Fair Haven Shelby County

Based on observation, staff interviews, and policy review, the facility staff failed to sign out narcotics when administered. This affected seven (#4, #7, #11, #20, #22, #26, and #43) of 62 residents in the facility randomly observed during medication cart review. The facility census was 62. Findings include: Observation on 06/04/25 at 12:59 P.M., of Sycamore Hall medication cart with Registered Nurse (RN) #262 revealed Resident #7's Lorazepam 0.5 milligram (mg) one (1) tablet signed out during cart inspection and Oxycodone 5 mg 1 tablet signed out during cart inspection, and Resident #26's Alprazolam 0.5 mg 1 tablet signed out during cart inspection. Observation on 06/04/25 at 1:05 P.M., of Sycamore Hall medication cart with RN #262 revealed Resident #7's Lorazepam 0.5 mg count sheet revealed 11 tablets remaining, medication card shows 10 tablets present. Interview on 06/04/25 at 1:05 P.M., with RN #262 confirmed Resident #7's Lorazepam 0.5 mg and Oxycodone 5 mg was signed out during cart inspection, and Resident #26's Alprazolam 0.5 mg was signed out during cart inspection. RN…

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, observations, staff interviews, review of medication inserts, and policy review, the facility failed to ensure medication were administered per physician orders and medications were documented when administered. This affected 16 (#4, #6, #7, #11, #15, #17, #18, #22, #26, #31, #32, #35, #43, #53, #61, and #115) of 62 residents in the facility. The facility census was 62. Findings include: Observation on 06/04/25 at 12:59 P.M. of Sycamore Medication Cart Narcotic Count Sheets with Registered Nurse (RN) #262 revealed Resident #7's Lorazepam 0.5 mg narcotic count sheet was off by two, one tablet signed out at time of observation. Resident #7's Oxycodone 5 mg narcotic count sheet was off by one, one table signed out at time of observation. Resident #26's Alprazolam 0.5 mg narcotic count sheet was off by one, one tablet signed off at time of observation. Interview on 06/04/25 at 1:05 P.M., with Registered Nurse (RN) #262 confirmed Resident #7's Lorazepam 0.5 mg narcotic count sheet was off by two, one tablet signed out at time of observation. Resident #7's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and review of the policy, the facility failed to ensure the refrigerator used by family to store foods brought in from outside for residents was maintained in a clean manner. This had the potential to affect 44 (#03, #04, #05, #06, #07, #08, #10, #11, #12, #13, #15, #16, #18, #20, #21, #22, #23, #26, #28, #30, #31, #33, #34, #35, #36, #38, #40, #42, #43, #45, #46, #47, #48, #49, #50, #52, #53, #54, #55, #57, #59, #115, #116, #165, and #215) of 44 residents who utilized the refrigerator The facility census was 62. Findings include: Observation on 06/02/25 at 2:34 P.M. revealed four plastic dishes in the resident refrigerator, located in the lounge area near room [ROOM NUMBER], without dates, one plastic dish dated 04/30/25, and one small dish of salsa dated 04/15/25. The floor of the refrigerator was covered in food particles. Interview at the time of discovery with Certified Nursing Assistant (CNA) #258 revealed all of the food dishes belonged to Resident #12, and verified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, resident interview, observation, review of the Sani-Cloth Bleach wipes container instructions, review of glucometer manufacture's recommendations, review of the Centers for Disease Control and Prevention (CDC) website, and policy review, the facility failed to ensure hand hygiene was completed during a pressure ulcer dressing change for Resident #49; failed to ensure recommendations for enhanced barrier precautions (EBP) were initiated for Resident #26; failed to ensure gloves were worn during assistance with food for Resident #17 and #56; and failed to ensure glucometer was properly cleaned for Resident #115. This affected four residents (#17, #26, #49, and #56), with the potential to affect a limited number of resident who received assistance with meals, glucometer checks or were on enhanced barrier protection. The census was 62. Findings included 1. Medical record review for Resident #49 revealed an admission assessment dated [DATE] with diagnoses including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and policy review, the facility failed to ensure residents were treated with dignity, when staff stood over residents while providing assistance with eating. This affected three (#2, #37, and #41) of three residents reviewed for feeding assistance. The facility census was 62. Findings include: Review of the medical record for Resident #2 revealed and admission date of 11/12/20, with diagnoses of Alzheimer's disease with late onset, dementia in other diseases classified elsewhere, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident has a memory problem and cognitive skills were severely impaired. Resident #2 was dependent on staff assistance with all activities of daily living (ADL)s. Review of the care plan dated 12/04/23 revealed the facility will provide and serve meals as ordered and provide adaptive equipment to improve self-feeding skills.…

