stop at 2:00 P.M. Observations on 04/18/24 at 8:50 A.M. revealed Activity Aide #210 was doing leg exercises with residents in the common area. Observations on 04/18/24 at 11:11 A.M. revealed Residents #1, #2, #12, #17, #24, #26, #30, #34, and #36 were sitting in the common area watching television and sleeping. Staff were seated at the nurse's desk; no organized activities were observed. Observations on 04/18/24 at 1:10 P.M. revealed Residents #1, #2, #12, #17, #24, #26, #30, #34, and #36…

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 ensure residents had a dignified eating experience. This affected three ( #12, #19, #34) of 20 residents observed for meals. Findings include: Review of the medical record for Resident #12 revealed an admission date of 12/26/23. Diagnoses included epilepsy, legal blindness, and cerebral infarction due to unspecified occlusion of the cerebral artery. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/31/24, revealed Resident #12 had impaired cognition and required moderate assistance for eating. Review of the medical record for Resident #19 revealed an admission date of 09/16/23. Diagnoses included multiple sclerosis, quadriplegia, and muscle weakness. Review of the quarterly MDS assessment, dated 02/03/24, revealed Resident #19 had intact cognition and required setup and clean up for eating. Review of the medical record for Resident #34 revealed an admission date of 09/02/23. Diagnoses included unspecified dementia and legal blindness. Review of the quarterly MDS assessment, dated 02/28/24,…

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 Based on record review, review of the facility reported incident, review of facility policy and interview, the facility did not ensure Resident #52 was free from physical abuse by Resident #46. This affected one resident (#52) out of four residents reviewed for abuse. The facility census was 49. Findings include: Review of the medical record for Resident #52 revealed an admission date of 10/06/23 and a discharge date of 11/10/23. Diagnoses included depression, bipolar disorder, anxiety disorder, and vascular dementia. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/19/23, revealed Resident #52 was severely impaired mentally and exhibited physical and verbal behavioral symptoms for one to three days. Review of progress notes for Resident #52, dated 10/09/23 through 10/19/23, revealed Resident #52 had documented behaviors of wandering into other resident's rooms, confusion, aggression and cursing directed towards others. Resident #52 was noted to be urinating in front of other resident's 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.

Based on observation and interview, the facility failed to maintain its garbage disposal area in a clean and sanitary condition. This had the potential to affect all 34 residents. Findings include: Observation of the facility's garbage disposal area with Dietary Director #218 on 05/15/23 at 9:53 A.M. revealed both lids were open on the dumpster. There was some trash and leaves accumulated around the dumpster. Dietary Director #218 verified the above findings at the time of observation.

Based on record review, interview, and facility policy review the facility failed to provide documented evidence an antibiotic stewardship program was in place. This affected six residents (#2, #21, #23, #32, #38, and #141) and had the potential to affect all 34 residents residing in the facility. Findings include: Review of the infection control documentation revealed no documented evidence that an antibiotic stewardship program was in place. Interview on 05/17/23 at 5:22 P.M. with the Director of Nursing (DON) and Administrator revealed antibiotic stewardship was stopped during the COVID-19 pandemic as the task was waivered and had not started back up yet. Review of the facility matrix revealed Residents #2, #21, #23, #32, #38, and #141 were on antibiotics. Review of the facility policy titled Antibiotic Stewardship, dated 12/16, revealed antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program.

Based on observation and interview, the facility failed to ensure the resident's environment was kept clean, neat, well lit, and homelike. This had the potential to affect all 34 residents residing in the facility. Findings include: During the initial tour of the facility on 05/15/23 from 8:43 A.M. through 9:20 A.M. revealed light bulbs were burned out in the main hall by rooms #101, #107, #109, #111, #116, #208, #212, #301, #304, #308, #309, #310, #312, #313, one of two bulbs of a two-light sconce in the TV room, four can lights in the nurse's station and one ballast. There were no coverings of ballast light bulbs by rooms #104, #112, #116, #120, #202, #206, #301, #305, #317, #321, #323, outside the central bath and eight around the nurse's station. There were multiple heavily soiled spots in the carpeting throughout the facility. Interview on 05/15/23 at 2:16 P.M. with Maintenance #261 verified the burned-out light bulbs and stated the bulbs were ordered but failed to produce the order requisition. He verified the multiple stains in the carpets. He verified the missing plastic…

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 have an accurate Minimum Data Set (MDS) for Resident #3, Resident #4, Resident #7, Resident #8, and Resident #15. This affected five residents (#3, #4, #7, #8, and #15) of fifteen residents reviewed for MDS accuracy. The facility census was 34. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 01/27/21. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, cervical disc displacement, diabetes, and osteoarthritis. Review of the quarterly MDS assessment dated [DATE] stated Resident #4 was not receiving hospice care. Review of the care plan revealed Resident #4 started hospice on 02/04/22. Interview on 05/18/23 at 1:09 P.M. with the Director of Nursing (DON) verified Resident #4 was on hospice. 2. Review of the medical record for Resident #8 revealed an admission date of 03/25/22. Diagnoses included Alzheimer's, diabetes, glaucoma, and the need for assistance with personal care. Review of…

