Seven Hills Health & Rehab Center

Based on record review and interview, the facility failed to ensure medical records were accurate. This affected one (Resident #5) of 16 resident medical records reviewed. The facility census was 63.Findings include: Review of the medical record for Resident #5 revealed an admission date of 12/09/16. Diagnoses included but were not limited to schizophrenia, anxiety disorder, obsessive compulsive disorder and osteoarthritis. Review of the 03/31/25 Minimum Data Set (MDS) 3.0 for Resident #5 revealed intact cognition and was dependent upon staff for bathing. Review of Resident 5's care plan dated 02/26/24 revealed she is dependent upon staff for bathing. Review of the shower sheets from 04/03/25, 4/07/25, 04/10/25, 04/14/25, 04/17/25, 04/20/25, 04/25/25, 05/06/25, 05/09/25, 05/13/25, 05/15/25, 05/20/25, 05/23/25, 05/27/25, 06/06/25, 06/10/25, and 06/17/25 revealed no evidence the nurse reviewed the shower sheet and no signature. Shower sheets that had documented refusals on 04/07/25, 04/14/25, 04/17/25, 04/20/25, 05/06/25, 05/15/25, and 05/27/25 revealed no evidence of a nursing…

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 and interviews, the facility failed to provide meaningful resident-centered activities for Resident #57. This affected one (Resident #57) out of three residents reviewed for activities. The facility census was 63. Findings include: Review of the medical record for Resident #57 revealed an admission date of 01/09/25 with diagnoses of metabolic encephalopathy, moderate protein-calorie malnutrition, dysphagia, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was cognitively impaired, rarely or never able to make needs known, and rarely or never understood communication. The assessment indicated that she was dependent upon two staff members to move in bed, take a shower or bath, and dependent on one staff member for dressing. Review of the current physician's orders revealed no pharmacological intervention for anxiety, agitation, or restlessness. Review of progress notes since admission revealed no…

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, interview, policy review, and review of the employee handbook, the facility failed to ensure staff performed transfers in a safe manner per physician's orders and re-assess fall risk after a fall occurred. This affected one resident (#19) out of four reviewed for accident hazards. The facility census was 63. Findings include: Review of the medical record for Resident #19 revealed an admission date of 10/22/24 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, convulsions, hyperlipidemia, hypertension, depression, aphasia, muscle weakness, need for assistance with personal care, and difficulty in walking. Review of the physician's orders for Resident #19 identified an order for a mechanical lift for transfers (ordered 10/23/24). Review of the most recent fall risk assessment, dated 10/23/24, revealed Resident #19 had no falls within the previous six months, was completely paralyzed or completely immobilized, and had a score 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, interviews, and observations, the facility failed to ensure that colostomy care was provided as ordered and per resident's preference. This affected one resident (Resident #26) out of two residents reviewed for ostomy care. Findings include: Review of medical record revealed that Resident #26 was admitted on [DATE] with diagnosis of heart failure, weakness, polyneuropathy, and major depression. Review of the annual Minimum Data Set (MDS) dated [DATE] Resident #26 was alert and oriented without cognitive impairment. They were dependent upon staff for toilet hygiene, shower and bath, as well as personal hygiene. Resident #26 was always incontinent of bladder and had a colostomy for bowel movements. Review of physician's orders reveal an order dated 01/26/25 to empty the colostomy bag every shift. Report any changes noted such as changes is color of stool, amount of stool, or consistency of stool. Document emptying contents and any changes noted. Review of the comprehensive care plan updated…