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

Based on observations, resident and staff interviews, and review of the policy, the facility failed to maintain a homelike environment for the residents. This directly affected two (#28 and #115) of 62 resident rooms observed. The facility census was 62. Findings include: 1. Observation on 06/03/25 at 8:00 A.M., revealed Resident #115 seated in a recliner in her room. The wall to the left, behind the back of the recliner, and to the left of the window, revealed an area round area approximately seven inches, with exposed plaster and a small pile of plaster dust on the floor below it. Interview with Resident #115, at the time of the observation, stated the wall had been like since her admission. 2. Observation on 06/03/25 at 8:55 A.M., revealed both walls in the small hallway leading into the room of Resident # 28 revealed large areas repaired but unpainted to match the wall coloring. Interview on 06/04/25 at 3:10 P.M., with Maintenance #215 revealed he had just finished repairing the walls, and they need sanded and repainted again. Maintenance #215 stated the walls need repaired…

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 interviews, and policy review, the facility failed to ensure medication administered was for an appropriate diagnosis. This affected one (#9) out of five residents reviewed for unnecessary medications. The facility census was 62. Findings include: Review of the medical record for Resident #9 revealed an admission date of 11/15/11, with diagnoses of unspecified dementia, unspecified severity, with agitation, bipolar disorder, peripheral vascular disease, major depressive disorder, and epilepsy, unspecified, not intractable, without status epilepticus. Review of the Annual Minimum Data Set, dated [DATE] revealed Resident #9 had severe cognitive impairment. Resident #9 had no mood behaviors, did not have indicators of psychosis, and had no behavioral symptoms. Resident was independent with bed mobility, required set-up assistance with eating, and required substantial assistance with oral hygiene and ambulation. Resident #9 was dependent on staff assistance with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure the comprehensive assessment was completed accurately to include a diuretic for one (Resident #9) and included falls without injury for one (Resident #40). This affected two (#9 and #40) of five residents reviewed for comprehensive assessments. The facility census was 62. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 11/15/11, with diagnoses of unspecified dementia, unspecified severity, with agitation, bipolar disorder, peripheral vascular disease, major depressive disorder, and epilepsy, unspecified, not intractable, without status epilepticus. Review of the Annual Minimum Data Set, dated [DATE] revealed Resident # 9 had severe cognitive impairment. Resident used high-risk drug of antipsychotics, antianxiety, antidepressant, and anticonvulsant. There was no diuretic use indicated. Review of the physician orders revealed an order dated 09/17/24 for Furosemide 20 milligram (mg) give one…

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, and policy review, the facility failed to ensure the comprehensive care plan was initiated to include contractures. This affected one (#32) of 23 residents reviewed for comprehensive care plans. The facility census was 62. Findings include: Review of the medical record for Resident #32 revealed an admission date of 03/11/22 with diagnoses of encephalopathy, post traumatic seizures, neuromuscular dysfunction of bladder, post-traumatic stress disorder, and personal history of traumatic brain injury. Review of the Annual MDS dated [DATE] revealed resident was cognitively impaired. Resident #32 is dependent on staff assistance with all Activities of Daily Living (ADLs), except resident does not eat. Review of the care plan dated 03/24/22 revealed had an alteration in musculoskeletal status related to fibromyalgia, muscle spasms, and right below the knee amputation with interventions of Resident #32 will remain free from pain or at a level of acceptable discomfort…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, observations and policy review, the facility failed to ensure dependent residents were provided personal hygiene. This affected two (#26 and #45) residents reviewed for activities of daily living (ADL). The facility census was 62. Findings include: 1. Review of the medical record for Resident #26 revealed an admission on [DATE] with diagnoses that include but not limited to Parkinson's disease, syncope and collapse, pacemaker, bulbous pemphioid, orthostatic hypotension, acute kidney failure, infection and inflammatory reaction of urethral catheter, urinary retention, anxiety disorder, atria fibrillation, bradycardia, depression, hypertension, and neuromuscular dysfunction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #26 revealed an impaired cognition. Resident #26 required set up or clean up assistance for eating, dependent for oral hygiene, dependent for toileting, dependent for shaving, dependent for bed mobility 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, medical record review, staff interview, and review of the policy, the facility failed to ensure a Resident #46 reviewed for activities of daily living, had a hand splint applied as ordered. The facility further failed to ensure wound assessments were completed for a non pressure sore for Resident #40. This affected two (#40 and #46) of 21 residents reviewed for quality of care. The facility census was 62. Findings include: 1. Review of the medical record of Resident #46 revealed an admission date of 09/17/21. Diagnoses include cerebral infarction and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #46 was cognitively impaired and had impairment of upper extremities. Review of the physician order dated 09/27/24 revealed to gently open right fingers and place a pillow splint in palm with strap over knuckles. Keep in hand at all times, except during hygiene for contracture…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, nurse practitioner interview, observations and policy review, the facility failed to ensure identified wounds were assessed, measured and documentated on discovery and pressure relieving devices were in place. This affected three (#1, #13, and #49) of three residents reviewed for pressure ulcers. The facility census was 62. Findings include: 1. Medical record review for Resident #13 revealed an admission on [DATE], with diagnoses including but not limited to heart failure, methicillin resistant staphylococcus aureus, local infection of the skin, Alzheimer's disease, major depressive disorder, dementia, abnormal weight loss, corns and callosities, peripheral vascular disease, hammer toes, atrial fibrillation, chronic obstructive pulmonary disease, stress incontinence and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #13 revealed intact cognition. Resident #13 is independent for eating, dependent for toileting, dependent for bed…

