Crestwood Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure oxygen was administered per physician orders and further failed to ensure oxygen tubing was routinely changed. This affected two (Resident #12 and #18) of two residents reviewed for oxygen administration. The facility identified 11 residents who received oxygen therapy. The facility census was 96. Findings include: 1. Review of the medical record for Resident #12 revealed an admission of 07/19/17. Diagnoses included acute and chronic respiratory failure with hypoxia, atrial fibrillation, morbid obesity, and hypertensive heart disease with heart failure. Review of the Minimum Data Set (MDS) assessment revealed Resident #12 had intact cognition and required assistance with activities of daily living (ADLs). Review of the physician orders for Resident #12 dated 09/02/24 revealed an order for oxygen two to three liters ER minute (LPM) via nasal cannula continuous every shift with oxygenation…

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 resident and staff interviews, record review, and review of facility policy, the facility failed to monitor weights and vital signs before and after dialysis and maintain adequate communication with the outside dialysis center for Resident #66. This affected one (Resident #66) of one resident reviewed for dialysis. The facility identified four residents receiving dialysis. The facility census was 96. Findings include: Review of the medical records for Resident #66 revealed an admission date 10/16/24. Diagnosis included stage III kidney disease and hemodialysis. The medical record for November 2024, December 2024, and January 2025 revealed there were no routine vital signs, pre or post dialysis assessments were completed. There was no dialysis communication noted in the medical record either. Review of the physician order dated 02/06/25 revealed to assess the resident upon return from dialysis in the afternoon every Monday, Thursday and Saturday. Complete a pre-dialysis assessment prior to dialysis on Tuesday, Thursday and Saturday. Interview on 02/25/25 at 1:24 P.M. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, medical record review, and facility policy review, the facility failed to ensure medications were administered according to physician orders resulting in a medication error rate which exceeded five percent (%). 27 opportunities were observed with two medication errors resulting in a 7.41% error rate. This affected two (Resident #57 and #69) of four residents observed for medication administration. The facility census was 96. Findings include: 1. Review of the medical records for Resident #57 revealed an admission date of 01/07/25 with a diagnosis including type II diabetes mellitus (DM) with hyperglycemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 had intact cognition. Review of the physician order dated 02/10/25 revealed an order for Lantus SoloStar subcutaneous solution pen-injector 100 unit per milliliter (ml), inject 50 units subcutaneous twice daily for DM. (Lantus is a long-acting insulin used to control high blood…

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, resident and staff interview, and policy review, the facility failed to ensure that residents were free from significant medication errors. This affected one (Resident #57) of four residents reviewed for medication administration. The facility census was 96. Findings include: Review of the medical record for Resident #57 revealed an admission date of 01/07/25 with a diagnosis including type II diabetes mellitus (DM) with hyperglycemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 had intact cognition. Review of the physician order dated 02/10/25 revealed an order for Lantus SoloStar subcutaneous solution pen-injector 100 unit per milliliter (ml), inject 50 units subcutaneous twice daily for DM. (Lantus is a long-acting insulin used to control high blood sugar). The scheduled times for this medication were 7:30 A.M. and 4:00 P.M. Additional insulin orders with a start date of 02/13/25 was Insulin Aspart FlexPen 100 unit per ml solution…

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, medical record review, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policy, the facility failed to ensure glucometers were properly disinfected, failed to implement enhanced barrier precautions (EBP) by donning personal protective equipment (PPE) when completing wound care, and failed to change gloves properly during wound care This affected one (Resident #57) of four residents observed for medication administrations and one (#54) of two residents observed for wound care. The facility identified five residents receiving blood glucose monitoring on the unit. The facility census was 96. Findings include: 1. Review of the medical record for Resident #57 revealed an admission date of 01/07/25 with a diagnosis including type II diabetes mellitus (DM) with hyperglycemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 had intact cognition. Review of the physician order dated 02/09/25 revealed an…

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 interviews, record reviews, and policy review, the facility failed to ensure resident's advance directives were readily available and communicated to the interdisciplinary team. This affected one (#100) of three residents reviewed for advance directives. The facility census was 86. Findings include: Review of the medical record for Resident #100 revealed an admission date [DATE]. Diagnosis included dementia and stated Do Not Resuscitate- Comfort Care (DNR-CC). Under the tab advance directive, it stated DNR-CC dated [DATE]. There was no DNR uploaded in Resident #100's medical record. Review of the plan of care dated [DATE] for advance directive for DNR-CC. Interventions included obtain copies of advanced directives from resident/resident representative to have on file, dated provider order for code status and obtain the state specific DNR form. Review of the physician orders for [DATE] revealed no order related to resident's code status. Code status for DNR-CC was discontinued on [DATE]. Review of the…