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

Based on observation, record review, and interview the facility failed to ensure staff hands were cleansed between residents when passing out meal trays to residents in their rooms for three residents (#17, #32 and #34), failed to ensure dirty linen was kept off the floor for Resident #38, failed to ensure urinary catheter bag was kept off the floor and catheter care was done properly for Resident #3. This affected five residents (#3, #17, #32, #34 and #38) of 34 residents reviewed for infection control. The facility census was 34. Findings include: 1. Observation on 05/15/23 at 4:37 P.M. revealed Resident #3's urinary catheter bag was on the floor under her bed. Interview on 05/15/23 at 5:09 P.M. with the Licensed Practical Nurse/Unit Manager (LPN/UM) #238 verified the catheter bag was on the floor under the bed. 2. Observation on 05/16/23 at 4:15 P.M. during the emptying of Resident #'s catheter/leg bag revealed State Tested Nursing Assistant (STNA) #234 did not place a barrier on the floor under the urinal. STNA #234 did not disinfect off the tip of the catheter/leg bag before…

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 have updated/revised care plans for Resident #8 and Resident #31. This affected two residents (#8 and #31) of fifteen residents reviewed for care plans. The facility census was 34. Finding include: 1. Review of the medical record for Resident #8 revealed an admission date of 03/25/22. Diagnoses included Alzheimer's, glaucoma, and the need for assistance with personal care. Review of the annual MDS assessment dated [DATE] revealed Resident #8 had intact cognition. The resident's hearing and vision were not assessed and bed mobility, transfers, locomotion, eating, toilet use, and personal hygiene had only occurred once or twice. Review of the care plan for activities of daily living (ADL) dated 10/06/22 for Resident #8 revealed a gait belt was needed for transfers. Interview on 05/18/23 at 3:18 P.M. with the Assistant Director of Nursing (ADON) #238 verified Resident #8 required a Hoyer lift (mechanical lift) for transfers, and the care plan was 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, interview, record review, and facility policy review the facility failed to ensure Resident #8 received timely nail care and failed to ensure Resident #38 received timely oral care. The facility failed to have accurate documented evidence that Resident's #3, #8, #14 and #31 had showers as ordered and/or per preference. This affected five residents (#3, #8, #14, #31, and #38) of fifteen residents reviewed for activities of daily living (ADL) care. The facility census was 34. Finding include: 1. Review of the medical record for Resident #8 revealed an admission date of 03/25/22. Diagnoses included Alzheimer's, glaucoma, and the need for assistance with personal care. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had intact cognition. The resident's hearing and vision were not assessed and bed mobility, transfers, locomotion, eating, toilet use, and personal hygiene had only occurred once or twice. Observation on 05/15/23 at 11:41 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.

Based on record review, interview, and observation the facility failed to administer medications with an error rate of 5 percent (%) or less. This affected Resident and #3 and Resident #17, two of five residents observed medication administration. There were three errors out of 30 opportunities resulting in an error rate of 10%. Findings include: 1. Observation on 05/17/23 at 8:19 A.M. revealed Licensed Practical Nurse (LPN) #275 was administering medication to Resident #3. LPN #275 administered vitamin B complex with vitamin C tablet (supplement) orally. Record review for Resident #3 revealed a physician order written on 04/25/23 for vitamin B complex daily. Interview with LPN #275 at 9:00 A.M. revealed the incorrect medication of vitamin B complex with vitamin C had been administered to Resident #3. Observation on 05/17/23 at 8:19 A.M. revealed LPN #275 was administering medication to Resident #3. LPN #275 administered Refresh Plus Ophthalmic Solution 0.5%. One drop in each eye. Record review for Resident #3 revealed a physician order written on 04/25/23 for Refresh Plus…

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

Based on observation and staff interview the facility failed to ensure its garbage disposal area was maintained in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 33. Findings Include: Observation of the facilities garbage disposal area with Dietary Manager (DM) #101 on 01/21/20 at 8:53 A.M. revealed there were plastic bags of garbage covered with snow around the outside dumpster. DM #101 verified the above observations at the time of discovery.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure comprehensive resident centered care plans were initiated, developed and implemented to meet the needs of its residents. This affected five (Residents #35, #136, #240, #241, #287) of fourteen sampled residents. The facility census was 33. Findings Include: 1. Resident #35 was admitted to the facility on [DATE] with diagnoses that included bronchitis, type 2 diabetes and kidney failure. Review of the care plan for Resident #35 revealed problem areas of shortness of breath, anticoagulant medication use, discharge planning, vision impairment, falls, pain and skin conditions . None of these areas were noted with resident specific focus areas or goals. Minimum Data Set Nurse #100 verified the lack of individualized focus areas and goals in an interview on 01/22/20 at 7:30 A.M. 2. Resident #136 was admitted to the facility on [DATE] with diagnoses that included cellulitis of the right leg, type two diabetes and hyperlipidemia. Review of the care…