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 the correct liquid nutritional liquid tube feeding supplement was being administered. This affected one (#32) of two residents reviewed for nutrition. The facility census was 62. Findings include: Review of the medical record for Resident #32 revealed an admission date of 03/11/22 with diagnoses of encephalopathy, post traumatic seizures, neuromuscular dysfunction of bladder, post-traumatic stress disorder, and personal history of traumatic brain injury. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed resident was cognitively impaired and was dependent on staff assistance with all activities of daily living (ADLs), except resident did not eat. Resident used a peg tube for feeding. Review of the care plan dated 03/23/22 revealed resident was tube feeding dependent with interventions to change feed container and tubing every 24 hours and resident was dependent on staff for tube feeding and water…

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, and staff interview, the facility failed to ensure tube feeding container was labeled with what solution was being administered. This affected one (#32) of two residents reviewed for nutrition. The facility censes was 62. Findings include: Review of the medical record for Resident #32 revealed an admission date of 03/11/22 ,with diagnoses of encephalopathy, post traumatic seizures, neuromuscular dysfunction of bladder, post-traumatic stress disorder, and personal history of traumatic brain injury. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed resident was cognitively impaired and was dependent on staff assistance with all activities of daily living (ADLs), except resident did not eat. Resident used a peg tube for feeding. Review of the care plan dated 03/23/22 revealed resident was tube feeding dependent with interventions to change feed container and tubing every 24 hours and resident was dependent on staff for tube feeding and water…

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 the medical record review, staff interviews, and policy reviews, the facility failed to address complaints of pain when reported. Additionally, the facility failed to monitor the effectiveness of routine pain medication. This affected one resident (#12) of two residents revealed for pain management. The facility census was 62. Findings include: Medical record review for Resident #12 revealed an admission on [DATE], with diagnoses including but not limited to heart failure, atrial fibrillation, hearing loss, peripheral vascular disease, insomnia, chronic kidney disease, rheumatoid arthritis, dementia, hypertension, osteoarthritis, anxiety disorder, and congestive heart failure. Review of the Annual Minimum Data Set assessment dated [DATE] for Resident #12 revealed resident was cognitively intact. Resident had no behaviors. Resident was independent with eating, dependent with toileting, supervision for bed mobility and transfers. Resident #12 received routine pain medication. Resident #12 reported pain in…

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

Based on record review and staff interviews, the facility failed to ensure the care plan was followed for dementia treatment when the facility failed ensure medications being used was for dementia and an attempt to reduce the use of psychoactive medication was made. This affected one (#9) of four residents reviewed for dementia care. The facility census was 62. Findings include: Review of the medical record for Resident #9 revealed an admission date of 11/15/11, with diagnoses of unspecified dementia, unspecified severity, with agitation, bipolar disorder, peripheral vascular disease, major depressive disorder, and epilepsy, unspecified, not intractable, without status epilepticus. Review of the Annual Minimum Data Set assessment, dated 03/09/25 revealed had severe cognitive impairment. Resident had no mood behaviors, did not have indicators of psychosis, and had no behavioral symptoms. Resident was independent with bed mobility, required set-up assistance with eating, and required substantial assistance with oral hygiene and ambulation. Resident was dependent on staff assistance…