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, interview, and facility policy review, the facility failed to ensure pain medications were administered timely to ensure effective pain management. This affected one resident (#120) out of eight residents reviewed for medication administration. The facility census was 63. Findings include: Review of medical record for Resident #120 revealed an admission date of 04/15/25 with diagnoses including pathological fractures, malignant neoplasm's of bone, malignant neoplasm of bladder, protein-calorie malnutrition, urostomy, and need for assistance with personal care. Review of Resident #120's Minimum Data Sheet (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition. Resident #120 required moderate assistance for upper body activities of daily living (ADLs) and maximum assistance for lower body and mobility needs. Resident #120 also needed maximum assistance for toileting and hygiene needs. Review of care plan 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 record review, observations and interviews the facility failed to ensure insulin was dated, labeled, and discarded properly. This affected six residents (#11, #12, #16, #30, #41 and Resident #53) of 12 residents reviewed for insulin storage. Findings include: Review of medical record for Resident #11 revealed an admission date of 05/22/21. Diagnosis included type two diabetes. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #11 dated 08/14/24 revealed the resident had impaired cognition. Review of medical record for Resident #12 revealed an admission date of 11/28/23. Diagnosis included type two diabetes. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #12, dated 09/26/24 revealed the resident had intact cognition. Resident #12 was ordered insulin. Review of medical record for Resident #16 revealed an admission date of 09/28/23. Diagnosis included type two diabetes. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #16 dated 09/30/24 revealed the resident had intact cognition. Resident #16 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure a medication error rate of less than 5% (percent). A total of 24 medications were observed with two errors for a medication error rate of 8.33%. This finding affected two (Resident #39 and #41) of three residents observed for medication administration. Findings include: 1. Review of medical record for Resident #39 revealed an admission date of 03/26/20. Diagnoses included type two diabetes with diabetic neuropathy, unspecified, major depressive disorder, recurrent and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of physician order dated 01/24/24 revealed orders for Novolin 70-30 via flexpen, administer 45 units one time a day. Observation on 10/03/24 8:43 A.M. revealed Licensed Practical Nurse (LPN) #836 administered 45 units of Novolin to Resident #39. LPN #836 retrieved the injector pen, sanitized the tip, twisted the injector needle…

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, interview and policy review the facility failed to maintain infection control standards when administering medications. This affected one (Resident #30) of three residents reviewed for infection control during medication administration. Findings include: Review of medical record for Resident #30 revealed an admission date of 05/02/24. Diagnoses included type two diabetes, alcoholic cirrhosis of the liver and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #1 dated 08/07/24 revealed the resident had intact cognition. Observations on 10/02/24 at 7:55 A.M. revealed Licensed Practical Nurse (LPN) #836 administering medications for Resident #30. LPN #836 placed nine medications into her bare hand before placing them in the medication cup. Interview during the observation with LPN #836 revealed she should not have put the medication in my hand, they should go in the cup. Review of the facility policy titled, Pharmacy Services and Procedure Manual, dated 2022 revealed staff should not touch the medication…

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 of video from camera in room and record review, the facility failed to ensure call lights were kept within reach and residents were able to use if desired. This affected Resident #152, one of three sampled residents. The census was 62. Findings include: Medical record review revealed Resident #152 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, peripheral vascular disease with bilateral lower extremities wounds, hypertension, type 2 diabetes, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease, dementia, cerebral infarction, protein-calorie malnutrition, osteomyelitis (bone infection), stage IV coccyx pressure wound and neuromuscular dysfunction of the bladder. Resident #152 was severely cognitively impaired and was totally dependent on staff for all activities of daily living including bed mobility, transfers, dressing, toileting, and personal hygiene. Review of Resident #152's care plan dated 07/27/23 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, record review, and interview, the facility failed to ensure previously placed Fentanyl transdermal patches were removed prior to placing a new patch. This affected Resident #152, one of three sampled residents. The census was 62. Findings include: Medical record review revealed Resident #152 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, peripheral vascular disease with bilateral lower extremities wounds, hypertension, type 2 diabetes, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease, dementia, cerebral infarction, protein-calorie malnutrition, osteomyelitis (bone infection), stage IV coccyx pressure wound and neuromuscular dysfunction of the bladder. Resident #152 was severely cognitively impaired and was totally dependent on staff for all activities of daily living including bed mobility, transfers, dressing, toileting, and personal hygiene. Review of current physician's orders indicated Resident #152 was to receive a…