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

Based on resident and staff interviews, record review and observation, the facility failed to ensure Resident #78's continuity of care was reviewed and implemented timely. This affected one (#78) of three residents reviewed for medications. The facility census was 86. Findings include: Review of the medical record for Resident #78 revealed an admission date 06/28/23. Diagnoses included heart disease, diabetes mellitus, and lymphedema. Review of the after-visit summary for obstetrics and gynecology dated 10/24/24 revealed a medication order changed for megestrol (hormone therapy) 40 milligrams (mg) two tablets twice a day to four tablets twice a day. Review of the Nurse Practitioner (NP) #300 dated 10/25/24 revealed Resident #78 reported she had a procedure in the gynecology office that left her really sore. Resident #78 stated she has had some relief with ibuprofen. Resident #78 has history of abnormal uterine bleeding and had a uterine scraping and was waiting to hear back if she needs a dilation and curettage (D&C) (a surgical procedure that involves dilating the cervix and using…

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

Based on record review and staff interview, the facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours each day, seven days a week. This had the potential to affect all residents residing in the facility. The facility census was 91. Findings include: Review of the daily staffing reports from 09/17/24 to 09/23/24 revealed the facility had no listed RN coverage for Saturday 09/21/24 and Sunday 09/22/24. An interview on 09/25/24 at 11:25 A.M. with the Director of Nursing (DON) verified she did not work in the building on 09/21/24 and 09/22/24 and verified there was not a RN on duty in the building on Saturday 09/21/24 and on Sunday 09/22/24. The DON verified the facility should have an RN on duty every day, at least eight hours a day. This deficiency represents non-compliance investigated under Complaint Number OH00157343.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interviews and policy review, the facility failed to timely inform and allow the resident to participate in their treatment. This affected one (#100) of three residents reviewed participation of their treatment/care. The facility census was 91. Findings include: Review of the medical record for Resident #100 revealed an admission date of 02/29/24. Diagnoses included osteoarthritis and chronic pain syndrome. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 had intact cognition. Resident #100 had pain occasionally in the last five days of the assessment reference period to which she received pain medication scheduled and as needed and did not receive non-medication interventions for pain. Review of Resident #100's August 2024 physician orders revealed an order for Oxycodone HCL (pain medication) oral tablet 10 milligrams (mg) administer one tablet by mouth two times a day for pain with a start date of 06/23/24. Oxycodone HCL 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 medical record review, staff interviews, and review of the facility policy, the facility failed to timely implement effective and individualized interventions to address a resident's behavioral health concerns. This affected one (Resident #200) of three residents reviewed for behavioral health services. The facility census was 91. Findings include: Review of the medical record for Resident #200 revealed an admission date of 08/01/24. Diagnoses included alcohol dependence with alcohol induced persisting dementia and blind. Resident #200 was discharged from the facility on 09/25/24. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 was unable to complete the interview a Brief Interview Mental Status (BIMS) score. He required substantial/maximal assistance from staff for toileting, personal hygiene, upper and lower body dressing. Resident #200 did not have rejection of care, no physical restraints, and did not exhibit physical, verbal or other behavior symptoms during the…

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

Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours each day, seven days a week. This had the potential to affect all residents residing in the facility. The facility census was 107. Findings include: Review of the daily staffing reports from 04/22/24 to 05/06/24 revealed the facility had no listed RN coverage for Saturday 04/27/24 and Saturday 05/04/24. An interview on 05/15/24 at 10:25 A.M. with Regional Director of Clinical Operations (RDCO) #250 verified the Director of Nursing was not working in the building on Saturday 04/27/24 or 05/04/24, nor was there any evidence any other RN worked on those two dates. RDCO #250 verified the facility should have an RN on duty every day, at least 8 hours a day. This deficiency represents non-compliance investigated under Complaint Number OH00153688.

Based on observation, interview, record review, policy review, and self reported incident (SRI) review, the facility failed to report, investigate and document allegations of resident-to-resident abuse. This affected six (Residents #100, #97, #98, #80, #83, and #101) of eight residents reviewed for abuse, neglect, and misappropriation of property. The facility census was 107. Findings include: Review of the medical record for Resident #100 revealed an admission date of 07/14/20. Medical diagnoses included frontal lobe and executive function deficit following cerebrovascular accident (CVA, stroke), depression, schizoaffective disorder, and insomnia. Review of Resident #100's Minimum Data Set (MDS) quarterly assessment, dated 02/20/24 revealed the resident had severely impaired cognition. Resident #100 was assessed as not having any hallucinations, delusions, behaviors, or rejection of care. Resident #100 required supervision with transfers and mobility, and was noted to require substantial/maximum assistance with dressing and was dependent on staff for showering, toileting hygiene,…