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, staff interviews, and policy review, the facility failed to ensure antibiotic use was necessary for one (#40) and failed to make recommendations for appropriate medication use for one (#9) This affected two (#9 and #40) of six residents reviewed for medication regimen review. The facility census was 62. Findings include: 1. Review of the medical record of Resident #9 revealed an admission date of 11/15/11, with diagnoses of unspecified dementia, unspecified severity, with agitation, bipolar disorder, peripheral vascular disease, major depressive disorder, and epilepsy. Review of the Annual Minimum Data Set (MDS) assessment reveled resident had severe cognitive impairment, had no behaviors exhibited or listed. Resident was independent with bed mobility, required set-up assistance with eating, required substantial assistance with oral hygiene and ambulation, and was dependent on staff assistance with toileting hygiene, bathing, dressing, personal hygiene, transfers,…

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 interviews, the facility failed to ensure antibiotic use was appropriate after a wound closed. This affected one (#40) of five reviewed for unnecessary medications. The facility census was 62. Findings include: Review of the medical record for Resident #40 revealed an admission date of 05/20/20 with diagnoses of inflammatory disease of prostate, Alzheimer's disease with late onset, dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident was cognitively intact. Resident was independent with eating, toileting hygiene, bed mobility, and wheelchair mobility. Resident required set-up assistance with oral hygiene and bathing. Resident required partial assistance with transfers. Resident required substantial assistance with dressing and personal hygiene. Resident did not have a pressure ulcer or a venous…

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 record review, observations, staff interviews, and policy review, the facility failed to ensure a medication error rate was below 5%. A total of 34 opportunities were observed with five errors for a error rate of 14.71%. This affected three (#17, #61, and #115) of four residents observed for medication administration. The facility census was 62. Findings include: 1. Review of the medical record for Resident #17 revealed an admission date of 05/06/25, with diagnoses of acute on chronic diastolic (congestive) heart failure, dementia, old myocardial infarction, and essential (primary) hypertension. Review of the physician orders revealed and order dated 05/22/25 for Aspirin Oral Tablet Chewable 81 milligram (mg) give 1 tablet by mouth one time a day for old myocardial Infarction. Observation on 06/04/25 at 7:43 A.M. of medication administration with Licensed Practical Nurse (LPN) #290 revealed Aspirin Enteric Coated (EC) 81 mg one tablet was administered. Interview on 06/04/25 at 10:17 A.M., with LPN #290 confirmed Resident #17 was administered Aspirin EC 81 mg one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and staff interview, the facility failed to ensure a resident receiving antibiotics was being tracked and monitored for use. This affected one (#40) of 8 reviewed for infection control. The census was 62. Findings include: Review of the medical record for Resident #40 revealed an admission date of 05/20/20 with diagnoses of inflammatory disease of prostate, Alzheimer's disease with late onset, dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident was cognitively intact. Resident was independent with eating, toileting hygiene, bed mobility, and wheelchair mobility. Resident required set-up assistance with oral hygiene and bathing. Resident required partial assistance with transfers. Resident required substantial assistance with dressing and personal hygiene. Resident did not have a pressure ulcer or a venous…

