Providence Care Center

Based on observation and staff interview, the facility failed to maintain the dumpster area in a clean and sanitary manner. This had the potential to affect all residents. The facility census was 96. Findings include: Observation on 05/20/25 at 8:30 A.M. of the outside dumpster area revealed numerous cardboard boxes, gloves, food scraps and six alcoholic beverage cans on the ground, outside of the dumpster. Interview on 05/18/25 at 8:45 A.M. with [NAME] (CK) #257 verified the debris located on the ground, around the dumpster.

Based on medical record review, staff interview and review of facility policy, the facility failed to maintain complete documentation of care provided for residents. This affected four (#14, #95, #301, and #35) of four residents reviewed for activities of daily living (ADLs). The facility census was 96. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 01/05/18. Diagnoses included atherosclerotic heart disease of native coronary artery, atrial fibrillation (a. fib), unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder, spinal stenosis, hypertension (HTN), major depressive disorder, anxiety, history of falling, unsteadiness on feet, generalized muscle weakness, and respiratory disorder. Review of the most recent quarterly Minimum Data Set (MDS) assessment revealed Resident #14 had a Brief Interview of Mental Status (BIMS) score of 11, indicating the resident was moderately cognitively impaired. The resident required assistance with hygiene. Review of the facility shower schedule revealed Resident #14 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 review of the facility infection tracking records, staff interview and review of the facility policy, the facility failed to ensure residents met infection criteria prior to the initiation of antibiotics. This affected 27 (#10, #11, #12, #18, #19, #24, #25, #26, #27, #30, #37, #40, #48, #50, #56, #62, #63, #64, #66, #69, #71, #75, #82, #88, #89, #102, and #301) of 27 residents reviewed for antibiotic stewardship. The facility census was 96. Findings include: Review of the facility infection tracking records from 12/01/25 through 01/31/25 revealed the facility utilized McGeer's (set of clinical and laboratory findings used to assist in identifying infections requiring antibiotic treatment) criteria to determine appropriate antibiotic usage. Further review revealed the following residents were ordered antibiotics without being reviewed to determine whether the McGeer's criteria for antibiotic use was met: • Resident #66, with an admission date of 09/12/23, was ordered ceftriaxone for a bladder infection on 12/02/24. • Resident #10, with an admission date of 10/10/24, 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, record review, staff interview, and review of the facility policy, the facility failed to ensure the physician was notified when a medication was unavailable for administration. This affected one (#57) of three residents reviewed for physician notification. The facility census was 96. Findings include: Review of Resident #57's medical record revealed an admission date of 10/07/24 with diagnoses including Parkinson's disease, hypertension (HTN), hyperlipidemia, hypothyroidism, major depressive disorder, anemia, and neuromuscular dysfunction of the bladder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/27/25, revealed a Brief Interview of Mental Status (BIMS) score of 13, indicating Resident #57 was cognitively intact. Review of a physician order, dated 10/07/24, revealed Resident #57 had an order for trihexyphenidyl hydrochloride (HCl) (used to treat movement problems caused by Parkinson's disease), two milligrams (mg) to be administered orally (PO) two times per day. Observation on 05/19/25 at 7:00 A.M. of medication administration 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.

Based on observation, staff interview, resident interview, and review of the facility policy the facility failed to ensure bedding was maintained in a clean and sanitary manner. This affected one (#16) resident reviewed for soiled bedding. The facility census was 96. Findings include: Review of the medical record for Resident #16 revealed an admission date of 06/01/23. Diagnoses included Parkinson's disease, chronic kidney disease, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/21/25, revealed Resident #16 was mildly cognitively impaired and required supervision for bathing. Observation on 05/18/25 at 10:30 A.M. of Resident #16's bedding revealed several light brown streaks on the fitted sheet of the bed and a dark brown spot on the bed pad. Concurrent interview with Resident #16 revealed her sheets had not been changed in a while and stated they were dirty. Observation on 05/19/25 at 9:40 A.M. of Resident #16's bedding revealed the sheets remained with the same brown streaks on the fitted sheet. Concurrent interview with Resident #16 confirmed…