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, staff and resident interview, policy review, and self-reported incidents (SRI) review, the facility failed to maintain accurate resident records. This affected four (Residents #84, #98, #101 and #100) of eight residents reviewed for accuracy of medical records. The facility census was 107. Findings include: 1. Review of the medical record for Resident #84 revealed an admission date of 11/17/23. Medical diagnoses included dementia without behavioral disturbance, anxiety, and schizophrenia. Resident #84 resided on the secured memory care unit. Review of Resident #84's interdisciplinary progress notes revealed a note dated 05/08/24 by Social Services Director (SSD) #300. The note referenced SSD #300 speaking to Resident #84 following an incident that occurred. The note revealed Resident #84 had no recollection of the event and no adverse psychosocial effects. Review of Resident #84's Treatment Administration Record (TAR), dated May 2024, revealed target behaviors staff was monitoring for included anxiety, refusing care, and refusing medications. Resident #84 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, staff and resident interview, record review and policy review, the facility failed to ensure timely and appropriate incontinence care was provided for a resident. This affected one (Resident #27) of three residents reviewed for activities of daily living. The facility census was 107. Findings include: Review of the medical record for Resident #27 revealed an admission date of 06/02/23. Medical diagnoses included mild dementia, chronic kidney disease, and muscle weakness. Review of Resident #27's incontinence care plan, dated 06/13/23, revealed he was incontinent of bowel and bladder. Interventions included to check the resident for incontinence, wash, rinse, and dry perineum, and change clothing after incontinence episodes. Resident #27's activities of daily living care plan, dated 06/05/24, revealed Resident #27 was dependent on staff for toileting hygiene. Review of the Minimum Data Set (MDS) annual assessment, dated 04/25/24, revealed Resident #27 had severely impaired cognition. Resident #27 was dependent for toileting and was always incontinent of bowel…

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, interview, and policy review, the facility failed to ensure physician-ordered treatments were applied as ordered. This affected two (Residents #45 and #50) of three residents reviewed for treatment administration. The facility census was 107. Findings include: 1. Review of the medical record for Resident #45 revealed an admission date of 07/14/21. Medical diagnoses included venous insufficiency, chronic pain, and muscle weakness. Review of Resident #45's physician's orders revealed an order dated 03/31/24 for Resident #45 to have compression wraps applied to both legs daily in the morning, remove at bedtime, for edema. Review of Resident #45's Treatment Administration Record (TAR) for April 2024 revealed the wraps were not applied on 04/01/24, 04/13/24, 04/15/24, 04/22/24, and 04/26/24. Review of Resident #45's interdisciplinary progress notes revealed no documentation the resident had refused leg wraps on the above specified dates. During an observation on 05/06/24 at 7:54 A.M., Resident #45 was lying in bed. Both legs were visibly swollen 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 staff interview, record review, and policy review, the facility failed to ensure physician-ordered laboratory testing was completed timely. This affected one (Resident #100) of three residents reviewed for laboratory testing. The facility census was 107. Findings include: Review of the medical record for Resident #100 revealed an admission date of 07/14/20. Medical diagnoses included frontal lobe and executive function deficit following cerebrovascular accident (CVA, stroke), depression, schizoaffective disorder, and insomnia. Resident #100 was discharged from the facility on 05/09/24. Review of Resident #100's care plan, revised on 02/22/24, revealed the resident used mood stabilizing medication related to schizoaffective disorder. Interventions included to monitor for side effects of medications, provide mood-stabilizing medications per medical provider's orders and provide psych consult and counseling services as needed. Review of Resident #100's physician's orders revealed an order dated 09/11/23 for Depakote 250 mg once daily in the morning, and 500 mg once daily 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and resident and staff interviews, the facility failed to ensure medication administration was accurately documented in the medical record. This affected one (#14) of five residents reviewed for medications. The facility census was 104. Findings include: Review of Resident #14's medical record revealed admission to the facility occurred on 06/13/19 with diagnoses including rheumatoid arthritis, diabetes, chronic pain, and chronic obstructive pulmonary disease. Review of a comprehensive assessment dated [DATE] revealed Resident #14 was assessed as completely alert and oriented. Review of Resident #14's medical record revealed a physician order for the immunosuppressive medication to treat arthritis Humira subcutaneous (SQ) every 14 days. Review of Resident #14's medication administration record (MAR) for March 2024 revealed Licensed Practical Nurse (LPN) #232 documented on the MAR that Resident #14 received his Humira injection on 03/27/24. There was no other documentation of the…

