Circle Of Care

Based on record review, review of fall investigations, interview, and review of facility policy, the facility failed to re-evaluate care planned fall interventions for effectiveness and update the care plan with new interventions after multiple falls for Resident #10. This affected one resident (#10) of three reviewed for falls. The facility census was 40. Findings include: Review of the medical record for Resident #10 revealed an admission date of 02/04/17 with diagnoses including neurocognitive disorder with Lewy bodies, major depressive disorder, altered mental status, cognitive communication deficit, dementia, personal history of traumatic brain injury, and anxiety. Review of the fall risk data collection tool, dated 02/23/24, indicated Resident #10 was at high risk for falls, with a score of 23, and had experienced multiple falls within the previous six months. Review of the facility's incident log indicated Resident #10 had falls on 08/02/24 at 5:00 P.M., 09/08/24 at 2:51 A.M., 09/10/24 at 3:20 A.M., 10/25/24 at 9:35 A.M., 10/27/24 at 10:32 P.M., 02/01/25 at 10:20 P.M., and…

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

Based on observation, interviews, and review of facility policy, the facility failed to ensure smoking materials were stored in a safe and secure location. This affected two residents (#17 and #20) of four residents reviewed for accidents. Residents #17 and #20 were also two of the six residents identified by the facility as smokers. The facility census was 40. Findings include: 1. Review of the medical record for Resident #20 revealed an admission date of 02/12/19 with diagnoses including encephalopathy, weakness, major depressive disorder, anxiety, abnormal reflex, history of opioid abuse, alcohol dependence with persisting dementia, tobacco use, ataxic gait, and lack of coordination. Review of the annual Minimum Data Set (MDS) 3.0 assessment completed on 02/06/25 revealed Resident #20 had intact cognition and required supervision or touching assistance for ambulating 10 feet in a room, corridor, or similar space. The MDS also revealed Resident #20 was a current tobacco user. Review of the care plan dated 02/11/25 revealed Resident #20 was a long-term smoker. Interventions…

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 medical record, and review of facility policy, the facility failed to ensure appropriate and timely services related to an intravenous (IV) midline catheter. This affected one of one resident (#28) reviewed who had an IV. The facility census was 40. Findings include: Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnoses including type two diabetes mellitus with other skin complications, acute kidney failure, necrotizing fasciitis, osteomyelitis, atrial fibrillation, sepsis, cellulitis, partial traumatic amputation of two or more right lesser toes, and non-pressure chronic ulcer of unspecified foot. Review of the annual Minimum Data Set (MDS) 3.0 completed on 03/07/25 revealed Resident #28 had intact cognition and no behaviors or rejection of care. Further review of the MDS revealed Resident #28 received IV medications. Review of the physician orders revealed an order dated 03/05/25 for ertapenem sodium injection solution, one gram…

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 reviews, review of pharmacy consultation reports, and interview, the facility failed to ensure the pharmacist recommendations for Resident #11 were reviewed and addressed by the physician. This affected one resident (#11) of five residents who were reviewed for unnecessary medications. The facility census was 40. Findings include: Review of the medical record for Resident #11 revealed an initial admission date of 11/01/18 and a re-entry date of 05/30/21 with diagnoses including end stage renal disease, unspecified heart failure, hypertension, anxiety, major depressive disorder, necrotizing fasciitis, overactive bladder, neuromuscular dysfunction of the bladder, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment completed on 01/19/25 revealed Resident #11 had intact cognition with medically complex conditions. Further review of the MDS revealed Resident #11 received hypoglycemic, antidepressant, diuretic, opioid, and anticonvulsant medications. Review of the medication orders revealed an order dated 11/12/24 for 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 record review and interview, the facility failed to limit as needed (PRN) psychotropic and antipsychotic medications to 14 days. This affected one resident (#3) of five reviewed for unnecessary medications. The facility census was 40. Findings include: Review of the medical record for Resident #3 revealed an admission date of 02/05/25 with diagnoses including epilepsy, type two diabetes mellitus, atrial fibrillation, chronic obstructive pulmonary disease, Alzheimer's disease, hypertension, hypokalemia, hyperlipidemia, hypothyroidism, adult failure to thrive, depression, and dementia with anxiety. Review of Resident #3's physician's orders for March 2025 identified orders for Alprazolam (antianxiety medication) tablet 0.25 milligram (mg) to give one tablet via feeding tube every eight hours PRN for anxiety or agitation (ordered on 03/11/25 with the end date listed as indefinite), Haloperidol (antipsychotic medication) oral tablet two mg to give one tablet along with the one mg tablet to equal three mg via feeding tube every six hours PRN for agitation or anxiety (ordered…