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 controlled substances (two Fentanyl transdermal patches) were disposed of properly after removal from resident. This affected Resident #152, one of three sampled residents. The total census was 62. Findings include: Medical record review revealed Resident #152 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, peripheral vascular disease with bilateral lower extremities wounds, hypertension, type 2 diabetes, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease, dementia, cerebral infarction, protein-calorie malnutrition, osteomyelitis (bone infection), stage IV coccyx pressure wound and neuromuscular dysfunction of the bladder. Resident #152 was severely cognitively impaired and was totally dependent on staff for all activities of daily Living including bed mobility, transfers, dressing, toileting, and personal hygiene. Review of physician's orders indicated 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 of video from camera in room, record review, and interview, the facility failed to ensure infection control protocols were followed when providing resident care. This affected Resident #152. The total census was 62. Findings include: Medical record review revealed Resident #152 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, peripheral vascular disease with bilateral lower extremities wounds, hypertension, type 2 diabetes, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease, dementia, cerebral infarction, protein-calorie malnutrition, osteomyelitis (bone infection), stage IV coccyx pressure wound and neuromuscular dysfunction of the bladder. Resident #152 was severely cognitively impaired and was totally dependent on staff for all activities of daily living including bed mobility, transfers, dressing, toileting, and personal hygiene. Observation of a video dated 09/16/23 obtained from the surveillance camera located 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 interview, record review, and review of the facility policy, the facility failed to ensure State Tested Nursing Assistants (STNA) received 12 hours of inservices annually. This had the potential to affect all 75 of 75 residents residing in the facility. Findings include: Record review of STNA #326's employee file revealed a hire date of 06/25/20. Record review of the the signed transcript for STNA #326 revealed a combined total of 10.10 hours of annual inservices. Record review of STNA #327 employee file revealed a hire date of 03/30/21. Record review of the the signed transcript for STNA #327 revealed a combined total of 6.70 hours of annual inservices. Interview on 09/19/22 at 9:30 A.M. with Administrator confirmed STNA #326 had a total of 10.10 hours of inservicing and STNA #327 had a total of 6.70 hours of inservicing. Administrator confirmed all STNA's were required 12 hours of inservicing annually. Record review of the policy titled, Annual Inservices revealed no less than 12 hours annual inservice training/staff education is required. Calculate the date by which…

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, facility policy review, and review of online resources for the Centers for Disease Control and Prevention (CDC), the facility failed to ensure staff wore personal protective equipment (PPE) as required when entering Resident #127 and #266's room who were under droplet precautions for COVID-19 observation. This had the potential to affect all 75 residents residing in the facility. Findings include: Review of medical record for Resident #127 revealed admission date 09/09/22 and a physician order dated 09/12/22 to 09/15/22 for droplet precautions. Review of the immunization record revealed Resident #127 had declined the COVID-19 vaccination. Review of medical record for Resident #266 revealed admission date of 09/12/22 and a physician order dated 09/13/22 to 09/20/22 for droplet precautions. Review of the immunization record revealed Resident #266 was not up to date on COVID-19 vaccination series. Observation on 09/14/22 at 8:08 A.M. revealed between Resident #127's room and #266's room there was a sign indicating droplet precautions and a bin with PPE…

