Allen View Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to ensure the resident's Minimum Data Set (MDS) assessments were accurately coded for falls and discharge location. This affected two (#90 and #109) of 23 residents reviewed for MDS accuracy. The facility census was 110. Findings include: 1. Review of Resident #90's medical record revealed Resident #90 admitted to the facility on [DATE]. Diagnoses included focal traumatic brain injury with loss of consciousness of thirty minutes or less and functional quadriplegia. Review of Resident #90's post fall evaluation dated 10/18/24 revealed Resident #90 fell at the facility on 10/18/24 at 9:00 P.M. Resident #90 was moving in his wheelchair in his room and Resident #90's wheelchair slid out from under him. Resident #90's wheelchair was not locked. Review of Resident #90's quarterly MDS assessment dated [DATE] revealed Resident #90 had no falls since the prior assessment. Interview with MDS Registered Nurse (MDS RN) #34 on 04/16/25 at 3:39 P.M. 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 record review and staff interview, the facility failed to notify the state mental health authority with a significant change Preadmission Screening and Resident Review (PASARR) for a resident that had a change in their mental health condition. This affected one (#90) of two residents reviewed for significant change PASARR. The facility census was 110. Findings include: Review of Resident #90's chart revealed Resident #90 admitted to the facility on [DATE]. Diagnosis included unspecified focal traumatic brain injury with loss of consciousness of thirty minutes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 was cognitively intact. Review of Resident #90's diagnosis list dated 04/21/25 revealed Resident #90 had a new diagnosis of major depressive disorder recurrent added on 12/26/24. Review of Resident #90's chart from 08/26/24 to 04/15/25 revealed Resident #90 did not have a significant change PASARR or notification to the state mental health authority 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 review of facility policy, staff interview, and record review, the facility failed to develop care plans to address a resident's use of an anticoagulant and a resident's vision needs. This affected two (#67 and #90) of 23 residents reviewed for care planning. The facility census was 110. Findings include: 1. Review of Resident #90's chart revealed Resident #90 admitted to the facility on [DATE]. Diagnosis included paroxysmal atrial fibrillation. Review of Resident #90's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and received an anticoagulant during the review period. Review of Resident #90's physician order dated 08/21/24 revealed Resident #90 was ordered Apixaban (anticoagulant) oral tablet five milligrams (mg) give one tablet by mouth every morning and bedtime for peripheral vascular disease. Review of Resident #90's care plan dated 04/15/25 revealed Resident #90 did not have a care plan for Resident #90's anticoagulant use and to monitor 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 observation, interview and record review, the facility failed to ensure residents were given the opportunity to participate in the development of their care plans and the care plan meetings had a interdisciplinary team present. This affected three (#16, #63, and #90) of six residents reviewed for resident participation in care planning. The facility census was 110. Findings include: 1. Review of Resident #63's chart revealed Resident #63 admitted to the facility on [DATE]. Diagnoses included with type two diabetes mellitus with hyperglycemia, major depressive disorder, non-pressure chronic ulcer of back limited to break down of skin, and cellulitis of right lower limb. Review of Resident #63's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #63's progress notes from 09/30/24 to 04/15/25 revealed Resident #63 did not have any care conferences or an opportunity to participate in the development of his care plan. Interview 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, and record review, the facility failed to ensure staff communicated with residents in a language or manner they could understand. This affected one (Resident #94) of one resident reviewed for communication and language. The facility census was 110. Findings include Review of the medical record for Resident #94 revealed an admission date of 10/01/24. Diagnoses included cerebral infarct, hemiplegia, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 had cognitive impairments. Review of Resident #94's care plan dated 10/02/24 revealed resident only spoke Haitian Creole with interventions including utilize language line for interpreter and provide the following tools to aide in communication in primary language (interpreter, communication board etc.) and offer interpretation services. Observation and interview on 04/14/25 at 11:15 A.M. with Resident #94 without use of interpreter revealed 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 observations, medical record review, staff interview, resident interview and policy review, the facility failed to ensure skin checks were completed weekly as care planned, wound treatments were completed as order and physician orders were clarified for skin impairment treatments. This affected one (#18) of three reviewed for non-pressure skin impairments. The facility census was 110. Findings include: Review of the medical record for Resident #18 revealed an admission date of 11/04/22. Diagnoses included post procedural hematoma, unspecified open wound of the left arm, end stage renal disease, renal dialysis, malnutrition and heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact and the resident had a stage four pressure wound and a non-pressure wound. Review of the plan of care dated 04/09/25 revealed resident was at risk for skin impairment with interventions to follow with wound provider, nursing to monitor skin impairments,…