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, record review, and interview, the facility failed to maintain Resident #34's record in a complete and accurate manner. This affected one resident (#34) of nineteen records reviewed. The facility census was 40. Findings include: Review of the medical record revealed Resident #34 was admitted on [DATE] with diagnoses including end stage renal disease, chronic obstructive pulmonary disease, pleural effusion, and type one diabetes mellitus. Resident #34 was discharged to the hospital on [DATE]. Review of the discharge (return anticipated) Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 discharged on 02/20/25 to a short-term general hospital. Review of the assessment titled Legionella Signs and Symptoms for Potential Exposure - V 2, dated 03/24/25 at 11:39 A.M., indicated Resident #34 had no symptoms of Legionella and the following vital signs were documented on 03/24/25 between 11:39 A.M. and 11:41 A.M.: blood pressure 128 systolic over 78 diastolic while lying, temperature…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record and interview with the staff the facility failed to ensure inventions were attempted prior to the use of an as-needed antianxiety medication, and failed to ensure an as- needed lorazepam was not administered more than 14 days without a stop date. This affected one resident (Resident #22) of three residents revealed for behaviors. The facility census was 35. Findings included: 1. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE]. Diagnoses included encephalopathy, end stage renal disease, altered mental status, congestive heart failure, chronic obstructive pulmonary disease, atherosclerotic heart disease, hypertension, dependent on a ventilator, tracheostomy, methicillin resistant staphylococcus aureus, intermittent explosive disorder, anxiety disorders, gastrostomy, anoxic brain damage, foot drop, intracranial hemorrhage, and chronic metabolic acidosis. Review of the significant change Minimum Data Set 3.0 assessment dated [DATE]…

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 ensure Resident #31 received nutritional supplements as recommended. This affected one resident (Resident #31) of three residents reviewed for nutrition. The facility census was 30. Findings included: Review of Resident #31's record revealed an admission date of 06/23/23 and a discharge date of 07/03/23. Diagnosis included multiple sclerosis (MS), pressure ulcer of left buttock, stage 4, diabetes mellitus (DM), depression, dehydration, acute myocardial infarction, and anxiety. Review of Resident #31's admission weight on 06/23/23 revealed she weighed 116.5 pounds. Review of the meal intake dated from 06/23/23 to 07/03/23 revealed Resident #31 had eaten most days 0 to 25 percent (%) or 26% to 50%. On one occasion she ate 51% to 75%. Review of Resident #31's care plan dated 06/25/23 revealed she was at risk for nutritional/hydration related to diagnosis of MS, DM, depression, hypothyroidism, anemia, abnormal labs, and sacral pressure wound. Resident #31's nutritional goals were to consume adequate food and fluids at meals…

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 review of personnel files, facility policy and procedure review and interview the facility failed to ensure all staff were checked against the Nurse Aide Registry (NAR) prior to employment to ensure the employee did not have a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. This had the potential to affect all 33 residents residing in the facility. Findings include: Review of staff personnel files for staff hired since the last annual recertification survey revealed the following: a. Review of Housekeeping/Laundry Supervisor #15's personnel file revealed a hire date of 06/16/21. There was no evidence Housekeeping/Laundry Supervisor #15's name had been checked against the NAR for potential findings of abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. b. Review of [NAME] #48's personnel file revealed a hire date of 07/21/20. There was no evidence [NAME] #48's name had been checked against the NAR for potential findings of abuse,…