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

Based on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure valid indications for the use of mobility restricting devices. This affected two (#3 and #56) of two residents reviewed for elopement. The facility census was 96. 1. Review of Resident #3's medical record revealed an admission date of 06/01/22. Diagnoses included Alzheimer's disease, dementia, hypothyroidism and congestive heart failure. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/04/25, revealed Resident #3 was severely cognitively impaired, required supervision for completing activities of daily living (ADLs) and exhibited no wandering behaviors. Further review of the MDS assessments since Resident #3's admission to the facility revealed the resident was never identified as having any wandering behaviors. Review of the Elopement Risk Assessment, dated 04/04/25, revealed Resident #3 had no history of elopement in the last six months and was identified as not being an elopement risk. Review of the care plan, dated 06/01/22, revealed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure residents who received psychotropic medications were monitored for behaviors, adverse effects, and efficacy. This affected one (#15) of five residents reviewed for unnecessary medications. The facility census was 96. Findings include: Review of the medical record revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included anxiety, depression, psychotic disorder, and schizophrenia. Review of the Minimum Data Set (MDS) assessment, dated 04/21/25, revealed Resident #15 was cognitively intact. Review of the plan of care, revised 03/08/24, revealed Resident #15 used psychotropic medications. Interventions included administering medications as ordered and monitoring for side effects and effectiveness, and monitoring and reporting as needed side effects and adverse reactions of medication. Review of Resident #15's active physician orders for May 2025 revealed an order for buspirone…

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

Based on medical record review and staff interview, the facility failed to complete timely Minimum Data Set (MDS) assessments following a significant change. This affected one (#91) of one resident reviewed for hospice services. The facility identified five residents receiving hospice services. The facility census was 96 Findings include: Review of Resident #91's medical record revealed an admission date of 11/11/24. Diagnoses included dementia, insomnia and neck fracture. Review of the most recent Minimum Data Set (MDS) 3.0 assessment, dated 02/13/25, revealed Resident #91 was severely cognitively impaired and required extensive assistance from staff for activities of daily living (ADLs). The MDS did not indicate Resident #91 received hospice services. Review of the physician orders revealed an order dated 04/29/25 to consult a local hospice provider for potential admission for Resident #91. Further review of the medical record revealed Resident #91 elected hospice services on 05/01/25, with a diagnosis of senile degeneration of the brain. Additional review of the MDS assessments…

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

Based on record review, observation and staff interview the facility failed to ensure residents care plans were an accurate representation of current resident conditions This affected two (#3 and #56) of two residents reviewed for elopement. The facility census was 96. Findings include: Review of Resident #3's medical record revealed an admission date of 06/01/22. Diagnoses included Alzheimer's disease, dementia, hypothyroidism and congestive heart failure. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/04/25, revealed Resident #3 was severely cognitively impaired, required supervision for completing activities of daily living (ADLs) and exhibited no wandering behaviors. Further review of the MDS assessments since Resident #3's admission to the facility revealed the resident was never identified as having any wandering behaviors. Review of the Elopement Risk Assessment, dated 04/04/25, revealed Resident #3 had no history of elopement in the last six months and was identified as not being an elopement risk. Review of the care plan dated 06/01/22 revealed Resident #3…

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, resident interview, medical record review, staff interview and review of the facility policy, the facility failed to ensure residents were provided assistance with oral hygiene. This affected one (#89) of one resident reviewed for oral hygiene. The facility census was 96. Findings include: Review of the medical record revealed Resident #89 was admitted to the facility on [DATE]. Diagnoses included lack of coordination, unsteadiness on feet, hypertension (TN), gastro-esophageal reflux disease (GERD), glaucoma, muscle weakness, and need for assistance with personal care. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #89 was cognitively intact. The resident required supervision/touching assistance for oral hygiene. Review of the plan of care dated 10/21/24 revealed Resident #89 had an activities of daily living (ADLs) self-care performance deficit. Interventions included providing all necessary equipment to complete oral care and setting up and assisting as…