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, family interview, staff interview and policy review, the facility failed to ensure vision services were provided as recommended by vision specialist. This affected one (#67) of one resident reviewed for vision services. The facility census was 110. Findings include: Review of the medical record for Resident #67 revealed an admission date of 05/19/24. Diagnoses included Alzheimer's disease, dementia, failure to thrive, dysphasia, heart disease, kidney failure, and subdural hemorrhage. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 was cognitively impaired and was dependent on staff mobility and activities of daily living. Review of eye exam notes dated 10/11/24 revealed new orders or recommendations for cataract surgery with ophthalmology consult with follow up with the eye provider in five to six months. The medical record contained no other information about cataract surgery or eye provider follow ups. Review of the care plan on 04/17/25 found…

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 reviews, staff interviews and policy review, the facility failed to ensure falls were thoroughly investigated to determine potential cause of the falls to prevent future falls. This affected one (#67) of three residents reviewed for falls. The facility census was 110. Findings include: Review of the medical record for Resident #67 revealed an admission date of 05/19/24. Diagnoses included Alzheimer's disease, dementia, failure to thrive, dysphasia, heart disease, kidney failure, and subdural hemorrhage. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 was cognitively impaired and was dependent on staff mobility and activities of daily living. Review of the care plan with initiated date of 05/19/24 revealed the resident was at risk of falls with interventions for bed in lowest position, perimeter mattress, floor mats at bedside to prevent injury from fall, toileting upon rise, and after meals and as needed at night, educate resident how to use bed remote control,…

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

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure a resident's urinary catheter collection bag was properly maintained to prevent potential infections. This affected one (#211) of two residents reviewed for urinary catheters. The census was 110. Findings include: Review of Resident #211's medical record revealed an admission date of 04/10/25. Diagnoses listed included type two diabetes mellitus, hypertension, hyperlipidemia, atrial fibrillation, and malnutrition. Observation on 04/15/25 at 7:38 A.M., revealed Resident #211's urinary catheter collection bag was observed on the floor beside the bed. Resident #211 was lying in bed. Interview on 04/15/25 at 7:49 A.M., with Certified Nurse Aide (CNA) #30 confirmed Resident #211's urinary catheter collection bag was on the floor. CNA #30 stated Resident #211's family requested the urinary catheter collection bag remain on the floor due to his confusion. Interview with on 04/15/25 at 8:00 A.M., with Divisional Director of Clinical Services (DDCS) #131 confirmed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, staff interview and policy review, the facility failed to ensure a resident received routine dental care. This affected one (#63) of two residents reviewed for dental care. The facility census was 110. Findings include: Review of Resident #63's medical record revealed Resident #63 admitted to the facility on [DATE], with diagnoses of type two diabetes mellitus with hyperglycemia, morbid obesity due to excess calories, obstructive and reflux uropathy, calculus of ureter, presence of urogenital implants, muscle weakness, iron deficiency anemia, hypothyroidism, hyperlipidemia, major depressive disorder, tachycardia, localized edema, non-pressure chronic ulcer of back limited to break down of skin, and cellulitis of right lower limb. Review of Resident #63's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and Resident #63 was independent with eating. Resident #63 required set up assistance with eating and oral 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 medical record review, policy reviews and staff interviews, the facility failed to ensure the accuracy and thoroughness of the documentation in the resident medical record. This affected two (#18 and #107) of 23 sampled resident records reviewed. Facility census was 110. Findings include: Review of the medical record for Resident #18 revealed an admission date of [DATE]. Diagnoses included post procedural hematoma, unspecified open wound of the left arm, end stage renal disease, renal dialysis, malnutrition and heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact and revealed the resident had a stage four pressure wound and a non-pressure wound. Review of the plan of care dated [DATE] revealed resident was at risk for skin impairment with interventions to follow with wound provider, nursing to monitor skin impairments, administer treatments as ordered and complete weekly skin checks. Review of physician orders dated [DATE] 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 record review and staff interview, the facility failed to ensure arbitration agreements provided for the selection of a venue that was convenient to both parties. This affected three (#90, #98 and #99) of three residents reviewed for arbitration agreements. The facility census was 110. Findings include: 1. Review of Resident #90's chart revealed Resident #90 admitted to the facility on [DATE], with diagnoses of unspecified focal traumatic brain injury with loss of consciousness of thirty minutes or less, unspecified viral hepatitis c without hepatic coma, paroxysmal atrial fibrillation, anemia, functional quadriplegia, polycystic kidney adult type, bipolar disorder, chronic pain syndrome, major depressive disorder, insomnia, glaucoma, hypertension, mood disorder, alcohol dependence, acute kidney failure, and seborrheic dermatitis. Review of Resident #90's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and Resident #90 was independent with eating,…