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, facility policy and procedure review and interview the facility failed to ensure food items were stored appropriately in refrigerators on the nursing units to prevent contamination and/or spoilage. This affected one resident (#24) and had the potential to affect 28 of 28 residents who received oral intake. The facility identified five residents (#2, #4, #18, #20 and #30) who had orders for nothing by mouth. Findings include: 1. On 04/25/22 at 8:32 P.M., observations of the third floor nutrition refrigerator revealed a brown bag with Resident #24's name on it with notation of beef stew. It was dated 04/10/22. In addition, there was a plastic zip lock baggie with some type of meat and a container of spaghetti that had no name or date. On 04/25/22 at 8:32 P.M. interview with State Tested Nursing Assistant (STNA) #32 revealed the meat looked like ham or corned beef to her and she thought it also belonged to Resident #24 although there was no date or name on the plastic baggie. STNA #32 did not give a definitive response when asked how long food was kept in…

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

Based on record review and staff interview the facility failed to complete a Legionella risk assessment and ensure control measures were in place to decrease the risk of Legionella in the facility. This had the potential to affect all 33 residents residing in the facility. Findings include: Review of the facility Legionella Prevention Program revealed no evidence facility conducted a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. There was no evidence of specifying testing protocols, acceptable ranges for control measures, and documenting of the results of testing and corrective actions taken when control limits were not maintained. On 04/27/22 at 4:00 P.M. interview with Maintenance #7 verified the facility did not have a Legionella Risk assessment to determine where pathogens could grow and spread. Maintenance #7 also revealed the facility did not have specified testing protocols and acceptable ranges. Maintenance #7 revealed the facility had been running water weekly in 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 review and staff interview the facility failed to maintain a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility. This affected 17 residents (#6, #7, #8, #10, #12, #13, #14, #15, #16, #17, #19, #21, #23, #25, #27, #31 and #32) of 21 residents identified to have personal fund accounts managed by the facility. The facility census was 33. Findings include: Review of the resident personal fund account balances revealed the following: Resident #6 had $3285.01 Resident #7 had $1479.39 Resident #8 had $10.00 Resident #10 had $1538.75 Resident #12 had 1685.65 Resident #13 had $3084.48 Resident #14 had $60.00 Resident #15 had $1450.54 Resident #16 had $1717.72 Resident #17 had 762.76 Resident #19 had $42.95 Resident #21 had $22.28 Resident #23 had $25.30 Resident #25 had $1951.84 Resident #27 had $2045.64 Resident #31 had $1121.27 Resident #32 had $3113.31 This equaled a total for all residents 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 review of COVID-19 tracking information documents, facility policy and procedure review, review of the Center for Medicare and Medicaid (CMS) Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes (QSO-20-29-NH) and interview the facility failed to notify residents and their representatives of positive staff and resident COVID-19 cases in the facility as required. This had the potential to affect all residents residing in the facility beginning on 01/14/22. The facility census was 33. Findings include: Review of a facility provided COVID-19 tracking information document revealed on 01/14/22 Resident #11, who resided on Level Four of the facility tested positive for COVID-19. Continued review revealed the facility only notified residents and representatives (of the positive COVID-19 test) who resided on Level Four and one of the residents/their representative who resided on Level Three. Review of a facility provided COVID-19 tracking information document revealed on 01/30/22 Medical…