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

Based on medical record review, review of a self-reported incident, staff interview, and policy review, the facility failed to ensure residents were free from improper physician restraints. This affected one (#85) of three residents reviewed for restraints. The facility census was 104. Findings include: Review of Resident #85's medical record revealed admission to the facility occurred on 01/05/24 with medical diagnosis including subdural hematoma, alcohol abuse, stroke, seizures, and dementia. Review of a self-reported incident (SRI) dated 03/09/24 at 11:44 A.M. identified Licensed Practical Nurse (LPN) #214 observed LPN #220 place Resident #85 in a Broda chair (a type of chair use to help positioning) at the nurses' station with a gait belt strapped around her waistline. The investigation identified LPN #214 called the Director of Nursing (DON) to report the concern. The report identified the DON told LPN #214 to send LPN #220 home, remove Resident #85 from the Broda chair, and take the gait belt off. Interview with LPN #214 was completed on 04/02/24 at 7:39 A.M. The interview…

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, staff interview, and policy review, the facility failed to ensure medications were stored in a safe and proper manner. This affected one (#17) of five residents reviewed for medications. The facility census was 104. Findings include: Review of Resident #17's medical record revealed the resident was admitted to the facility on [DATE] with medical diagnoses including subdural hemorrhage, kidney failure, and convulsions. Review of Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with severe cognitive impairment. Observation on 04/02/24 at 9:31 A.M. in Resident #17's room revealed there was a cup full of medications sitting on the bedside stand. Continued observation revealed Licensed Practical Nurse (LPN) #213 was overheard telling Resident #17 she would leave the medications for him to take later, and LPN #213 was then observed to moving the medication cart down the hallway away from the resident's room.…

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

Based on record review, staff interview, and review of facility policy, the facility failed to ensure implementation of their abuse policy and obtain an employee background check was completed for Culinary Aide #423 prior to working with residents and failed to keep the background check log up to date. This had the potential to affect all residents who reside in the facility who can receive service from Culinary Aide #423. The facility census was 104. Findings include: 1.Review of Culinary Aide #423's personnel file revealed a hire date of 08/09/23. Further review revealed no evidence of the completion, or attempt to complete, a background check prior to employment. Review of the staff schedules from 08/01/23 through 02/27/24 revealed Culinary Aide #423 was assigned to work on 08/09/23, 08/15/23, 08/16/23, 08/18/23, 08/22/23, 08/23/23, 08/25/23, 08/30/23, 09/01/23, 09/05/23, 09/06/23, 09/08/23, 09/12/23, 09/13/23, 09/15/23, 09/19/23, 09/20/23, 09/22/23, 09/23/23, 09/26/23, 09/27/23, 09/29/23, 10/03/23, 10/04/23, 10/06/23, 10/08/23, 10/10/23, 10/11/23, 10/13/23, 10/17/23, 10/18/23,…

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, observation, and policy review, the facility failed to serve foods at the appropriate temperatures. The had the potential to affect all residents that resided in the facility as the facility identified all residents received food from the kitchen. The facility census was 104. Findings include: Interview on 02/21/24 at 12:40 P.M. with Resident #57 revealed the food is fair but usually cold. Interview on 02/21/24 at 12:55 P.M. with Resident #40 revealed the food delivered to his hall was usually last and the food was cold. Interview on 02/21/24 at 1:20 P.M. with Resident #43 revealed the food was not always hot. Interview on 02/21/24 at 3:17 P.M. with Resident #48 revealed sometimes the food was served cold. Observation of the lunch tray line on 02/22/24 at 11:56 A.M. with Culinary Director #490 and District Manager #111 revealed the lunch menu consisted of Italian sausage, Penne pasta, and spinach. Interview on 02/22/24 at 1:07 P.M. with Culinary Director #490 revealed they ran out of spinach for the lunch service. Culinary Director #490 stated broccoli was the…

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

Based on record review, review of personnel records, and staff interview the facility failed to provide training on the rights of the residents to the staff. This affected three (Licensed Practical Nurses [LPNs] #435 and #443, and State Tested Nursing Assistant [STNA] #520) of the five personnel records reviewed. This had the potential to affect all 104 residents who resided in the facility. Findings include: Review of STNA #520 employee personnel file revealed a hire date of 12/11/23. The employee file contained no documented evidence of the rights of the residents training being provided to the employee prior to working in the facility. Review of LPN #435's employee personnel file revealed a hire date of 06/02/23. The employee file contained no documented evidence of the rights of the residents training being provided to the employee prior to working in the facility. Review of LPN #443's employee personnel file revealed a hire date of 07/07/23. The employee file contained no documented evidence of the rights of the residents training being provided to the employee prior to working…