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 residents had accurate advance directives within the medical records. This affected four residents (Residents #14, #43, #59, and #62) of twelve residents reviewed for advanced directives. Findings include: 1. Review of medical record for Resident #14 revealed admission date of 06/25/22 with diagnoses including revealed diabetes mellitus, hepatitis C, gout, end stage renal disease, dependence on renal dialysis, and right below knee amputation. Review of physician's order dated 06/25/22 revealed Resident #14 was a full code. Review on 09/12/22 at 3:57 P.M. of Resident #14's hard medical chart revealed no indication of code status. Interview on 09/12/22 at 4:28 P.M. with Licensed Practical Nurse (LPN) #313 confirmed there was no indication of code status in hard medical chart. LPN #313 indicated the code status was supposed to be indicated in hard medical chart. Interview on 09/12/22 at 4:29 P.M. with Social Services Designee (SSD) #314 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure meal intakes were monitored. This affected five residents (Resident #8, #14, #23, #61, and #62) of five residents reviewed for nutrition monitoring. Findings include: 1. Review of the medical record for Resident #8 revealed admission date of 08/30/21 with diagnoses including catatonic disorder, depression, and hyperlipidemia. Resident #8 had physician's order dated 09/01/21 for a regular diet. Review of the care plan dated 06/17/22 revealed Resident #8 was at increased nutritional risk. Interventions included monitor dietary intake, monitor need for increased nutritional intervention, and provide diet as ordered. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #8 was independent during meals. Review of electronic medical record (EMR) meal intake documentation from September 2022 revealed no documentation of meal intake for breakfast, lunch, or dinner. Review of paper medical record for meal intakes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure regular nail care was provided for Resident #23. This affected one resident (Resident #23) of three reviewed for activities of daily living care. The facility census was 75. Findings include: Review of medical record for Resident #23 revealed admission date of 03/11/22 with diagnoses including rectal cancer, depression, anxiety disorder, unspecified side hemiplegia, and vital hepatitis C. Review of the care plan dated 03/14/22 revealed Resident #23 had activities of daily living (ADL) self-care deficit. Interventions included to assist with ADL of grooming, assist of two for bathing and hygiene, and refer to therapy as needed. Review of Medicare Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #23 required extensive one staff assistance for personal hygiene and one staff physical help for bathing. Review of Monthly Nursing Note dated 09/12/22 revealed Resident #23 was alert, oriented, pleasant, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure regular podiatry care was provided for Resident #23. This affected one resident (Resident #23) of three reviewed for activities of daily living care. Findings include: Review of medical record for Resident #23 revealed admission date of 03/11/22 with diagnoses including rectal cancer, depression, anxiety disorder, unspecified side hemiplegia, and vital hepatitis C. Review of the care plan dated 03/14/22 revealed Resident #23 had activities of daily living (ADL) self-care deficit. Interventions included to assist with ADL of grooming, assist of two for bathing and hygiene, and refer to therapy as needed. Review of physician's order dated 06/11/22 revealed Resident #23 may see podiatrist. Review of Medicare Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #23 required extensive one staff assistance for personal hygiene and one staff physical help for bathing. Review of Weekly Skin Evaluation 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 observation, interview, and record review, the facility failed to ensure Resident #25's aerosol treatment was administered properly. This affected one resident (Resident #25) of out four residents observed for medication administration. Findings include: Record review for Resident #25 revealed an admission date of 07/13/21 with diagnosis including quadriplegia, cerebrovascular disease, pneumonia, heart failure, and muscle wasting and atrophy. Record review of the annual MDS dated [DATE] revealed Resident #25 was rarely or never understood. Resident #25 had a short term and long term memory problem. Resident #25 was total dependence for all activities of daily living. Record review of the physician orders for September 2022 revealed Resident #25 had orders for albuterol solution 0.5-0.25 milligrams (mg) per three milliliters (ml) inhale orally every four hours as needed for shortness of breath. Observation on 09/13/22 at 4:15 P.M. revealed Resident #25 was lying in bed. Resident #25 had an aerosol mask…

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, interview, and review of manufacture's guidelines, the facility failed to ensure a medication error rate of less than five percent (%). Four errors occurred within 26 opportunities for error resulting in a medication error rate of 15.38%. This affected two residents (Resident #25 and #31) of four residents observed during the mediation administration observation. The facility census was 75. Findings include: 1. Review of Resident #25's medical records revealed an admission date of 07/13/21 with diagnoses including hyperglycemia, necrotizing fasciitis, quadriplegia, dysphagia, heart failure, and chronic kidney disease. Review of the care plan dated 07/12/22 revealed the resident had risk for unstable blood glucose related to diabetes. Review of the Minimum Data Set (MDS) dated [DATE] revealed had severely impaired cognition and required total care of two plus for bed mobility, transfers, toileting, and bathing. Resident #25 required total care of one assistance for dressing…