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 review of advance beneficiary notices, facility policy and procedure review and staff interview the facility failed to ensure residents and/or their responsible parties received the appropriate advance beneficiary notices when discharged /cut from Medicare (MCR) Part A services. This affected two residents (#11 and #183) of three residents reviewed for liability/beneficiary protection notification. Findings include: 1. A review of the facility list of residents, who received a liability notice in the past six months, revealed Resident #11 was cut from MCR Part A services on 12/24/21. The resident was identified as having remained in the facility after her skilled service had ended. The facility was not able to provide documented evidence of Resident #11 and/or the resident's representative receiving the CMS Form 10055 (Skilled Nursing Facility Advance Beneficiary Notice) that should have been provided to the resident and/or the resident's representative when she was cut from MCR Part A services. On 04/27/22 10:51 A.M. interview with Business Office Manager #42 confirmed 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 review, facility policy and procedure review and interview the facility failed to ensure Resident #10, Resident #13, Resident #27 and Resident #32 were free from potential incidents of misappropriation when receipts for monies removed from their personal funds account were not completed/maintained. This affected four residents (#10, #13 #27 and #32) of five residents whose personal funds were reviewed. Findings include: 1. Review of the medical record for Resident #13 revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, convulsions, major depressive disorder, Alzheimer's dementia, hypertension, anxiety, and cognitive communication deficit. Review of the Resident Fund Management Service authorization and agreement form, dated 05/15/17 revealed Resident #13 had a resident funds account with the facility and his social security check was deposited into the account by an automatic transfer every month. The resident had a $50.00 monthly allowance. The form…

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 the Ombudsman was notified of transfer/discharges for Resident #24, Resident #30 and Resident #33 as required. This affected three residents (#24, #30 and #33) of 16 sampled residents reviewed for hospitalization. Findings include: 1. Review of the medical record for Resident #24 revealed an admission date of 09/30/21 with diagnoses including chronic obstructive pulmonary disease, hyperlipidemia, peripheral vascular disease, and hypertension. Review of Resident #24's nursing note, dated 02/07/22 revealed Resident #24 was admitted to the hospital on this date. Record review revealed no evidence the Ombudsman was notified of the resident's hospital transfer. Review of Resident #24's Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed Resident #24 had intact cognition. On 04/27/22 at 9:45 A.M. interview with the Administrator verified there was no evidence Resident #24's transfer/discharge notice was sent to the Office 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 record review and interview the facility failed to ensure a comprehensive plan of care was developed and implemented for Resident #24 related to falls/fall risk. This affected one resident (#24) of sixteen residents whose care plans were reviewed. Findings include: Review of the medical record for Resident #24 revealed an admission date of 09/30/21 with diagnoses including chronic obstructive pulmonary disease, hyperlipidemia, peripheral vascular disease and hypertension. Review of Resident #24's Minimum Data Set (MDS) 3.0 comprehensive assessment, dated 04/15/22 revealed Resident #24 had intact cognition. The assessment revealed the resident's balance was not steady during transitions and walking and the resident used a wheelchair for mobility. Review of Resident #24's Fall Risk Data Collection Tools, dated 09/30/21 and 03/19/22 revealed Resident #24 was at a moderate risk for falling. Review of Resident #24's nursing notes dated 03/19/22 revealed Resident #24 had an unwitnessed fall from a chair and was transported to the hospital for evaluation. Review of Resident #24'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 observation, record review and interview the facility failed to ensure Resident #4's gastrostomy tube was checked for proper placement prior to the administration of medications to prevent complications and to ensure medications were administered as ordered. This affected one resident (#4) of five residents observed for medication administration. Findings include: Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with dependence on a ventilator, diabetes mellitus, hypertension, adult failure to thrive, pneumonia and traumatic hemorrhage of the cerebrum. Review of the physician's orders revealed Resident #4 had an order (dated 01/21/22) for the enteral feeding, Isosource 1.5 at 70 milliliters per hour continuously. On 04/27/22 at 12:00 P.M. LPN #12 was observed to administer medications via enteral tube to Resident #4. The LPN obtained and crushed Acetaminophen 325 milligrams (mg) and Mucinex 600 mg and placed 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 record review and interview the facility failed to ensure a physician attended Quality Assurance committee meetings. This had the potential to affect all 42 residents. Findings include: Review of the facility's undated Quality Assurance (QA) Management Policy and Procedure indicated QA meetings were scheduled for the last Thursday of the month following each calendar quarter. Per the policy, members of the committee included the medical director. The chairperson was responsible for verifying attendance of the outside committee members. Monthly medical director reports were to be reviewed at the quarterly meeting. Review of attendance sign in sheets for the QA committee meetings held 07/26/18, 10/25/18, 01/31/19, and 04/25/19 revealed no physician signature at any of the meetings. On 07/03/19 at 1:07 P.M., the Director of Nursing (DON) revealed the medical director was the physician on the QA committee. The DON indicated the medical director did not attend QA meetings but did complete medical director reports. The DON indicated meetings were held on Thursdays and the Medical…