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 a facility self-reported incident (SRI), staff and Detective #40 interviews, and policy review, the facility failed to thoroughly investigate an injury of unknown injury. This affected one (#11) out of three residents reviewed for injuries of unknown origin. The facility census was 57. Findings include: Review of medical record for Resident #11 revealed admission date of 10/24/23. Diagnoses include late onset Alzheimer's, right femoral head fracture, depression, heart failure, and dementia with mood disturbance. Resident #11 was discharged to the hospital on [DATE] and did not return to the facility. Review of Resident #11's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed she required set up for eating and was dependent for toileting hygiene, bed mobility and transfers. Review of the care plan revealed Resident #11 had impaired Activities of Daily Living (ADL's) with the goal to maintain existing ADL self-performance created on 12/07/23. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews, the facility failed to develop a comprehensive care plan to address the amount of assistance a resident required with activities of daily living (ADL's). This affected one (#11) out of three resident reviewed for ADL assistance. The facility census was 57. Findings include: Review of medical record for Resident #11 revealed admission date of 10/24/23. Diagnoses include late onset Alzheimer's, right femoral head fracture, depression, heart failure, and dementia with mood disturbance. Resident #11 was discharged to the hospital on [DATE] and did not return to the facility. Review of Resident #11's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed she required set up for eating and was dependent for toileting hygiene, bed mobility and transfers. Review of the care plan revealed Resident #11 had impaired Activities of Daily Living (ADL's) with the goal to maintain existing ADL self-performance created on 12/07/23. Further review of Resident #11'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 medical record review, staff interviews and policy review, the facility failed to assess a resident and complete a post fall investigation after a resident experienced a fall. This affected one (#11) out of three residents reviewed for falls. The facility census was 57. Findings include: Review of medical record for Resident #11 revealed admission date of 10/24/23. Diagnoses include late onset Alzheimer's, right femoral head fracture, depression, heart failure, and dementia with mood disturbance. Resident #11 was discharged to the hospital on [DATE] and did not return to the facility. Review of Resident #11's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed she required set up for eating and was dependent for toileting hygiene, bed mobility and transfers. Review of the care plan revealed Resident #11 had impaired Activities of Daily Living (ADL's) with the goal to maintain existing ADL self-performance created on 12/07/23. Further review of Resident #11's care plan revealed there 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 record review, observation, and resident, family, and staff interview, the facility failed to ensure they had a qualified professional activities director and activities were provided to the residents as scheduled. This affected two residents (#45 and #63) of four residents reviewed for activities. This had the potential to affect all residents except for the 18 residents identified by the facility who usually decline to attend activities. The facility census was 67. Findings include: 1. Review of the medical record for Resident #45 revealed an admission date of 04/08/24 with diagnoses including dementia, Alzheimer's disease, major depressive disorder, and altered mental status. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had moderate cognitive impairment. Review of the care plan dated 10/10/24 revealed the resident needed assistance/escort for activity functions, preferred activities included reading the bible, church, family and friends, bingo, special events,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to administer medications per physician order. This affected one (Resident #63) of three residents reviewed for medication administration. The facility census was 67. Findings include: Review of the medical record for Resident #63 revealed an admission date of 07/16/24 with diagnoses including congestive heart failure, dementia, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 was cognitively intact. Review of Resident #63's Medication Administration Record (MAR) for September 2024 revealed cyancobalamin 1,000 (Vitamin B12) microgram (mcg) per milliliter (ml) give one ml on the 26th of every month was not given due to medication being available. Levothyroxine (treats thyroid) 25 mcg was not signed off as administered on 09/17/24 and 09/27/24. The MAR for October 2024 revealed Levothyroxine 25 mcg was not signed off as administered on 10/01/24 and 10/02/24. Interview on 10/09/24 at 4:06 P.M. with 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 reviews, staff interview, and policy review, the facility failed to administer medications as ordered. This affected four (#2, #3, #17, and #25) out of the four residents reviewed for medication administered as ordered. The facility census was 66. Findings included: 1. Review of the medical record for Resident #2 revealed an admission date of 04/16/21 with medical diagnoses of cerebral infarction with right hemiparesis, dementia, depression, and anxiety. Review of the medical record for Resident #2 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #2 had moderate cognitive impairment and required substantial staff assistance with bathing, bed mobility, and transfers, and was independent with eating. Review of the medical record for Resident #s revealed physician orders dated 03/07/22 for ferrous sulfate 325 milligram (mg) one tablet by mouth two times per day, 12/03/19 for Dilantin 100 mg one capsule by mouth three times per day, 10/30/19 for fish oil…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, medical record reviews, and policy review, the facility failed to ensure medications were administered as ordered resulting in two medication errors out of 33 opportunities or six percent (%) medication error rate. This affected two (#2 and #17) out of the three residents observed for medication administration. The facility census was 66. Findings included: 1. Review of the medical record for Resident #17 revealed an admission date of 06/06/15 with medical diagnoses of cerebral infarction with left hemiparesis, chronic pain syndrome, diabetes mellitus, and depression. Review of the medical record for Resident #17 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #17 was cognitively intact and required substantial staff assistance with toilet hygiene, bathing, and bed mobility. Review of the medical record for Resident #17 revealed a physician order dated 07/24/18 for lisinopril 20 milligram (mg) one tablet by mouth daily for 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 medical record review, observation, staff interviews, and policy review, the facility failed to follow infection control guidelines when performing incontinence care. This affected one (#53) out of three residents reviewed for incontinence care. The facility census was 66. Findings included: Review of the medical record for Resident #53 revealed an admission date of 12/02/16 with medical diagnoses of Alzheimer's disease, macular degeneration, peripheral vascular disease, and anxiety. Review of the medical record for Resident #53 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #53 had severe cognitive impairment and was dependent for toilet hygiene, bed mobility, transfers, eating, and bathing. The MDS indicated Resident #53 was always incontinent of bladder and bowel. Observation on 02/06/24 at 12:51 P.M. revealed Registered Nursing (RN) #108 and Stated Tested Nursing Assistant (STNA) #106 completed incontinence care for Resident #53. The observation revealed STNA…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, observation, and review of facility recipes, the facility failed to make pureed food to the correct texture and failed to follow a recipe to make the pureed food. This had the potential to affect six (#5, #15, #20, #24, #38, and #53) residents who have orders for pureed food. Facility census was 75. Finding include: Observation and interview on 10/18/22 at 11:00 A.M. revealed Dietary Staff #73 placed an unmeasured amount of grilled chicken in a blender to make pureed chicken, then seven,four ounce scoops of gravy were added. The food was blended and the remainder of the pot of gravy was poured into the mixture (unmeasured). Dietary staff revealed they put in typically seven to eight chicken breasts to make the required seven pureed meals. The mixture appeared to be thin and smoothie like consistency. Observation and interview on 10/18/22 at 11:07 A.M. revealed Dietary Staff #73 placed four, four ounce scoops of mixed vegetables in the blender, blended the vegetables 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 observations, staff interview and policy review, the facility failed to safety store food items in the refrigerator, freezer, and dry storage areas. This had the potential to affect 74 out of 75 residents residing in the facility, the facility identified one (#52) resident who receives no food from the kitchen. Facility census was 75. Findings include: Observation on 10/17/22 at 11:20 A.M. to 11:40 A.M. revealed the following concerns in the walk in refrigerator: - shredded lettuce left open to air with no date - shredded white cheese left open to air with no date - both containers of cranberry juice were had expired 10/13/22 - unknown pureed food in a styrofoam bowl with no label and no date - butter sticks were left open to air and undated - lunch meat turkey was open to air and undated - hotdog's were left open to air and undated - chunk of meat (appeared like ham) was not labeled or dated Observations in the walk in freezer revealed the following concerns: - pie missing slice and two whole pies were undated - breadsticks undated - slices of bread and rolls undated -…