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, policy review, pest control invoice review and staff interviews, the facility failed to ensure a pest free environment. This affected two (#5 and #94) of two residents reviewed for pest control. Facility census was 110. Findings include Review of the medical record for Resident #94 revealed an admission date of 10/01/24. Diagnoses included malnutrition, diabetes, cerebral infarct, hemiplegia, dysphasia, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 was cognitively intact and would ambulate with use of a walker. Review of the medical record for Resident #5 revealed an admission date of 05/11/20. Diagnoses included cerebrovascular disease, hemiplegia, diabetes, dysphasia, and unspecified psychosis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively impaired and would ambulate with use of a wheelchair. Observation and interview on 04/15/25 at 10:49…

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 resident and staff interviews, the facility failed to accommodate resident preferences to create a home-like environment when the common dining room was closed without resident notice. This affected 10 (#6, #25, #32, #36, #38, #41, #71, #79, #92, and #110) of 114 residents who frequently dine in the common dining room. The facility identified two (#33 and #53) residents who receive no food by mouth. The census was 116. Finding included: Observation on the dining room door leading into the dining room for residents on 02/04/25 at 7:22 A.M. revealed there was a sign on the door indicating the dining room was closed. Interview with Dietary Aide (DA) #305 on 02/03/25 at 7:25 A.M. revealed the sign on the door referred to 02/02/25 because a nurse aide from the facility told them they did not have enough staff and the residents would not be coming to the dining room for meals for that day. Interview with DA #159 on 02/03/25 at 7:27 A.M. revealed there were only four nurse aides on the hall and there was not enough nurse aides to provide service in the dining 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 observation, resident and staff interviews, and policy review, the facility failed to ensure there was sufficient staffing levels to accommodate for the common dining room to remain open for resident use. This affected 10 (#6, #25, #32, #36, #38, #41, #71, #79, #92, and #110) of 114 residents who frequently dine in the common dining room. The facility identified two (#33 and #53) residents who receive no food by mouth. The census was 116. Finding included: Observation on the dining room door leading into the dining room for residents on 02/04/25 at 7:22 A.M. revealed there was a sign on the door indicating the dining room was closed. Interview with Dietary Aide (DA) #305 on 02/03/25 at 7:25 A.M. revealed the sign on the door referred to 02/02/25 because a nurse aide from the facility told them they did not have enough staff and the residents would not be coming to the dining room for meals for that day. Interview with DA #159 on 02/03/25 at 7:27 A.M. revealed there were only four nurse aides on the hall and there was not enough nurse aides to provide service in the dining…

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, family interview, staff interview, record review, review of the staffing tool, review of staff schedules, and review of facility policy, the facility failed to ensure the facility had adequate staffing to meet the resident's needs. This affected one (Resident #104) of three residents reviewed for staffing and had potential to affect all facility residents. The facility census was 113. Findings include Review of the medical record for Resident #104 revealed an admission date of 12/06/24. Diagnoses included fracture of unspecified part of the neck of femur, chronic obstructive pulmonary disease, dementia with anxiety, hearing loss, heart disease, muscle weakness, and a ruptured abdominal aortic aneurysm. Review of the plan of care dated 12/07/24 revealed Resident #104 required assistance from staff for activities of daily living (ADL). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #104 was cognitively intact with a Brief Interview of Mental…

