Continuing Healthcare Of Shadyside

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview the facility failed to ensure medications were reconciled correctly on admission. This affected one resident (#181) of one resident reviewed for psych/opioid medication review. The census was 75. Findings include: Review of the closed medical record review for Resident #181 revealed the resident was admitted on [DATE] under hospice services and discharged to the hospital on [DATE]. The resident's diagnoses include senile degeneration of the brain, chronic obstructive pulmonary disease, dementia, Alzheimer's disease, malignant neoplasm of the bronchus or lung and repeated falls. Review of the baseline care plan dated 02/08/25 revealed Resident #181 was at risk of injury related to smoking, at risk for elopement/wandering related to dementia, at risk for falls and potential injury related to history, psychoactive medication required due to alteration in mood and behavior related to anxiety and wandering without purpose. Intervention included to have commonly used…

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, review of operational manual, observation, and interview the facility failed to ensure a pressure relieving air mattress was accurately set per the resident's weight and maintained per the manufacturer's guidelines. This affected one resident (#34) of four residents reviewed for pressure ulcers. Findings included: Medical record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including suspected deep tissue injury (SDTI) (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue), peripheral vascular disease, anemia, chronic kidney disease, vascular dementia, hemiplegia, protein-calorie malnutrition, and diabetes. Review of Resident #34's Minimum Data Set (MDS) dated [DATE] revealed the resident was at risk for pressure…

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, facility document review and facility policy review the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) when caring for COVID-19 positive residents, performed hand hygiene and disposed of sharps appropriately, and failed to ensure the disinfectant wipes outside of COVID-19 isolation rooms was not expired. Staff not wearing the appropriate PPE and the expired disinfectant wipes had the potential to affect all 56 residents residing in the facility who had not tested positive for COVID-19. The hand hygiene concern affected Resident #233 and the improper disposal of sharps had the potential to affect all residents residing in the facility. The facility census was 69. Findings included: 1. Observation on [DATE] at 9:00 A.M. upon entrance into the facility revealed signage on the entrance door reading Please be aware that (Facility Name) is currently in Outbreak due to Positive staff/residents which informed those who enter the building that 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, review of liability notices, and staff interview, the facility failed to ensure a resident received appropriate notice prior to the end of their Medicare (MCR) Part A services and residents that opted to receive those services continued to receive them while MCR was billed for an official decision on payment. This affected two residents (#1 and #48) of three residents reviewed for liability notices. Findings include: 1. A review of Resident #1's medical record revealed she was admitted to the facility on [DATE]. She was readmitted to the facility on [DATE]. Her diagnoses included end stage renal disease, dependence on renal dialysis, dementia with a mood disturbance, congestive heart failure and chronic obstructive pulmonary disease. Her diagnoses list was updated n 05/01/23 to reflect she had a below the knee amputation of the right leg. A review of Resident #1's Notice of MCR Non-Coverage (NOMNC) revealed her skilled services ended on 05/24/23. The resident received the notice 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 resident record review, interview, and facility policy review, the facility failed to ensure residents who were being transferred to the local emergency room for care received a copy of the bed hold notice. This affected two residents (#24 and #66) of two residents reviewed for hospitalization. The facility census was 69. Findings included: 1. Review of Resident #24's medical record revealed she was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, stage three, acute and chronic combined systolic and diastolic heart failure, neuromuscular dysfunction of the bladder, weakness, and essential hypertension. Review of Resident #24's admission Minimum Data Set (MDS) 3.0 assessment, dated 07/25/23, revealed she was cognitively intact and had active diseases of chronic kidney disease, stage three and heart failure. Review of Resident #24's progress note dated, 08/01/23 at 1:30 P.M., revealed her daughter was called and updated on her mother being sent to the emergency room for…