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

Based on observations and staff interview, the facility failed to maintain covered and clean trash receptacles in the kitchen. This had the potential to affect 74 out of 75 residents residing in the facility, the facility identified one (#52) resident who receives no food from the kitchen. Facility census was 75. Findings include Observation on 10/17/22 at 11:20 A.M. to 11:40 A.M. revealed the kitchen had one blue recycling bin that was overflowing with items piled on top of the lid. Their was a large gray round trash bin with a trash bag that had fallen off the rim down into the trash can with no lid or covering. Four black kitchen trash cans were observed to have no lids or coverings. Interview on 10/17/22 at 11:45 A.M. with Kitchen Manager #42 confirmed trash cans did not have lids. Kitchen manager #42 revealed the lids were thrown out before she started and she was told they were unsanitary. The facility confirmed this had the potential to affect 74 out of 75 residents residing in the facility, the facility identified one (#52) resident who receives no food from the kitchen.

Based on observations and staff and resident interviews, the facility failed to serve food at a palatable temperatures. This has the potential to affect all 96 residents residing in the facility who are receiving food from the kitchen. The facility census was 96. Findings include: On 11/18/19 at 10:47 A.M. Resident #296 states the food is poor quality, always cold, and the taste is not good. She stated the problem is they don't have a microwaves on this side of the building. Observation of the plating of lunch on 11/20/19 at 11:35 A.M. revealed Dietary Assistant #415 plated food then placed the plate on a tray. Fourteen trays were placed on an open cart for the Sycamore (skilled) Unit. At 11:50 A.M. Chef #406 took the cart from the kitchen to the Sycamore Unit . The cart arrived on the unit at 11:52 A.M. At 11:58 A.M. Resident Assistant (RA) #394 began passing the trays to the residents in their rooms on the unit. At 12:00 P.M. State Tested Nursing Assistant (STNA) #366 began delivering trays from the open cart. At 12:07 P.M. the last tray was delivered to a resident's room. A test…