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

Based on observations, staff interview, and review of facility policy, the facility failed to ensure resident meals were prepared, distributed, and served in a clean and sanitary manner to prevent contamination. This had the potential to affect all facility residents, except two (#74 and #87) that were identified with orders for no oral intake (NPO). The census was 113. Findings include: Observations on 12/24/24 from 11:45 A.M. to 12:20 P.M. revealed the trays were soaked and puddles of dish water were noted. Plates were placed on the trays and then held over the food warming table. While the trays with plates were hovering over the food warming table, (dish) water from the trays dripped into the food on the service line from the bottom of the tray. The divided plates were then brought from the dish area for the meal service. [NAME] #410 held a divided plate over the food while scooping food onto the plate and during that time, dishwater dripped from the divided plates into the food on the service line. [NAME] #410 wore gloves during tray line service and touched the handle for 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 interviews, family interviews, staff interviews, record review, review of the State agency online reporting portal, and review of facility policy, the facility failed to ensure allegations of abuse were reported to the State agency within the required timeframes. This affected one (Resident #100) of five residents reviewed for abuse. Findings include Review of the medical record for Resident #100 revealed an admission date of 12/14/24. Diagnoses included heart failure, headache, chronic obstructive pulmonary disease, peripheral vascular disease, muscle weakness, and bacterial infection. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 was cognitively intact with a Brief Interview of Mental Status (BIMS) of 15 and was dependent on staff for showering/bathing and lower body dressing. Resident #100 also required supervision/touching assistance for bed mobility and moderate assistance for transfers and mobility. Interview on 12/24/24 at 1:10 P.M. with Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, review of hospital records, and review of facility policy, the facility failed to ensure Resident #115 was able to return to the facility following a hospital stay. This affected one (Resident #115) out of three residents reviewed for discharges. Findings include: Review of the medical record for Resident #115 revealed an admission date of 10/07/24 and a discharge date of 12/03/24, with diagnoses of paraplegia, non-pressure chronic ulcer of buttock with unspecified severity, and unspecified injury at T7 to T10 level of the thoracic spinal cord. The resident was his own responsible party. Review of Resident #115's care plan dated 10/14/24 revealed resident was totally dependent on staff assistance for toileting hygiene and dressing and he required substantial/maximal assistance for bathing. Further review of the care plan revealed on 12/03/24 a care plan was initiated for behavioral health consults as needed. Review of the Discharge Return Not Anticipated Minimum Data Set…

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, resident interview, staff interview, and facility policy and procedure, the facility failed to ensure Resident #100 received the home health company of choice upon discharge. This affected one (Resident #100) out of three residents reviewed for discharges. Findings include: Review of the medical record revealed Resident #100 admitted to the facility on [DATE] and discharged on 11/12/24 with diagnoses of acute on chronic diastolic (congestive) heart failure, chronic obstructive pulmonary disease, and extended spectrum beta lactamase (ESBL) resistance. Review of the Discharge Return Not Anticipated Minimum Data Set (MDS) dated [DATE] revealed Resident #100 was cognitively intact and required supervision with toileting hygiene, bathing, dressing, bed mobility, transfers, and ambulation. Review of the Discharge Summary assessment dated [DATE] revealed Interim Healthcare Home Health Services were contacted by Social Services Designee #403 to provide home health services for Resident #100 upon…