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, review of personnel records, and staff interviews, the facility failed to provide abuse, neglect, exploitation and misappropriation of resident property training for staff. This affected three (Licensed Practical Nurses [LPNs] #435 and #443, and State Tested Nursing Assistant [STNA] #520) of the five personnel records reviewed. This had the potential to affect all 104 residents who resided in the facility. Findings include: Review of STNA #520's personnel file revealed a hire date of 12/11/23. The employee file contained no documented evidence of abuse, neglect, exploitation, and misappropriation of resident property training being completed prior to working in the facility. Review of LPN #435's personnel file revealed a hire date of 06/02/23. The employee file contained no documented evidence of abuse, neglect, exploitation, and misappropriation of resident property training being completed prior to working in the facility. Review of LPN #443's personnel file revealed a hire date of 07/07/23. The employee file contained no documented evidence of abuse,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interviews, record review, and policy review, the facility failed to ensure physician visits were completed as required. This affected four (Residents #01, #40, #43, and #200) of six residents reviewed for physician visits. The facility census was 104. Findings include: 1. Review of the medical record for Resident #01 revealed an admission date of 12/05/23. Medical diagnoses included dementia, cellulitis, malnutrition, and venous insufficiency. Review of the admission Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] revealed Resident #01 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Review of the medical record revealed Resident #01 was seen by the previous medical director, Medical Doctor (MD) #700 on 12/06/23. The record revealed Resident #01 had multiple visits by Nurse Practitioner (NP) #475 but did not contain evidence that Resident #01 had been seen by the new medical director, MD #750, or any other 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 observation, staff, resident, and family interviews, record review, policy review, and review of a local police report, the facility failed to ensure Resident #200 was not unnecessarily discharged from the facility and failed to ensure complete and accurate documentation related to Resident #200's discharge was recorded in the resident's medical record. This affected one (Resident #200) of three residents reviewed for discharge. The facility census was 104. Findings include: Review of the medical record for Resident #200 revealed an admission date of 10/02/23 and a discharge date of 01/29/24. Medical diagnoses included Chronic Obstructive Pulmonary Disease (COPD), poly neuropathy, anemia, venous insufficiency, and lymphedema. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. He was recorded as having verbal and other behaviors not affecting others during one to three days…

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 resident interview, staff interview, medical record review, review of food committee minutes, and policy review, the facility failed to ensure snacks were available in the evening and at bed time. This had the potential to affect all 96 residents. The facility census was 96. Findings include: Interview with [NAME] #800 on 10/23/23 at 9:11 A.M. confirmed residents receiving snacks on the second shift was an ongoing issue. [NAME] #800 stated she and the day shift staff pass snacks at 10:00 A.M., and set up the snack cooler for the second shift snack pass at 3:00 P.M. prior to leaving for the day. [NAME] #800 stated more often then not the snack cooler was not touched. [NAME] #800 stated she, the Dietary Manager, and the Administrator have been trying to resolve the issue for months with little success. Interview with the Administrator on 10/23/23 at 9:29 A.M. revealed she was aware of the afternoon snack passing issue. Interview with Registered Dietician (RD) #801 on 10/23/23 at 9:34 A.M. revealed she was aware of the afternoon snack passing issue. Interview with Resident #1…

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 medication storage observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure controlled substances and narcotic medication were disposed of in a timely manner. This affected four (#30, #88, #91, and #92) of four residents reviewed for disposition of controlled substances and narcotics upon discontinuation of orders or discharge. The facility census was 96. Findings include: 1. Observation of the controlled substance drawer of the Whitney Way medication cart on 10/31/23 at 8:12 A.M. with Licensed Practical Nurse (LPN) #200 revealed Resident #88 had 55 pills of the nerve pain medication Lyrica in 25 milligram (mg) doses located in the drawer. Interview with LPN #200 during the observation on 10/31/23 at 8:12 A.M. verified Resident #88's Lyrica in the medication cart, and stated the Director of Nursing (DON) and unit managers are the only staff members permitted to remove a resident's controlled medications from the medication carts when the orders are discontinued or the resident discharges from the facility. 2.…

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, facility staff interview, the facility failed to provide a clean and sanitary environment for one (Residents #10) of seven residents reviewed for environment. The facility census was 93. Findings include: Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included paraplegia, chronic obstructive pulmonary disease, sepsis, pressure ulcer, acute kidney failure, complications of colostomy, and neurogenic bladder. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 had no memory problems and was independent with his daily decision making. Resident #10 dad verbal behaviors directed toward others one to three days of the review period. Resident #10 required set up assist with eating and oral hygiene, supervision or touching assistance for upper body dressing, personal hygiene and sit to lying mobility, partial moderate assistance for toileting, rolling and chair to bed transfer, 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, record review, resident interview, staff interview, and policy review, the facility failed to maintain the proper position of a urinary catheter drainage bag for one (Resident #10) of one reviewed for urinary catheters. The facility census was 93. Findings include: Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included paraplegia, chronic obstructive pulmonary disease, sepsis, pressure ulcer, acute kidney failure, complications of colostomy, neurogenic bladder, and muscle spasms. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 had no memory problems and was independent with his daily decision making. The resident had verbal behaviors directed toward others one to three days of the review period. Resident #10 required set up assist with eating and oral hygiene, supervision or touching assistance for upper body dressing, personal hygiene and sit to lying mobility, partial moderate…