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 and staff interview, the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASARR) documents were accurate to resident current conditions and diagnoses. This affected three residents (#44, Resident #9, and Resident #15) of three residents reviewed for PASARR documents. The census was 69. Findings Include: 1. Medical record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis, osteomyelitis, major depressive disorder, bipolar disorder, and dementia. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 09/01/23, revealed the resident was cognitively intact, and had diagnoses of dementia, depression and bipolar disorder. Review of Resident #44's PASARR document, dated 10/27/22, revealed under Section E, there were no diagnoses listed. Review of the resident's diagnoses list revealed bipolar disorder and major depressive disorder were added on 01/24/20. During interview 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 record review, observation, and staff interview, the facility failed to ensure a resident who was dependent on staff for personal care received the assistance needed with the removal of unwanted facial hair. This affected one resident (#48) of three residents reviewed for activities of daily living (ADL's). Findings include: A review of Resident #48's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included cognitive communication deficit, dementia with agitation, depression, anxiety disorder, difficulty walking, weakness, and abnormalities of gait and mobility. A review of Resident #48's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was severely impaired. She was not known to have rejected any care during the seven days of the assessment period. She required an extensive assist of one for transfers and personal hygiene and was totally dependent on one for bathing. A review of Resident #48's care plans revealed she had a 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, interview, and policy review, the facility failed to ensure Resident #32's constipation was treated timely. This affected one resident (#32) of two residents reviewed for constipation. Findings include: Medical record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including fracture of the cervical vertebra, fracture of the right femur, dementia, and interstitial pulmonary disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/08/23, indicated the resident was severely cognitively impaired. The MDS assessment revealed the resident required extensive, two-person assistance with bed mobility, transfers, and toileting. Review of the Care Plan, dated 03/13/23, revealed the resident was at risk for pain with interventions including to monitor/document for side effects of pain medications and to observe for constipation and to report occurrences to the physician. Review of a physician order, dated 03/01/23, revealed the order for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and policy review, the facility failed to properly store Resident #19's nebulizer machine, tubing, and mouthpiece and failed to ensure Resident #31 received the correct dosage of oxygen as ordered by the physician. This affected two residents (#19 and #31) of two residents reviewed for respiratory care. Findings include: 1. Medical record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including myocardial infarction, dementia, obesity, and weakness. Review of Resident #19's physician orders, dated 02/27/23, revealed the order for ipratropium-albuterol solution 0.5-2.5 milligrams (mg)/2 milliliters (ml), inhale orally every four hours as needed for shortness of breath via nebulizer. Review of the Medication Administration Record (MAR) dated September 2023, revealed the resident was administered the nebulizer treatment on 09/16/23. Observation on 09/18/23 at 12:26 P.M., revealed Resident #19 lying in bed with her eyes closed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the dialysis contract, and staff interview, the facility failed to ensure dialysis communication forms were completed by the facility and the dialysis center to maintain good communication of the resident's condition and services rendered during dialysis treatments. This affected one resident (#1) of one resident reviewed for hemodialysis treatments. Findings include: A review of Resident #1's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included end stage renal disease (ESRD) and dependence on renal dialysis. A review of Resident #1's physician's orders revealed she received dialysis treatments every Tuesday, Thursday, and Saturday. That order had been in place since 05/09/23. A review of Resident #1's care plans revealed she had a care plan in place for receiving dialysis every Tuesday, Thursday, and Saturday related to ESRD. The interventions included checking for new orders upon the resident's return from dialysis and maintaining…

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 and interview the facility failed to ensure residents were free from unnecessary medications. This affected two residents (#11 and #15) of seven residents reviewed for unnecessary medication. The facility census was 69. Findings include: 1. Record review revealed Resident #11 was admitted on [DATE] with diagnoses including traumatic subdural hemorrhage without loss of consciousness, sepsis due to Escherichia coli, extended spectrum beta lactamase (ESBL) resistance, diffuse large b-cell lymphoma, intra-abdominal lymph nodes, essential (primary) hypertension, gastro-esophageal reflux disease without esophagitis, benign prostatic hyperplasia with lower urinary tract symptoms, sleep apnea, insomnia, and overactive bladder. Review of the Minimum Data Set (MDS) assessment from 08/21/23 also revealed Resident #11 had a Stage 3 pressure ulcer to the coccyx present on admission and experienced frequent bowel incontinence. Review of Resident #11's medical record 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, facility self-reported incident (SRI) review, and policy review, the facility failed to ensure residents were free from abuse by Resident #73, a resident with a known history of aggressive behaviors. In addition, the facility failed to ensure residents were free from verbal abuse from State Tested Nurse Aide (STNA) #300. This affected six residents (#44, #53, #75, #76, #77, and #78) of eight residents reviewed for abuse. The facility census was 73. Findings included: 1. Review of Resident #73's medical record revealed an initial admission on [DATE] and a readmission on [DATE]. The resident had diagnoses including Alzheimer's disease, dementia in other diseases classified elsewhere, major depressive disorder, anxiety disorder, hallucinations, and unspecified psychosis not due to a substance of known physiological condition, manic disorder, insomnia, cognitive disorder. On 05/12/23 intermittent explosive disorder diagnosis was added. Review of Resident #73'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 record review, staff interview, facility self-reported incident (SRI) review, and policy review, the facility failed to report physical abuse to the state agency. This affected four residents (#44, #53, #73, #75). Findings included: Review of Resident #73's medical record revealed an initial admission on [DATE] and a readmission on [DATE]. The resident had diagnoses including Alzheimer's disease, dementia in other diseases classified elsewhere, major depressive disorder, anxiety disorder, hallucinations, and unspecified psychosis not due to a substance of known physiological condition, manic disorder, insomnia, cognitive disorder. On 05/12/23 intermittent explosive disorder diagnosis was added. Review of Resident #73's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognition impairment and was rarely/never understood. His cognitive skills for daily decision making were moderately impaired and his decisions were poor and he required supervision and cues. He had…