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 2. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included anxiety, depression, psychotic disorder, and schizophrenia. Review of the five-day Minimum Data Set (MDS) assessment, dated 04/21/25, revealed Resident #15 was cognitively intact. Review of the plan of care, dated 08/28/18, revealed Resident #15 was at risk for constipation related to decreased mobility and medication side effects. Interventions included following the facility bowel protocol for bowel management and recording bowel movement pattern. Review of Resident #15's active physician orders for May 2025 revealed an order dated 04/17/25 for Oxycodone (opioid medication) five milligram (mg) oral capsule, give one capsule by mouth every six hours as needed for pain. Review of the Medication Administration Record from 04/17/25 through 05/19/25 revealed Resident #15 received Oxycodone on 11 occasions. Review of Resident #15's bowel tracking record from 04/21/25 through 05/19/25 revealed there were…

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

Based on medical record review, review of optometry (vision) notes, and staff interview, the facility failed to ensure residents received routine eye care timely. This affected one (#35) of one resident reviewed for vision care. The facility census was 96. Findings include: Review of the medical record for Resident #35 revealed an admission date of 06/13/23. Diagnoses included metabolic encephalopathy, type two diabetes mellitus (DM2), hepatic encephalopathy, dysphagia, need for assistance with personal care, respiratory disorders, hypertension (HTN), depression, obstructive sleep apnea (OSA), and osteoarthritis. Review of the Minimum Data Set (MDS) assessment, dated 03/09/25, revealed Resident #35 had a Brief Interview of Mental Status (BIMS) score of 11, indicating the resident was moderately cognitively impaired. Review of an optometry note, dated 11/13/23, revealed Resident #35 was seen by the optometrist for an examination (exam). The resident had complaints of blurred vision in both eyes, which was getting worse. New eyeglasses were ordered. Further review revealed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents identified to smoke were assessed for safety. This affected one (#68) of one resident resident identified by the facility as a smoker. The facility census was 96. Findings include: Review of the medical record revealed Resident #68 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), anxiety, depression, hypertension, and difficulty in walking. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/01/25, revealed Resident #68 was cognitively intact. The resident required partial/moderate assistance from staff when wheeling 50 or 150 feet once seated in their wheelchair. Review of the plan of care, dated 09/11/24, revealed Resident #68 was a daily smoker, had been informed of the facility non-smoking status, and would abide by smoking off of facility property at all times. 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 2. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE]. Diagnoses included respiratory failure, chronic kidney disease, panic disorder, seizures, schizophrenia, anxiety, migraine, low back pain, pain in the right leg, and pain in the right hip. Review of the MDS assessment, dated 03/31/25, revealed Resident #30 was cognitively intact. Review of the active physician orders for May 2025 revealed an order dated 05/14/25 for Vancomycin (antibiotic medication) intravenous (IV) solution 1250 milligrams/250 milliliters (mg/ml), use 1250 ml IV one time per day for cellulitis for 10 days. The scheduled time for the medication to be administered was 9:00 A.M. Observation on 05/20/25 at 12:12 P.M. revealed Resident #30 was sitting up on the side of their bed. The resident was receiving Vancomycin IV via a midline catheter at the time of observation. A pole located next to the resident's bed contained a pump with medication administration settings. A bag containing fluid/medication 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 medical record review, staff interview, family interview, and policy review, the facility failed to inform the resident and/or family regarding need to discontinue a seizure medication. This affected one (#107) of three residents reviewed for notification. The facility census was 106. Findings include: Review of Resident #107's medical record for Resident #107 revealed an admission date of 07/17/24 and a discharge date of 08/31/24. Diagnoses for Resident #107 included hypertensive urgency, urinary tract infection (UTI), schizophrenia, chronic