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, review of the facility policy, and resident and staff interviews, the facility failed to serve food at a safe and palatable temperature. This had the potential to affect all 101 residents residing in the facility who received food from the kitchen. The facility census was 101. Findings include: Interviews on 09/26/22 at 9:30 A.M to 12:30 P.M. with Residents #5, #11, #86, and #92 revealed the food was not served at a palpable temperature. Interview on 09/28/22 at 11:07 A.M. with [NAME] #304 revealed the food temperatures on the steam table were obtained at 11:10 A.M. The hot dogs were held at 160 Fahrenheit (F), zucchini at 150 F and bake beans at 190 F. On 09/28/22 at 11:15 A.M., a test tray was requested. The cart with test tray left the kitchen at 12:26 P.M., arrived on the unit at 12:28 P.M., and the last tray was served at 12:46 P.M. Review of a sample tray on 09/28/22 at 12:47 P.M., after all the room trays were served to the residents, revealed the hot food was not served at a palatable temperature. The food temperatures on the test tray was obtained 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, and policy review, the facility failed to store dishware appropriately for food service safety and follow the facility's warewashing procedures. This had the potential to affect all 101 residents in the facility who received food from the kitchen. Findings include: During the initial observation on 09/26/22 at 10:40 A.M. of kitchen revealed three trays of cups, one tray of fruit bowls, and three trays of bowls were stacked and put away wet. There were three trays with cups and bowls that had black speckles on them. Interview on 09/26/10:40 A.M. with Dietary Manager (DM) #324 revealed washware were to be air dried prior to stacking on trays to be put away. DM #324 verified the cups, bowls, and fruit cups were put away wet and should be stored on clean trays. Follow up observation on 09/28/22 at 11:12 A.M. of the kitchen revealed there were bowls and cups stored wet, after being cleaned. Interview on 09/28/22 at 11:15 A.M. with DM #324 verified the trays of cups and bowls were stacked and put away wet. Review of the facility's policy titled…

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, review of the facility policy, and family and staff interviews, the facility failed to maintain a resident's privacy during incontinence care. This affected one (Resident #5) of six residents observed for personal care. The facility census was 101. Findings include: Review of Resident #5's medical record revealed an admission to the facility occurred on 08/07/20. Diagnoses included liver cirrhosis, insomnia and high blood pressure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was alert with impairment of cognition. Resident #5 required assistance of staff with activities of daily living. Interview with Resident #5's family member on 09/27/22 at 8:31 A.M. revealed he has come to the facility to visit and was upset to see Resident #5 was naked with no privacy curtain pulled in his room between the beds or door closed to the hallway. Resident #5's family stated Resident #5 had a roommate. Observation of Resident #5 on 09/27/22 at 1:40…

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 interviews, the facility failed to provide written notification to a resident and/or resident representative and to the Office of the State Long-Term Care Ombudsman for the reason for a residents' transfer or discharge from the facility. This affected one (Resident #15) of two residents reviewed for hospitalizations. The facility census was 101. Findings include: Review of Resident #15's medical record revealed an admission to the facility occurred on 08/17/18. Diagnoses included anemia, chronic pain, and bariatric surgery. Resident #15 required transfer to the hospital from [DATE] through 08/09/22 and again on 09/19/22 through 09/23/22. There was no evidence in the medical record that Resident #15 and/or his representative were provided a written notification of the reason for the hospital transfers. Interview with Social Services Director (SSD) #340 on 09/28/22 at 11:03 A.M. stated she was new to her position and does not currently have a system in place to complete the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Review of medical record for Resident #56 revealed an admission date of 07/19/17. Diagnoses included acute gastroenteropathy, type II diabetes mellitus, heart failure, major depressive disorder, and anxiety disorder. Interview on 09/26/22 at 11:36 A.M. with Resident #56 revealed he would like to participate in his care plan meetings. Interview 09/27/22 at 10:59 A.M. with Social Service Designee (SSD) #340 confirmed she was only doing care plan meetings on admission and had no idea she should be doing the meetings on a quarterly basis. Review of the facility's policy titled Plan of Care Overview, revised 07/26/18, revealed the facility will review care plans quarterly and schedule meeting to accommodate resident's representative that may include conference calls, video conference sessions, or live sessions. 2. Review of Resident #43's medical record revealed Resident #43 was admitted to this facility on 04/04/22. Diagnoses included dementia with behavioral disturbances, chronic obstructive pulmonary disease,…