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 facility records, staff interview and facility policy review the facility failed to establish and maintain an Infection Prevention and Control Program (IPCP) designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections which included a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, and visitors. This had the potential to affect 96 residents of 96 residents residing in the facility. Facility census was 96. Findings include: Review of the facility IPCP with Director of Nursing (DON) on 11/21/19 at 10:38 A.M. revealed the facility IPCP had not been completed since since 08/24/19. DON verified the last entry on the facility Infection Control Log was dated 08/24/19. DON verified no had completed the IPCP since the previous DON resigned on 09/30/19. The prior DON's last day was 09/25/19. DON stated she thought she would eventually assume the responsibility. DON stated the only…

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 facility records, staff interview and facility policy review, the facility failed to develop and implement an Antibiotic Stewardship Program (ASP) to promote facility-wide monitoring for the appropriate use of antibiotics. This had the potential to affect 96 residents of 96 residents residing in the facility. Facility census was 96. Findings include: Review of the facility IPCP with Director of Nursing (DON) on 11/21/19 at 10:38 A.M. revealed the facility Infection Prevention Control Program (IPCP) had not been completed since since 08/24/19. The IPCP included the ASP. DON verified the last entry on the facility Infection Control Log was dated 08/24/19. DON verified no one had completed the IPCP since the previous DON resigned on 09/30/19. The prior DON's last day was 09/25/19. DON stated she thought she would eventually assume the responsibility. DON stated the only infection information currently being collected was a running list of residents being treated with antibiotics which was not thoroughly completed and had not been reviewed by anyone since 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, review of facility self reported incidents (SRI's), review of facility incident reports, observations, staff, resident and physician interview and review of the facility policy, the facility failed implement their abuse policy to ensure injuries of unknown origin were immediately reported to the to administrator/designee and to the state agency as required and to ensure injuries of unknown origin were thoroughly investigated. This affected four (#38, #66, #67 and #70) out of four residents reviewed for abuse. The facility census was 96. Findings include: 1. Review of the medical record for Resident #38 revealed she was admitted to the facility on [DATE] with diagnoses of peripheral vascular disease, right eye blindness, hypertension, cardiac arrhythmia, anemia, hypothyroidism, chronic kidney disease and mental disorders due to known physiological condition. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #38 was cognitively impaired. 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 medical record review, review of facility self reported incidents (SRI's), review of facility incident reports, observations, staff, resident and physician interview and review of the facility policy, the facility failed to immediately report injuries of unknown origin to administrator/designee and to the state agency as required. This affected four (#38, #66, #67 and #70) out of four residents reviewed for abuse. The facility census was 96. Findings include: 1. Review of the medical record for Resident #38 revealed she was admitted to the facility on [DATE] with diagnoses of peripheral vascular disease, right eye blindness, hypertension, cardiac arrhythmia, anemia, hypothyroidism, chronic kidney disease and mental disorders due to known physiological condition. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #38 was cognitively impaired. Review of the nurse progress note dated 10/05/19 at 2:43 A.M. revealed a skin tear three centimeters (cm) long was observed on 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, review of facility self reported incidents (SRI's), review of facility incident reports, observations, staff, resident and physician interview and review of the facility policy, the facility failed to thoroughly investigate injuries of unknown origin. This affected four (#38, #66, #67 and #70) out of four residents reviewed for abuse. The facility census was 96. Findings include: 1. Review of the medical record for Resident #38 revealed she was admitted to the facility on [DATE] with diagnoses of peripheral vascular disease, right eye blindness, hypertension, cardiac arrhythmia, anemia, hypothyroidism, chronic kidney disease and mental disorders due to known physiological condition. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #38 was cognitively impaired. Review of the nurse progress note dated 10/05/19 at 2:43 A.M. revealed a skin tear three centimeters (cm) long was observed on Resident #38's left knee. The area was open and unable 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 3. Resident #65 was admitted to the facility on [DATE] with a readmission to the facility on [DATE] with diagnoses including displaced fracture of left hip, anemia, peripheral vascular disease, anxiety disorder, Alzheimer's disease, dementia with behavior disturbances, major depressive disorder,and chronic kidney disease. Review of Resident #65's annual assessment dated [DATE] revealed the resident scored a three on the 'Brief Interview for Mental Status (BIMS) indicating she had severe cognitive impairment and exhibited no behaviors. She required supervision of one person physical assistance for bed mobility and toileting. She required extensive assistance of one person for personal hygiene and dressing. She was occasionally incontinent of urine and always continent of bowel. She received an antidepressant all 7 days of the assessment period. used a walker for ambulation. Review of the Care Area Assessment (CAA) stated the resident was at risk for falls based on loss of balance during transitions in position.…