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, facility self-reported incident (SRI) review, and policy review, the facility failed to have evidence that allegations of physical abuse was thoroughly investigated. This affected four residents (#44, #53, #73, #75). Findings included: Review of Resident #73's medical record revealed an initial admission on [DATE] and a readmission on [DATE]. The resident had diagnoses including Alzheimer's disease, dementia in other diseases classified elsewhere, major depressive disorder, anxiety disorder, hallucinations, and unspecified psychosis not due to a substance of known physiological condition, manic disorder, insomnia, cognitive disorder. On 05/12/23 intermittent explosive disorder diagnosis was added. Review of Resident #73's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognition impairment and was rarely/never understood. His cognitive skills for daily decision making were moderately impaired and his decisions were poor and he required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure residents were adequately supervised to assist in the prevention of resident to resident altercations. This affected one resident (#73) of three residents reviewed for resident-to-resident abuse. Findings include: Review of Resident #73's medical record revealed an initial admission on [DATE] and a readmission on [DATE] with diagnoses including Alzheimer's disease, dementia in other diseases classified elsewhere, major depressive disorder, anxiety disorder, hallucinations, and unspecified psychosis not due to a substance of known physiological condition, manic disorder, insomnia, cognitive disorder. On 05/12/23 the diagnosis of intermittent explosive disorder was added. Review of Resident #73's Minimum Data Set (MDS) 3.0 dated 08/13/23 revealed the resident had severe cognition impairment and was rarely/never understood. His cognitive skills for daily decision making was moderately impaired and his decisions were poor and required supervision 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 record review, interview, and facility policy review the facility failed to reimburse Resident #70 's funds to her family within 30 days of her death. This affected one resident (#70) out of three residents reviewed for resident funds. The facility census was 66. Findings include: Review of the medical record revealed Resident #70 was admitted into the memory care unit at the facility on [DATE] with diagnoses including unspecified dementia, right arm fracture, weakness, depression, and high blood pressure. Resident #70 expired at the facility on [DATE]. Review of Resident #70's invoice for services and room and board dated [DATE] revealed balance due of $2,400.00. Review of Resident #70's credit card statement from Capital One dated [DATE] revealed a credit card payment made to the facility dated [DATE] for $2,400.00. Review of Resident #70 accounts receivable adjustment request dated [DATE] revealed the facility requested a pro-rated patient liability adjustment due to Resident #70 expiring on [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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to maintain sufficient levels of nursing staff to meet the total care needs of all residents. This affected seven residents (#13, #14, #50, #162, #48, #55 and #165) and had the potential to affect all 68 residents residing in the facility. Findings include: 1. Review of Resident #50's medical record revealed diagnoses including low back pain, anxiety disorder, and generalized muscle weakness. A care plan initiated 01/21/20 addressed Resident #50's personal preferences. Interventions included honoring Resident #50's activity of daily living preferences as able and indicated Resident #50's preferred time to rise was 6:30 A.M. A quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/10/21 indicated Resident #50 was cognitively intact. Resident #50 required extensive assistance from staff for transfers, walking in the room, personal hygiene and dressing. On 10/18/21 at 2:42 P.M. interview with Resident #50 revealed she preferred to rise 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.

Based on review of department head schedules and interview the facility failed to ensure the Director of Nursing only served as a charge nurse when the census was 60 residents or fewer. This affected all 68 residents. Findings include: On 10/21/21 at 10:15 A.M. review of department head schedules from 09/19/21 to 10/21/21 with the Director of Nursing (DON) revealed the previous DON, (DON #171) was scheduled to work as a charge nurse on 09/19/21 from 7:00 P.M. to 7:00 A.M. The current DON revealed she took over the position of DON on 10/08/21. On 10/11/21 she worked as a charge nurse on day shift from 7:00 A.M. to 7:00 P.M. The census on 09/19/21 was 63. The census on 10/11/21 was 62.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure resident preferences for bathing and/or rising time were honored. This affected five residents (#13, #14, #50, #55 and #165) of 11 residents interviewed regarding choices and one additional resident (Resident #48). The facility census was 68. Findings include: 1. Review of Resident #13's medical record revealed diagnoses including paralysis and weakness on one side of the body following a stroke, chronic obstructive pulmonary disease (COPD), morbid obesity, generalized muscle weakness, rheumatoid arthritis, and osteoarthritis. A care plan initiated 10/10/19 indicated Resident #13 had an alteration in performance of activities of daily living related to impaired mobility, obesity, rheumatoid arthritis, osteoarthritis and COPD. Interventions included use of a Hoyer lift for transfers and indicated Resident #13 preferred three showers a week (Monday, Wednesday, Friday) and as necessary. A quarterly Minimum Data Set (MDS) 3.0 assessment,…