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 an adequate sized bed for Resident #14. This affected one, Resident #14, of three residents reviewed, Residents #14, #12 and #21 for adequate sized beds. The facility census was 33. Findings include: Record review revealed Resident #14 had an admission date of 11/20/19. Diagnosis for Resident #14 included heart failure, muscle weakness, type two diabetes mellitus, peripheral vascular disease, acquired abscess of other right toe. The minimum data assessment (MDS) dated [DATE] revealed Resident #14 had been at risk for developing pressure ulcers, and had one or more unhealed pressure ulcers. Record review of the wound documentation tool dated 11/20/19 included six wounds, two left lateral proximal foot diabetic ulcers, two left heel pressure ulcers, a right lateral ankle ulcer and a sacrum wound. Resident #14's care plan revealed Resident #14 required assistance with activities of daily living due to decreased mobility and overall…

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 a thorough skin assessment was done on a newly admitted resident. This affected one resident (Resident #286 ) out one resident reviewed for skin issues not pressure related. The facility census was 33. Findings Include: Resident #286 was admitted to the facility on [DATE]. His admitting diagnoses included urinary tract infection, cerebral infarction due to unspecified occlusion or stenosis, delirium due to physiological condition, type II diabetes, and dementia. Review of the resident's admission assessment revealed the resident did have cognitive impairment. He needed assistance of one for a majority of activities of daily living including toileting. Review of skin assessment from this admission showed no noted skin issues or wounds on admission. Observation of Resident #286 on 01/22/20 at 1:00 P.M. revealed the resident had a bruise on his right hand from below the thumb to the wrist. This area was dark purple in color. There 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.

Based on observation, interview and record review, the facility failed to monitor supplemental intake for Resident #12. This affected one, Resident #12, of one residents reviewed for supplemental intake. The facility census was 33. Record review revealed Resident #12 had an admission date of 07/22/15. Diagnosis for Resident #12 included type two diabetes mellitus, abnormalities of gait and mobility, dependence on a wheelchair, and unspecified dementia without behavioral disturbances. The minimum data assessment (MDS)completed on 12/06/19 revealed Resident #12 required set up help only for eating. The care plan dated 10/03/19 revealed Resident #12 had been at nutritional risk due to a variable food intake. Resident #12 had a significant negative weight decrease of 10.7 percent in the previous six months. Resident #12 began to refuse meals. An intervention included in the care plan was to monitor the meal intake with each meal. Record review of Dietitian #204 recommendations from 10/03/19 included to start Glucerna (a nutritional supplement) five times a day. Resident #12's diet 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 and record review, the facility failed to give prescribed medications per physicians orders for Residents #287. This affected one, Resident #287 of five, Residents #4, #7, #9 and #14 , reviewed for unnecessary medications. The facility census was 33. Findings include: Record review on 01/22/20 revealed Resident #287 had an admission date of 01/10/19. The admitting diagnosis included acute embolism (obstruction of an artery typically by a clot of blood or an air bubble) and thrombosis (local clotting of the blood) of right femoral vein and acute embolism and thrombosis of left iliac vein. The care plan for Resident #287 included nursing was to administer medication to Resident #287 as per the physicians orders. Record review of medications ordered on 01/10/20 included warfarin sodium tablet 2 milligram (mg)tablet by mouth in the evening for anticoagulant. Review of the medication administration record (MAR) for 01/22/20 for unnecessary medications revealed Resident #287 had not received warfarin sodium nor any other anticoagulant medication. Review of physicians…

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 maintain a medication error rate of less then 5 percent. This affected one, Resident #4, of nine residents, Residents #241, #12, #32, #7, #236, #238, #287 and #239 reviewed for medication administration. The facility census was 33. Record review revealed Resident #4 had an admission date of 10/05/19. Resident #4 diagnosis included obesity, heart failure, and chronic obstructive pulmonary disease (COPD). The minimum data assessment dated [DATE] included Resident #4 had been cognitively intact, required limited assistance for bed mobility and personal hygiene and extensive assistance for transfers. Resident #4's plan of care dated 01/21/2 included nursing staff to administer medications as per physicians orders. Observation of medication administration on 01/22/20 at 09:00 A.M. revealed Licensed Practical Nurse (LPN) #102 administered Breo two puffs to Resident #4. After administration of the medication, LPN #102 exited Resident #4's 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.