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

Based on record review and interview the facility failed to implement a comprehensive and effective Legionella prevention program including water testing per the facility's plan. This had the potential to affect all 42 residents residing in the facility. Findings include: Review of the facility's Legionella Environmental Assessment Form, dated 05/18/18 revealed it included a water management plan. The plan indicated the facility monitored incoming water parameters by testing the water temperatures on the 4th floor for hot water to reach 105-115 degrees within five minutes. Record review revealed there was no evidence the water testing was completed as per the plan on the 4th floor. On 07/03/19 at 4:10 P.M. interview with Maintenance Director #119 verified water testing was not being completed per the facility Legionella plan.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to accurately reflect residents' status on required Minimum Data Set (MDS) 3.0 assessments. This affected four residents (Resident #4, #10, #22, and #30) of 20 residents whose MDS 3.0 assessments were reviewed. Findings include: 1. Review of Resident #10's medical record revealed an admission date of 03/26/19. Diagnoses included chronic obstructive pulmonary disease and atherosclerotic heart disease without angina pectoris. A 30-day MDS assessment dated [DATE] indicated Resident #10 received an anti-coagulant (blood thinner) seven days during the assessment reference period (04/17/19-04/23/19). Review of the April 2019 MAR did not reveal the use of an anti-coagulant. On 07/02/19 at 8:30 A.M., Licensed Practical Nurse (LPN) #153 verified the MDS dated [DATE] was coded erroneously for anti-coagulant use. LPN #153 stated she coded Plavix, anti-platelet medication as an anti-coagulant. 2. Review of Resident #4's medical record revealed diagnoses including…

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, record review and interview the facility failed to complete a comprehensive assessment related to activity preferences for Resident #8. This affected one resident (Resident #8) of two residents reviewed for activities. Findings include: Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, seizures, tracheostomy, gastrostomy, cerebral palsy and intellectual disabilities. The Minimum Data Set (MDS) 3.0 admission assessment for Resident #8 dated 03/27/19 indicated the section for Assessment for Daily and Activity Preferences was not competed with the resident or family member. The section for Staff Assessment for Daily and Activity Preferences was also not completed. This was verified with the MDS nurse, Licensed Practical Nurse (LPN) #153 on 07/02/19 at 10:15 A.M. LPN #153 indicated the activity director was responsible for completion of those sections of the MDS assessment. Resident #8 was observed 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 observation, record review and interview the facility failed to revise the care plan for range of motion for Resident #8. This affected one resident (Resident #8) of two residents reviewed for range of motion. Findings include: Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, seizures, tracheostomy, gastrostomy, cerebral palsy and intellectual disabilities. Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] for Resident #8 indicated the resident was totally dependent on two or more for bed mobility. He had functional limitation impairment in range of motion of both upper extremities and no impairment of lower extremities. Resident #8 was observed in bed on 07/01/19 at 10:34 A.M. with both legs flexed at the knees. Interview with the Respiratory Therapist (RT) #163 revealed the resident was not able to move his legs very much. On 07/02/19 at 8:29 A.M. Resident #8 was observed in bed with both…