obstructive pulmonary disease, muscle weakness, need for assistance with personal care, difficulty in walking, unsteadiness on feet, osteoarthritis, heart failure, seizures, pneumonia, vascular dementia, benign prostate hyperplasia (BPH), Alzheimer's disease, atrial fibrillation (a. fib), and seizures. Review of the Minimum Data Set (MDS) Assessment revealed a Brief Interview of Mental Status (BIMS) score of 13, indicating Resident #107 is cognitively intact. Review of the August 2024 monthly physician orders revealed an order 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 observation, staff interview, review of medical record, and review of policy, the facility failed to ensure infection control policies and procedures were followed for maintaining urinary catheter bags. This affected two (#50 and #87) of three residents reviewed for urinary incontinence. The facility census was 106. Findings include: 1.) Review of Resident #50's medical record revealed an admission date of 09/11/24, with diagnoses of multiple subsegmental thrombotic pulmonary emboli without acute cor pulmonale, depressive disorder, failure to thrive, hypokalemia, muscle weakness, unsteadiness, need for assistance with personal care, obstructive and reflux uropathy, anemia, syncope and collapse, other specified disorders of the male genital organs, Vitamin D deficiency, Vitamin B12 deficiency, and Barrett's esophagus. Review of the admission Minimum Data Set (MDS) Assessment, dated 08/13/24, for Resident #50 revealed a Brief Interview of Mental Status (BIMS) score of 14, indicating Resident #50 is cognitively intact. Observation on 09/25/24 at 11:27 A.M., revealed 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 observation, resident interview, staff interview, record review, review of the policy, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) when performing high-risk resident care activities for residents on Enhanced Barrier Precautions (EBP). In addition, the facility failed to implement EBP per physician order for Resident #87. This affected four (#37, #77, #87, and #95) of 25 residents identified on EBP. Findings included: 1. Record review revealed Resident #37 was admitted to the facility on [DATE]. Diagnoses included cardiomyopathy, respiratory disorders, lack of coordination, asthma, hyperlipidemia, retention of urine, and hypothyroidism. Review of Resident #37's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/10/23, revealed the resident was cognitively intact. The resident required extensive assistance of two staff for bed mobility, dressing, and toileting. The 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 observation, medical record review, resident and staff interviews, the facility failed to honor a resident's request to have a positioning side rail on her bed, to promote the resident's ability to assist with bed mobility. This affected one (#87) of 23 sampled residents for accommodation of needs. The facility census was 96. Findings include: Review of Resident #87's medical record revealed an admission date of 05/20/22, with medical diagnoses including: breast cancer with bone metastasis, muscle weakness, anxiety, and pain. Review of the most recent quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #87 is cognitively intact and required extensive assistance with bed mobility. Review of Resident #87's written plan of care for activities of daily living (ADL's) identified under the section of bed mobility encourage me and assist with repositioning in bed. The plan identified I use rails to reposition and turn in bed. Further review of the medical record revealed no evidence of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to submit a new Pre-admission Screening and Resident Review (PASARR) when a resident received a new diagnosis of bipolar disorder. This affected one (#71) of two residents reviewed for PASARR. The facility census was 96. Findings include: Review of PASARR results dated 08/02/23, revealed Resident #71 had no indications of serious mental illness. Record review revealed Resident #71 was admitted to the facility on [DATE], with diagnoses including chronic kidney disease, major depressive disorder, and dementia. Review of physician notes dated 08/10/23 revealed Resident #71 had a family history of schizoaffective disorder. Further review of the medical record revealed a new diagnosis of bipolar disorder was added for Resident #71 on 08/14/21. Review of the electronic and paper medical records revealed no evidence a new PASARR was completed when Resident #71 had a new diagnosis of bipolar disorder. Interview on 10/04/23 at 11:57 A.M., with Social…