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, review of the facility policy, observation, and family, resident, and staff interviews, the facility failed to ensure an ambulation program was established for two (Resident #5 and #38) of three residents reviewed for therapy discharge. The facility census was 101. Findings include: 1. Review of Resident #5's medical record revealed an admission to the facility occurred on 08/07/20. Diagnoses included liver cirrhosis, dementia, high blood pressure, insomnia, and fractured femur. Review of Resident #5's physical therapy (PT) Discharge summary dated [DATE] revealed to maintain current level of performance and in order to prevent decline, a development of and instruction for a Restorative Nursing Program (RNP) in ambulation has been completed with the interdisciplinary team (IDT) for Resident #5. Review of Resident #5's medical record revealed no RNP for ambulation had been established following PT discharge on [DATE]. Interview with Resident #5's family member on 09/27/22 at 8:31…

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, resident and staff interview, review of the facility policy, and record review, the facility failed to ensure a resident who required limited assistance from staff with activities of daily living, received adequate and timely assistance with personal hygiene. This affected one (Resident #2) of two residents reviewed for activities of daily living. The facility identified 99 residents required assistance from staff for bathing and 101 residents required assistance from staff with dressing. The facility census was 101. Findings include: Review of Resident #2's medical record revealed an admission dated of 03/15/22. Diagnoses included dementia, depression, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had impaired cognition and required one person staff assistance with personal hygiene. Review of the physician orders for September 2022 revealed Resident #2 required extensive assistance of one staff for personal hygiene. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview and record review, the facility failed to ensure residents received timely treatment and care for a resident exhibiting signs and symptoms of urinary tract infection. Additionally, the facility failed to ensure a resident with an indwelling catheter received routine catheter care as physician ordered. This affected one (Resident #53) of six residents reviewed for quality of care and affected one (Resident #40) of two residents reviewed for catheter care. The facility identified 13 residents with an indwelling or external catheter. The facility census was 101. Findings include: 1. Review of Resident #53's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included anxiety, depression, a history of urinary tract infection (UTI) and general weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 had mild cognitive impairment and was always continent. Review of the physician order dated 09/17/22…

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 facility anti-psychotic dose reduction/elimination records, and staff interviews, the facility failed to ensure a resident was not receiving an anti-psychotic medication without indication of continued use. This affected one (Resident #5) of six residents reviewed for unnecessary medication. The facility identified 20 residents who receive anti-psychotic medications. The facility census was 101. Findings include: Review of Resident #5's medical record revealed an admission date to the facility occurred on 08/07/20. Diagnoses included liver cirrhosis, dementia, and delusional disorder. Review of the physician orders dated 03/11/22 revealed Resident #5 was placed on Risperdal (anti-psychotic medication) on 03/11/22. Review of the facility's psychotropic medication evaluation dated 09/14/22 for Resident #5 revealed this was a semi-annual gradual dose reduction (GDR) attempt. The GDR evaluation revealed Resident #5 was appropriate for an attempt. A physician order was obtained to hold Resident #5's Risperdal for one week and if no changes then…

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 staff interview, observation, and record review, the facility failed to ensure a resident's urine sample for a urine analysis and culture and sensitivity was obtained per the physician's orders. This affected one (Resident #93) of four residents reviewed for urinary tract infections. The facility census was 101. Findings include: Review of Resident #93's medical record revealed Resident #93 was admitted to the facility on [DATE]. Her diagnoses included urinary tract infection (UTI), calculus of ureter, sepsis, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #93 had moderate cognitive impairment. Resident #93 required extensive assistance of two people for bed mobility, transfers, toileting, and personal hygiene. Review of the physician orders dated 09/06/22 revealed Resident #93 had an order for a complete blood panel and urine sample for analysis, culture and sensitivity. Review of the lab results revealed no urine culture was submitted as ordered.…

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

Based on medical record review and staff interview, the facility failed to ensure a resident was free from unnecessary antibiotic use. This affected one (Resident #5) of six residents reviewed for unnecessary medications. The facility census was 101. Findings include: Review of Resident #5's medical record revealed an admission date to the facility occurred on 08/07/20. Diagnoses included liver cirrhosis, dementia, and delusional disorder. The record revealed a scheduled urinalysis test was ordered every six months. The urinalysis was completed on 09/07/22. The record revealed no evidence a culture and sensitivity (C&S) was completed. The C&S results would identify if a specific bacteria and proper antibiotic that would be used to treat a urinary tract infection. Review of Resident #5's urinalysis results dated 09/07/22 revealed none seen for bacteria in the urinalysis test. Review of the medication administration record (MAR) for September 2022 revealed Resident #5 was administered Bactrim DS (antibiotic) 800/160 milligrams (mg) twice a day from 09/07/22 through 09/14/22, 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 medical record review and staff interview, the facility failed to ensure resident care plans were updated. This affected three residents (#70, #79, and #83) of 25 residents revealed for plans of care. The facility census was 125. Findings include: 1. Medical record review revealed Resident #79 was admitted to the facility on [DATE] with diagnoses including disorders of bladder, atrial fibrillation, and hypertension. Review of Resident #79's physician order dated 09/29/19 revealed an order for one liter of sodium chloride 0.9% intravenously (IV) every shift every seven days. There was no evidence a care plan had been developed for the use of the resident's IV fluids. Interview on 10/01/19 at 3:41 P.M. with Licensed Practical Nurse (LPN) #65 verified Resident #79's IV fluids were not addressed in a plan of care. 2. Review of Resident #83's medical record revealed an admission date of 08/14/19 with diagnoses including Alzheimer's disease, dementia, and fracture of cervical vertebra. Review 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.