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

Based on record review and interview the facility failed to provide a restorative ambulation program in accordance with Resident #12's restorative plan. This affected one resident (Resident #12) of ten residents interviewed regarding activities of daily living. Findings include: Review of Resident #12's medical record revealed diagnoses including Parkinson's disease, repeated falls, osteoarthritis, intervertebral disc degeneration in the lumbar region, and presence of a right artificial hip joint. A Restorative Ambulation Program assessment indicated Resident #12 required assistance to stand and walk with a walker. The assessment indicated Resident #12 was cooperative with the ambulation program but was unsteady and had a shaky gait. The assessment indicated Resident #12 was on a restorative ambulation program with maximum assistance of two persons and a front wheeled walker to ambulate 6-12 feet for 15 minutes for a minimum of 5-7 days per week with a goal to maintain his ability to ambulate 6-12 feet. Resident #12 needed cueing and encouragement and lots of time to complete the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to provide range of motion services in a timely manner for Resident #29. This affected one resident (Resident #29) of two residents reviewed for range of motion. Findings include: Record review revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, quadriplegia, end stage renal disease and ventilator dependence. The Minimum Data Set (MDS) 3.0 assessment for Resident #29 dated 05/02/19 indicated the resident required total dependence on two or more staff for bed mobility, transfers, bathing and dressing. He had functional limitation in range of motion (ROM) of the upper and lower extremities on both sides. Review of the Occupational Therapy (OT) evaluation dated 04/26/19 indicated OT treatment five times per week for 30 days for activities of daily living, wheelchair management, therapeutic exercise and activity and neuromuscular re-education. The treatment included passive…

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 check placement of a gastrostomy tube prior to the administration of medication for Resident #22. This affected one resident (Resident #22) of one resident observed for the administration of medications per gastrostomy tube of six residents observed during the medication administration. Findings include: On 07/02/19 at 7:50 A.M. medication administration was observed with Licensed Practical Nurse (LPN) #128. LPN #128 prepared medications for administration per gastrostomy tube (tube placed directly into the stomach for administration of nutrition and medications) for Resident #22. LPN #128 crushed a tablet of Oxycodone-acetaminophen (a narcotic pain medication)10-325 milligrams (mg) and mixed it with a small amount of water in a medication cup. She administered approximately 30 milliliters (ml) of water per the resident's gastrostomy tube via gravity per syringe. She then administered the narcotic pain medication mixture via gravity per syringe, followed by a water flush. LPN #128 did not check the gastrostomy…

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, policy review and interview the facility failed to administer oxygen in accordance with physician orders for Resident #10. This affected one resident (Resident #10) of 15 residents screened for oxygen use. The facility identified 15 residents with oxygen orders. Findings include: Review of Resident #10's medical record revealed an admission date of 03/26/19. Diagnoses included chronic obstructive pulmonary disease (COPD) and atherosclerotic heart disease. Resident #10 had a physician order dated 03/27/19 for oxygen to be delivered at three liters per nasal cannula as necessary for COPD. A care plan indicated Resident #10 required continuous oxygen therapy related to respiratory illness. On 07/01/19 at 11:00 A.M., Resident #10 was observed lying in bed with the head of his bed elevated. An oxygen concentrator placed between the foot of the bed and the chair was operating with a setting at two liters per minute (LPM). The tubing from the concentrator was observed going under the covers but there was no oxygen on Resident #10. When Resident #10 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 record review and interview the facility failed to monitor laboratory tests in accordance with physician orders to ensure the adequate use of medications at the prescribed dose for Resident #4. This affected one resident (Resident #4) of five residents reviewed for medication use. Findings include: Review of Resident #4's medical record included diagnoses including chronic obstructive pulmonary disease, atherosclerotic heart disease, congestive heart failure, type 1 diabetes mellitus, and anemia. Resident #4's medication regimen included Metformin 1000 milligrams (mg) twice a day, 80 units of Basaglar insulin twice a day, 40 mg of Lasix every day and 40 milliequivalents (mEq) Potassium chloride every day. Resident #4 had a basal metabolic panel (BMP- blood test that gives doctors information about the blood glucose level, levels of electrolytes like sodium and potassium, and how well the kidneys are working) and a complete blood count (CBC-a blood test used to evaluate your overall health and detect a wide range of disorders, including anemia, infection and leukemia) drawn…

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.