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 document Resident #126's hospitalization. This affected one resident (Resident #126) of four residents reviewed for hospitalization. Findings include: Record review of the medical records for Resident #126 revealed an admission date of 08/26/22 with diagnosis including paraplegia, neurogenic bowel, neuromuscular dysfunction of bladder and necrotizing fasciitis. Record review of the admission assessment dated [DATE] at 6:00 P.M. revealed Resident #126 arrived at the facility on 08/26/2022 at 6:00 P.M. for rehabilitation. Resident#126 had a discharge goal to return to the community. Resident #126 was alert and oriented and required one person assist for toileting. Record review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #126 was cognitively intact. Record review of the care plan dated 09/02/22 revealed Resident#126 had an activity of daily living (ADL) self care deficit. Interventions included toileting with assist of one 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 interview and record review, the facility failed to ensure the duration of Resident #18 antibiotic use was implemented and monitored properly. This affected one resident (Resident #18) out of three residents reviewed for urinary tract infections. The facility census was 75. Findings include: Record review revealed Resident #18 had an admission date of 05/24/21 with diagnosis including dementia and multiple fractures of the pelvis. Record review of the care plan for Resident #18 dated 05/25/21 revealed Resident #18 had altered genitourinary status with a history of urinary tract infections (UTI) prior to admission. Interventions included to administer medications as indicated by the physician. Record review quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #18 was rarely or never understood. Record review of the urine specimen for Resident #18 collected on 08/02/22 revealed the urine was positive for nitrates with many bacteria presen , blood 1+, slightly cloudy, and mucous was present. 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 observation, record review and interview the facility failed to use alcohol-based hand sanitizer within dispensers mounted within resident care areas on the first and second facility resident care hallways. This had the potential to affect all 77 residents residing within the facility. The facility also failed to ensure Tuberculosis (TB) tests were completed or had the first step read before new employees started to work for five new employees (State Tested Nursing Assistant (STNA) #640, STNA #641, STNA #660, STNA #663, and STNA #697) out of ten employees reviewed. This had the potential to affect all 77 residents in the facility. Findings include: 1. During the initial facility tour on 09/03/19 between 8:24 A.M. and 8:42 A.M., 19 hand sanitizer dispensers mounted within resident care areas on the first and second floors of the facility were observed to contain hand sanitizer gel labeled no alcohol. Review of Centers for Disease Control Guidelines for Healthcare Providers for Hand Hygiene, located at https://www.cdc.gov/handhygiene/providers/index.html, last reviewed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure treatments were given per physician's orders. This affected one resident (Resident #56) of two residents reviewed for non-pressure skin conditions. The facility census was 77. Findings include: Review of Resident #56's medical record revealed an admission date of 08/07/19 and diagnoses including chronic kidney disease, hypertension (high blood pressure), history of falls and peripheral vascular disease. Review of an admission comprehensive assessment dated [DATE] revealed Resident #56 was cognitively impaired and required limited assistance with assist of one staff for dressing and toileting. Review of a physician order dated 08/23/19 revealed a treatment consisting of Dakin's solution 0.5% (product used to treat skin infections) apply to left lateral ankle, topically, every day shift, for wound care; cleanse area with wound cleaner, pat dry, then apply Dakin's soaked gauze, cover with ABD (thick pad used for dressing wounds), 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 record review, observation, and interview, the facility failed to ensure tube feed bags delivering enteral nutrition to residents were labeled with the formula, resident name, and time administered. This affected one resident (Resident #33) out of five residents identified by the facility as receiving tube feeds. The total census was 77. Findings include: Observation on 09/03/19 at 10:12 A.M. revealed Resident #33 had tube feed infusing via a gastric feeding tube from an unlabeled, undated bag of formula. No indication was found on the bag or tubing indicating what type of formula was infusing, when it was hung, or which staff member hung it. This observation was confirmed with Licensed Practical Nurse (LPN) #600 on 09/03/19 at 10:25 A.M. Review of the facility's Enteral Therapy (Tube Feeding) and Care of G-Tube/J-Tube policy (revised August 2019) and policy titled Enteral Feeding Via Continuous Pump (revised October 2015)indicated nurses would administer enteral feeding as ordered by physician.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to prevent significant medication errors for two residents (#31 and #58) of five residents reviewed for medication administration. The census was 77. Findings include: 1. Medical record review revealed Resident #31 was admitted to the facility for skilled care on 06/19/19 with diagnoses including end-stage renal disease, dependence on renal dialysis, type 2 diabetes, hypertension, blindness and muscle weakness. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #31 was cognitively intact and received insulin. Review of the physician order dated 06/19/19 indicated Resident #31 was to have her blood sugar checked four times a day. Review of the physician order dated 07/10/19 revealed Resident #31 was to receive Basaglar solution (insulin) 30 units one time a day. Review of the Medication Administration Record (MAR) for September 2019 indicated the Basaglar insulin was scheduled once a day at 9:00 A.M. During an interview on 09/03/19 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.