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, residents and staff interviews, record reviews, and review of facility policy and procedure, the facility failed to ensure dependent residents received assistance with activities of daily living (ADL). This affected one (Resident #104) of three residents reviewed for activities of daily living. Findings include Review of the medical record for Resident #104 revealed an admission date of 12/06/24. Diagnoses included fracture of unspecified part of the neck of femur, chronic obstructive pulmonary disease, dementia with anxiety, hearing loss, heart disease, muscle weakness, and a ruptured abdominal aortic aneurysm. Review of the plan of care dated 12/07/24 revealed Resident #104 required assistance from staff for activities of daily living. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #104 was cognitively intact with a Brief Interview of Mental Status (BIMS) of 15 and required substantial maximum assistance for showering and bathing and was dependent 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 record review, staff interview, and review of facility policy, the facility failed to ensure appropriate nursing services to assure residents could attain and/or maintain the highest practicable physical, mental, and psychosocial well-being while ensuring Resident #115's mobility was not restricted. This affected one (Resident #115) out of three residents reviewed for discharges. Findings include: Review of the medical record for Resident #115 revealed an admission date of 10/07/24 and a discharge date of 12/03/24, with diagnoses of paraplegia, non-pressure chronic ulcer of buttock with unspecified severity, and unspecified injury at T7-T10 level of thoracic spinal cord. Review of Resident #115's care plan dated 10/08/24 revealed the resident was at risk for impaired psychosocial well being related to a history of trauma and/or trauma related symptoms with interventions to approach the provision of care and services for those residents with a history of trauma with dignity and respect and provide…

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 ensure medications were administered in a clean and sanitary manner. This affected three residents (#97, #100, and #104) out of five residents reviewed for medication administration. Findings include: 1. Observation on 12/24/25 at 8:54 A.M. with Licensed Practical Nurse (LPN) #401 revealed medication administration of a Norvasc 10 milligram (mg) tablet. LPN #401 dropped the medication onto the top of the medication cart and picked it up with her bare hands and administered it to Resident #97. 2. Observation on 12/24/24 at 9:13 A.M. with LPN #401 revealed medication administration of a Vitamin D 25 microgram (mcg) tablet. LPN #401 dropped the medication onto the top of the medication cart and picked it up with her bare hands and administered it to Resident #100. 3. Observation on 12/24/24 at 9:31 A.M. with LPN #401 revealed medication administration of two Oyster Calcium 500 mg tablets. LPN #401 dropped the medication onto the top of the medication cart and picked it up with her bare hands 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 observations, resident and staff interviews, record review, and facility policy, the facility failed to ensure equipment was maintained and in working order. This affected two residents (#99 and #100) of three reviewed for environment. Findings include: 1. Review of the medical record for Resident #100 revealed an admission date of 12/14/24. Diagnoses included heart failure, headache, chronic obstructive pulmonary disease, peripheral vascular disease, muscle weakness, and bacterial infection. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 was cognitively intact with a Brief Interview of Mental Status (BIMS) of 15 and was dependent on staff for showering, bathing, and lower body dressing. The resident also required supervision/touching assistance for bed mobility and moderate assistance for transfers and mobility. Interview on 12/24/24 at 11:05 A.M. with Maintenance Director #555 revealed he started a few days ago and that the facility had no outstanding list 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 closed record review and interview, the facility failed to provide residents with discharge summaries. This affected three (#110, #111, and #112) out of three residents reviewed for discharge. The facility census was 100. Findings include: 1. Review of the closed medical record for Resident #110 revealed an admission date of 07/04/24 and a discharge date of 09/17/24. Diagnoses included disruption of internal operation surgical wound, acute metabolic acidosis, severe sepsis with septic shock, type two diabetes mellitus with unspecified diabetic retinopathy without macular edema, chronic obstructive pulmonary disease, atherosclerotic heart disease of native coronary artery without angina pectoris, end stage renal disease, congestive heart failure, and major depressive disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 had severely impaired cognition. Resident #110 was assessed to require partial to moderate assistance for eating, oral hygiene, personal…

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, staff interview and policy review, the facility failed to initiate treatment on a pressure ulcer present upon a resident readmission. This affected one (#77) out of three residents reviewed for wound care. The facility census was 102. Findings include: Record review revealed Resident #77 was admitted to the facility on [DATE] and was recently readmitted on [DATE]. Diagnoses include acute and subacute infective endocarditis, bacteremia, anxiety, morbid obesity, type two diabetes, non-displaced fracture of the fifth metatarsal bone, right foot, and obstructive sleep apnea. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/15/23 revealed Resident #77 had a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device - one stage three pressure area present. Review of Resident #77's care plan initiated on 01/06/24 revealed a care focus for set-up assistance with eating with intervention of staff assistance of set-up. A care focus for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, activity calendar review and policy review, the facility failed to ensure a variety of activities were offered to meet residents' needs and interests. This affected two (#41 and #48) of two residents reviewed for activities and had potential to affect all facility residents. The facility census was 100. Findings include: 1. Review of the medical record for Resident #41 revealed an admission date of 12/28/17. Diagnoses included chronic obstructive pulmonary disease, aortic aneurysm, poly neuropathy, dysphagia, and pneumonia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was cognitively intact with a BIMS of 15 and was independent with mobility. Review of the activity assessment dated [DATE] was completed by the activity manager and revealed Resident #41's preferred activity setting included activities in his own room and included more art themed activities and a private area for visitation for residents in semiprivate…