Based on observation, staff interview and facility policy review, the facility failed to ensure medication carts were maintained secured. This had the potential to affect 18 residents (#10, #12, #13, #23, #26, #40, #47, #49, #75, #83, #91, #92, #94, #99, #112, #116, #120 and #174) whom the facility identified as confused and mobile. The facility census was 125. Findings include: 1. Observation of the medication administration on 10/01/19 at 7:24 A.M. with Registered Nurse (RN) #29 revealed after she obtained all of Resident #103's medications she entered the resident's room and did not lock or secure the medication cart. The RN was in Resident #103's room for approximately five minutes. Interview with RN#29 confirmed she did not secure the medication cart prior to entering Resident #103's room. 2. Observation of the medication administration on 10/01/19 at 7:40 A.M. with Licensed Practical Nurse (LPN) #43 revealed the LPN was administering medications to Resident #15, on Unit #2. LPN #43 obtained all medications for Resident #15 and entered Resident #15's room, while leaving 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 medical record review, observations, and staff interview, the facility failed to ensure fall interventions were in place for two residents (#9 and #66) of five reviewed for falls. The facility census was 125. Findings include: 1. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with the following diagnoses; peripheral vascular disease, difficulty in walking, and type II diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had mild cognitive impairment. The resident had one fall since admission resulting in no injuries and required extensive assistance with two persons for transfers. Review of Resident #9's progress notes dated 09/22/19 revealed the resident had a fall and a new intervention included to add a dycem (a non-slip material) to the resident's hoyer lift sling prior to transferring the resident. Review of Resident #9's care plan revised on 9/23/19 revealed the resident was at risk for falls 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 medical record review, observation, and staff interview, the facility failed to ensure oxygen therapy was completed as ordered for one resident (#69) of two reviewed for respiratory care. The facility census was 125. Findings include: Medical record review revealed Resident #69 was admitted to the facility on [DATE] with diagnoses of malignant neoplasm of the brain (cancer), seizures and hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 was severely cognitively impaired. Review of Resident #69's current physician order summary revealed the resident was to have oxygen at a flow rate of 3 liters per minute, every shift since 11/11/18. On 09/30/19 at 2:41 P.M. observation of Resident #69 revealed her to have continuous oxygen through a nasal cannula at a flow rate of 1.5 liters. On 10/02/19 at 02:04 P.M. observation and interview with Licensed Practical Nurse (LPN) #44 of Resident #69 revealed the resident's oxygen was at a flow rate of 1.5 liters. LPN #44…

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 interview, staff interview, and review of antibiotic stewardship policy, the facility failed to ensure a pharmacy recommendation was acted upon to discontinue a medication for one resident (#25 of five reveiwed for unnecessary medication. The facility census was 125. Findings include: Review of Resident #25's medical record revealed admission to the facility on [DATE] with diagnoses including stroke, major depression and chronic pain. The resident was noted to be cognitively intact. There was no evidence the resident had a significant history of urinary tract infections (UTIs). Review of Resident #25 progress notes revealed she was having some painful urination on 07/05/19 and was ordered a urine culture and sensitivity testing. On 07/07/19 the culture returned and was identified positive growing less than 100,000 colony forming units (cfu/ml). The record identified at that time Resident #25 was placed on the prophylactic antibiotic. There was not evidence 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 medical record review, observations and staff interview, the facility failed to communicate a resident's behavior to hospice care takers. This affected one resident (#59) of one reviewed for hospice services. The facility census was 125. Findings include: Medical record review revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, dementia, depression and heart disease. The resident was noted to be receiving hospice services as of 08/06/19. Review of Resident #59's current care plan revealed the resident was receiving hospice services and in the event the resident experienced any changes in conditions to include increased behaviors; hospice was to be notified. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of Resident #59's progress notes from 08/09/19 to 10/01/19 revealed 19 individual nurses' notes were documented between the hours of 10:00 P.M. to 06:00 A.M. which 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.