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, pharmacist and staff interview and facility policy review, the facility failed to ensure the licensed pharmacist reported medication irregularities to the attending physician, medical director and the Director of Nursing. This affected five (#31, #64, #65, #68 and #87) out of five residents reviewed for unnecessary medications. The facility census was 96. Findings include: 1. Review of the medical record for Resident #31 revealed she was admitted to the facility on [DATE] with diagnoses including chest pain, diabetes, cataract, spinal stenosis, nail dystrophy, depression, anxiety, obsessive-compulsive disorder, left bundle branch block, hemiplegia, cardiomyopathy, congestive heart failure and hypertension. Review of the Plan of Care for Resident #31 revealed a focus of psychotropic medication use which included Prozac and Xanax related to depression and anxiety. The goal was Resident #31 will receive the lowest effective dose of psychoactive medication to manage her symptoms. 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, staff interview and policy review, the facility failed to provide written notification of transfer or discharge to the resident and the resident's representative. This affected two (#90 and #65) out of three residents reviewed for hospitalization. The facility census was 96. Findings include: 1. Review of the medical record for Resident #90 revealed he was admitted to the facility on [DATE]. His diagnoses included left hip fracture dated 09/15/19, Parkinson's disease, cataracts bilaterally, glaucoma, atrial fibrillation, prostate cancer, hypotension and cardiac pacemaker. Review of the discharge Minimum Data Set (MDS) dated [DATE] revealed Resident #90 was discharged , return anticipated on 09/11/19. The Entry MDS dated [DATE] revealed Resident #90 returned to the facility on [DATE]. Review of the medical record revealed no evidence Resident #90 was provided information in writing of the reason for his transfer to the emergency room and subsequent admission to the hospital 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, staff interview and policy review, the facility failed to provide written notification of the bed hold policy to the resident or resident representative at the time of discharge to the hospital. This affected two (#90 and #65) out of three residents reviewed for hospitalization. The facility census was 96. Findings include: 1. Review of the medical record for Resident #90 revealed he was admitted to the facility on [DATE]. His diagnoses included left hip fracture dated 09/15/19, Parkinson's disease, cataracts bilaterally, glaucoma, atrial fibrillation, prostate cancer, hypotension and cardiac pacemaker. Review of the discharge Minimum Data Set (MDS) dated [DATE] revealed Resident #90 was discharged , return anticipated on 09/11/19. The Entry MDS dated [DATE] revealed Resident #90 returned to the facility on [DATE]. Review of the medical record revealed no evidence Resident #90 and/or his representative were provided information in writing of bed-hold policy at the time of his…

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 implement a a dietary recommendation and physician order to increase a dietary supplement for a resident with a history of a significant weigh loss. This affected one (#91) out of two residents reviewed for significant weight loss/nutrition. The facility census was 96. Findings include: Resident #91 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, contracture of the left knee and bilateral hands, and peripheral vascular disease. Review of the annual minimum data set (MDS) assessment dated [DATE] documented the resident had short and long term memory loss. She exhibited rejection of care four to six days of the assessment period. She required extensive assistance of one person for eating. She had no swallowing or chewing difficulties. Her weight at the time of the assessment was 124 pounds with no weight loss. Review of an annual MDS assessment dated [DATE] revealed the resident required total assistance…

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 and staff interview, the facility failed to ensure meals were served under sanitary handling conditions for Resident #122. This affected one (#122) randomly observed resident receiving a hall tray on the Sycamore hall. The facility census was 96. Findings include: Observation on 11/18/19 from 11:52 A.M. to 12:16 P.M. of hall trays being served on the sycamore hall revealed -no issues identified until the last room tray for infection control. Observation on 11/18/19 at 12:12 P.M. of Resident Assistant (RA) #394 passing hall trays on the sycamore hall revealed the RA #394 touched Resident #122's shoulder to awaken the resident. RA #394 assisted Resident #122 by cutting up her food. It was observed RA #394 had a rope type dangling bracelet on her left wrist. It was observed the bracelet was dangling and went into the residents beverage several times as she was cutting up the food. Interview on 11/18/19 at 12:16 P.M. with RA #394 verified after touching her bracelet, the bracelet was wet and had gone into Resident #122's beverage.