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 safely store food in the walk in freezer and dry storage areas of the kitchen. This affected all residents except Resident #16 and #76 who do not eat food from the kitchen. The facility census was 100. Finding include Observation on 03/27/23 at 9:51 A.M., revealed in the walk in freezer: chicken tenders were left open to air and undated; hamburger patties were left open to air and undated; fish patties were left open to air and updated; cinnamon rolls were left open to air and updated and three boxes of cookie dough were left open to air and undated. Observation on 03/27/23 at 9:57 A.M., revealed in the dry storage: two - one gallon bottles of red cooking wine was stamped best if used by 06/21/22. Interview on 03/27/23 at 10:03 A.M., with Kitchen Manager #181 confirmed above findings. Observation on 03/27/23 at 10:05 A.M., revealed a sign on walk-in freezer stating all items must have opening date. Review of the policy titled, Food Storage Dry Goods dated September 2017 revealed dry storage goods…

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 resident council minutes, staff and resident interviews and policy review, the facility failed to ensure resident council concerns were addressed in a timely manner. The facility also failed to ensure residents were knowledgeable on how to file a complaint with the state or contact the Ombudsman. This affected three (#31, #36, #20) of 10 residents that regularly attend the resident council, with the potential to affect the 10 residents. The facility census was 100. Findings included: Review of the resident council meeting minutes from 06/28/22 through 02/23/23 revealed there wasn't any education given to the residents about contacting the state agency about a complaint about their care, or how to contact the ombudsman regarding any issues they may have. All of the minutes said to place concerns on concern forms and distribute to appropriate department heads. There was various concerns brought up for different departments. There was no resolution forms or areas of corrections forms related to the concerns brought up by residents. Interviews on 03/30/23 at 11:33…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Interview on 03/28/23 at 9:10 A.M., with Resident #31 revealed at times the bathroom sink water was too hot. Observation on 03/28/23 from 9:29 A.M. to 9:42 A.M., revealed Resident #31's bathroom sink had a temperature of 139 degrees Fahrenheit (F) and Resident #41's bathroom sink had a temperature of 138 degrees F. Interview on 03/28/23 at 9:42 A.M., with Resident #41 revealed the bathroom sink water temperature was hot to touch. Observation on 03/28/23 from 9:50 A.M. to 10:10 A.M., with Administrator revealed water temperature as follows: Resident #31's room water temperature was 137.8 degrees F; Resident #28 and #87's room water temperature was 135.3 degrees F; Resident #23 and #41's room water temperature was 137.8 degrees F; Resident #53 and #58's room water temperature was 132.9 degrees F; Resident #2 and #10's room water temperature was 138.6 degrees F; Resident #29 and #63's room water temperature was 133.8 degrees F; Resident #66's room water temperature was 136.5 degrees F; Resident #77 and #84'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.

Based on observation, review of policy, and staff interviews, the facility failed to ensure medications were stored with open dates and not kept past expiration dates. This affected 13 (#10, #15, #21, #87, #54, #86, #89, #96, #19, #95, #37, #64, and #27) of 13 residents' insulins observed in medication storage. The facility identified 23 Residents who currently receive insulin. The facility census was 100. Findings include: Observation on 03/30/23 at 2:41 P.M., of the 300 hall medication cart with Licensed Practical Nurse (LPN) #128 verified the Lantus insulin vial for Resident #10 had no open date or correlating expiration date. Observation on 03/30/23 at 2:55 P.M., of the 200 hall medication care with LPN #169 verified the insulin Aspart vial for Resident #15 opened 02/25/23 was expired and should not be in the cart. Observation on 03/30/23 at 3:02 P.M., of the 400 hall medication cart with LPN #123 verified the Lantus Pen for Resident #21, the Humalog vial for Resident #87, the Humalog Pen for Resident #87, and the Insulin Glargine Pen for Resident #54 had no open date or…