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, medical record review, policy review, resident and staff interviews, the facility failed to ensure a daily dressing was completed for a diabetic ulcer. This affected one (#95) of two residents reviewed for skin ulcers. The facility census 96. Findings include: Review of Resident #95's medical record revealed an admission date of 06/23/22, with medical diagnoses including: Diabetes Mellitus (DM) with foot ulcers, severe peripheral vascular disease (PVD) and hypertension. Review of the most recent [NAME] Data Set (MDS) assessment dated [DATE], identified Resident #95 was cognitively intact and able to make his needs known. The assessment revealed Resident #95 is identified with one diabetic ulcer to the outer right foot. Review of physician orders dated 09/01/23 revealed an order for the right outer foot wound to clean ulcer with Vashe (wound solution), apply Santyl and a dry dressing daily on day shift. Interview on 10/02/23 at 9:49 A.M., with Resident #95 stated the staff did not change…

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, medical record review, policy review, resident and staff interviews, the facility failed to ensure a daily dressing was completed for a pressure ulcer. This affected one (#95) of four residents reviewed for pressure ulcers. The facility census 96. Findings include: Review of Resident #95's medical record revealed an admission date of 06/23/22, with medical diagnoses including: Diabetes Mellitus (DM) with foot ulcers, severe peripheral vascular disease (PVD) and hypertension. Review of the most recent [NAME] Data Set (MDS) assessment dated [DATE], identified Resident #95 was cognitively intact and able to make his needs known. The assessment revealed Resident #95 is identified with one stage 4 (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer) wound to the left heel. Review of physician orders dated 09/01/23 revealed an order for the left heel pressure ulcer wound to clean ulcer with Vashe (wound…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidance, and review of policy, the facility failed to ensure a suprapubic catheter was positioned to allow urine to freely flow. This affected one (#77) of three residents reviewed for catheters. The facility census was 96. Findings include: Review of the medical record revealed Resident #77 was admitted to the facility on [DATE]. Diagnoses included heart failure, hyperlipidemia, mixed receptive-expressive language disorder, gastro-esophageal reflux disease, bladder-neck obstruction, urethral diverticulum, contracture of left hand, and hemiplegia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/08/23, revealed the resident was severely cognitively impaired. The resident required extensive assistance of two staff for bed mobility, dressing, and personal hygiene. The resident had an indwelling catheter. Review of Resident #77's current plan of care, dated 03/06/23, revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interviews, the facility failed to ensure residents received medications as ordered. This affected three (#31, #48, and #87) of 21 residents on the Cederview hallway. The facility census was 96. Findings include: 1. Review of Resident #31's medical record revealed an admission date of 12/10/17, with medical diagnoses including: chronic kidney disease (CKD), major depression, anemia, delusional disorder, paranoid schizophrenia, chronic pain, and obsessive-compulsive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] identified the resident was cognitively intact. Review of Resident #31's Medication Administration records (MAR) dated 10/02/23, for medications scheduled upon rising, included Cymbalta 60 milligram (mg), Gabapentin 400 mg and Oxcarbazepine 600 mg, contained no evidence of initials listed to indicate Resident #31's medications were administered. Interview on 10/02/23 at 8:11 A.M., with Resident #31 stated she did not receive any of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of facility self-reported incidents, review of controlled substances signs out sheets, review of policy, and staff interviews, the facility failed to prevent diversion of residents narcotic medications. This potentially affected 31 residents (Resident #1, #2, #3, #4, #9, #10, #12, #16, #20, #22, #25, #32, #35, #37, #41, #44, #50, #52, #57, #58, #66, #67, #83, #85, #90, #93, #101, #105, #110, #111 and #112) who resided on the Rosewood unit. The facility census was 106. Findings include: Review of facility self-reported incidents (SRI) #237089, #237081, #237080, and #237077, were all dated [DATE], the reports indicated the facility identified concerns regarding potential diversion of narcotic medications. During the facility investigation, additional concerns were identified. Review of the controlled drug administration records for 31 residents (#1, #2, #3, #4, #9, #10, #12,…