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, facility admission Guidance review and interview the facility failed to maintain acceptable infection control practices, including the proper use, cleaning and disposal of personal protective equipment when entering the room of a resident (Resident #214) who was in quarantine for COVID-19 precautions to prevent the potential spread of COVID-19. This had the potential to affect all 36 residents (#3, #4, #7, #12, #13, #14, #15, #16, #17, #18, #20, #21, #22, #23, #24, #28, #35, #36, #39, #42, #43, #48, #49, #50, #54, #55, #57, #58, #162, #163, #164, #165, #166, #213, #214 and #215) who resided on the East Hall. The facility census was 68 Findings include: Review of Resident #214's medical record revealed the resident was admitted on [DATE] and was on droplet precautions, designed to reduce the risk of droplet transmission of infectious agents, for 14 days related to COVID -19 precautions due to the resident not being vaccinated. On 10/19/21 at 4:30 P.M. observation of 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 record review, review of facility policy and procedure and interview the facility failed to exercise reasonable care for the protection of Resident #55's property from loss or theft and ensure timely follow up regarding missing/lost items. This affected one resident (#55) of two residents reviewed for missing property. Findings include: Review of Resident #55's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including osteoarthritis, anxiety disorder and depression. Review of the 10/08/21 annual Minimum Data Set Assessment (MDS) 3.0 assessment revealed the resident was moderately impaired for daily decision making, required supervision for toilet use and personal hygiene, required one person assist for bed mobility, transfers and dressings, required supervision set up for eating and was dependent on one staff for bathing. Interview on 10/18/21 at 4:07 P.M. with Resident #55 revealed she had lost a white furry jacket (date not provided) with her name in it. 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 interview the facility failed to ensure Resident #53 and Resident #55 and/or their responsible parties were notified timely and invited to participate in quarterly care conferences. This affected two residents (#53 and #55) of four residents reviewed for care planning conferences. Findings include: 1. Review of Resident #55's medical record revealed the resident was admitted [DATE] with diagnoses including osteoarthritis, anxiety disorder and depression. Record review revealed the resident had a court appointed guardian. Review of the 10/08/21 annual Minimum Data Set (MDS) 3.0 assessment revealed the resident was moderately impaired for daily decision making, required supervision for toilet use and personal hygiene, required one person assist for bed mobility, transfers and dressings, and required supervision set up for eating and was dependent on one staff for bathing. On 10/18/21 at 4:10 P.M. interview with the resident revealed the resident did not recall being in a meeting…

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, facility policy and procedure review and interview the facility failed to ensure Resident #25 received oxygen therapy as ordered. This affected one resident (#25) of three residents reviewed who had orders for oxygen. Findings include: Record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including a stroke which affected his speech and swallowing receiving feeding through a tube in his stomach, chronic obstructive pulmonary disease (COPD) and hypoxia due to aspiration. Review of the physician's orders revealed an order, dated 08/05/21 to provide two liters of oxygen as needed when short of breath (SOB). Review of the 09/08/21 Minimum Data Set (MDS) 3.0 assessment revealed Resident #25 was alert and oriented, required extensive assistance with activities of daily living (ADL) care and was transferred utilizing a mechanical lift. On 10/18/21 at 11:00 A.M. Resident #25 was observed receiving oxygen set at five liters via nasal cannula. 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 medical record review and staff interview the facility failed to ensure antibiotics were prescribed based on culture and sensitivity results to ensure appropriate antibiotic use. This affected two residents (#6 and #47) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #6's medical record revealed an admission date of 08/20/20 with a diagnosis that included neuromuscular dysfunction of bladder. A nurse's progress note, dated 01/10/21 revealed staff identified foul smelling urine and informed the physician who ordered a urinalysis with culture and sensitivity (lab test to determine urinary tract infection (UTI) and appropriate medication to treat). The urinalysis was obtained on 01/14/21 and culture and sensitivity results were completed and returned to the facility on [DATE], which indicated Resident #6 had a UTI with morganella morganii as the organism and to avoid 1st, 2nd and 3rd generation cephalosporins. Review of physician's orders indicated 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.