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 observations, staff interview, and review of the facility policy, the facility failed to wear hairnets in the kitchen, serve residents lunch in a sanitary manner and use proper hand hygiene when preparing foods. This had the potential to affect 109 of 109 residents who receive meals from the facility kitchen. Resident #62, identified by facility, had an order for nothing by mouth. The facility census was 110. Findings include: 1. Observation on 06/21/20 at 8:50 A.M., during the initial tour of the kitchen, revealed three staff in the kitchen, including Dietary Manger #136. None of the staff were observed wearing hairnets. Observation on 06/21/21 at 8:55 A.M. with Dietary Aide (DA) #129 revealed DA #129 was not wearing a hairnet. DA #129 had her hair pulled up, with loose strands of hair hanging. DA #129 was scooping butterscotch pudding into serving dishes. Interview at the time of the observation with the DM #136, verified the staff, including herself, were not wearing hairnets. DM #136 stated the air conditioning was out in the kitchen and she had told staff they did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and review of the facility policy review, the facility failed to ensure medications were stored in a safe and effective manner. This had the potential to affect 31 (#14, #37, #40, #41, #43, #44, #50, #67, #68, #69, #72, #73, #74, #88, #91, #94, #99, #100, #101, #104, #109, #262, #362, #363, #364, #365, #366, #367, #368, #400 and #401) residents who receive medications in a total facility census of 110. Findings include: Observation on [DATE] at 8:17 A.M., of the medication cart in the Rosewood Lane hallway revealed medications that were expired included Tylenol liquid (pain reliever/fever reducer) 160 milligram (mg) per five milliliter (ml) expired 06/2020, and Melatonin (sleep aide) three mg tablets expired 01/2021. Interview on [DATE] at 8:25 A.M. with Licensed Practical Nurse (LPN) #176, verified one bottle of Tylenol liquid 160 milligram (mg) per five milliliter (ml) expired 06/2020, and one bottle of Melatonin three mg tablets expired 01/2021. Observation on [DATE] at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interview and review of the facility policy, the facility failed to follow their policy and procedure for donning and doffing personal protective equipment (PPE). This affected 30 (#14, #37, #40, #41, #43, #44, #67, #68, #69, #72, #73, #74, #88, #91, #94, #99, #100, #101, #104, #109, #262, #362, #363, #364, #365, #366, #367, #368, #400 and #401) of 30 residents who reside on the Rosewood Lane hallway. In addition, the facility failed to properly disinfect a glucometer. This affected four (#67, #100, #262 and #365) residents who utilize the glucometer machine on the Rosewood Lane hallway. The facility census was 110. Findings include: Review of the medical record for Resident #109 revealed an admission date of 06/06/21, with an original admission date of 05/18/21. Diagnoses included muscle weakness, chronic obstructive pulmonary disease, Type 2 diabetes mellitus, diastolic heart failure, chronic gout and anemia. Review of the quarterly Minimum Data Set 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 observations, staff interview, record review and review of the facility policy, the facility failed to apply Thrombo-Embolus Deterrent (TED) hose/compression stockings as ordered by the physician for a resident with edema. This affected one (#56) of one resident reviewed for edema. The facility census was 110. Findings include: Review of Resident #56's medical record revealed an admission date of 11/07/16. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side; contracture, right hand; dysphagia following other cerebrovascular disease; chronic obstructive pulmonary disease, unspecified (COPD); contracture, right ankle; and Type II diabetes mellitus with unspecified complications. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #56 was moderately cognitively impaired and required total dependence, two-person assistance with bed mobility and transfers and extensive two-person assistance with dressing. Review of a physician…

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, staff interview, and review of the facility policy, the facility failed to provide treatments for a Stage IV pressure ulcer as ordered by the physician for one resident. This affected one (#62) of three residents reviewed for pressure ulcers. The facility census was 110. Findings include: Review of Resident #62's medical record revealed an admission date of 05/20/20 and a readmission date of 02/03/21. Diagnoses included other specified disorders of brain; pressure ulcer of sacral region, Stage IV; hypertensive heart disease with heart failure; mixed receptive-expressive language disorder; contracture of left hand; and bladder-neck obstruction. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #62 was moderately cognitively impaired, required extensive two-person physical assistance with bed mobility, dressing, toilet use and personal hygiene and had a Stage IV pressure ulcer. Review of the plan of care revealed Resident #62 was at risk for skin breakdown due to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review and review of the facility policy, the facility failed to apply a Prafo boot as care planned for one resident to prevent a decline of the contracture. This affected one (#56) of three residents reviewed for positioning and mobility. The facility census was 110. Findings include: Review of Resident #56's medical record revealed an admission date of 11/07/16. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side; contracture, right hand; dysphagia following other cerebrovascular disease; chronic obstructive pulmonary disease, unspecified (COPD); contracture, right ankle; and Type II diabetes mellitus with unspecified complications. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #56 was moderately cognitively impaired and required total dependence, two-person assistance with bed mobility and transfers and extensive two-person assistance with dressing. Review of the plan of 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, staff interview, review of hospital discharge documents, review of the fall investigation and review of the facility policy, the facility failed to provide adequate supervision of two assist to prevent a fall. This affected one (#56) of five residents reviewed for falls. The facility census was 110. Findings include: Review of Resident #56's medical record revealed an admission date of 11/07/16. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side; contracture, right hand; dysphagia following other cerebrovascular disease; chronic obstructive pulmonary disease, unspecified (COPD); contracture, right ankle; and Type II diabetes mellitus with unspecified complications. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #56 was moderately cognitively impaired and required total dependence, two-person assistance with bed mobility and transfers. Additional review of the MDS dated [DATE], revealed Resident #56…

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.