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 and resident interviews and policy review, the facility failed to ensure a resident was treated with respect and dignity during resident care. This affected one (#48) of three residents reviewed for dignity and respect. The facility census was 100. Findings included: Review of Resident #48's medical record revealed an admission date of 01/28/19, with diagnoses including nontraumatic intracerebral hemorrhage, deep vein thrombosis, diabetes and obesity. Review of annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #48 was cognitively intact. Resident #48 functional status was extensive assistance with two-person assistance with bed mobility and toilet use. Resident #48 was frequently incontinent of bowel and bladder. Review of the care plan dated 01/05/23 revealed Resident #48 was at risk for bowel and bladder incontinence related to impaired mobility. Interview with Resident #48 on 03/28/23 at 11:45 A.M., reported he has urgency and will go a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interview and policy review, the facility failed to ensure residents and resident representatives were offered the opportunity to participate in care planning. This affected two (#31 and #60) of two residents reviewed for care conferences. Facility census was 100. Findings include 1. Review of the medical record for the Resident #31 revealed an admission date of 01/21/13. Diagnoses included diabetes, convulsions, dementia, contractures of bilateral knees, and edema. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was cognitively intact and was independent with mobility. Review of the medical record revealed no evidence of a care conference being held during the second quarter of 2022. Interview on 03/29/23 at 4:55 P.M., with the Director of Nursing (DON) verified there was no evidence of a care conference being held in the second quarter of 2022. 2. Medical record review for Resident #60 revealed an admission date of 03/13/20.…

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 and resident interviews and medical record review, the facility failed to ensure a resident was assessed for self-administration of medication. This affected one (#41) of 26 residents observed in the sample. The facility census was 100. Findings include: Review of the medical record for Resident #41 revealed an admission date of 12/28/17. Diagnoses included chronic obstructive pulmonary disease, aortic aneurysm, poly neuropathy, dysphagia, and pneumonia. Review of the Self Administration of Medication assessment dated [DATE] revealed Resident #41 required assistance with ear drops, suppositories and subcutaneous injections. Resident #41 had no recent assessments for self-administration of medication. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was cognitively intact and was independent with mobility. Review of the plan of care dated 03/30/23 revealed Resident #41 did not have a care plan entry related to medication self-administration prior 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.

Based on record review and staff interview, the facility failed to issue the CMS -20052 form to indicate skilled coverage was ending. This affected two (#35 and #26) of three residents who exhausted their Medicare Part A Skilled Services. The facility census was 100. Findings include: Review of Resident #206's (Skilled Nursing Facility) SNF Beneficiary Protection Notification Review revealed the last day covered was 12/08/22 the Resident discharged on 12/09/23. The Form CMS-20052 was not issued 48 hours prior to the resident's last day of coverage. Review of Resident #38's SNF Beneficiary Protection Notification Review revealed his last day of coverage was 03/23/22 and Resident #38 went home on 3/24/23. The Form CMS-20052 was no issued 48 hours prior to the resident's last day of coverage . Interview on 03/28/23 at 10:00 A.M., with Registered Nurse (RN) #200 verified she did not issue the Form CMS-20052 was no issued 48 hours prior to the resident's last day of coverage because the residents decided to be discharged .

Based on observations, resident and staff interviews, the facility failed to ensure a resident's room was provided a room in a home like environment by not utilizing the resident's room for facility storage. The affected one (#18) of six residents reviewed for environment. The facility census was 100. Findings include: Interview on 03/27/23 at 9:30 A.M., with Resident #18 revealed there was items stored in his room that was not his and he keeps his curtain pulled. Observation on 03/27/23 at 9:30 A.M., 03/28/23 at 5:27 P.M., and on 03/29/23 at 4:51 P.M., of Resident #18's room revealed the room was a two person room. Resident #18 resided in B bed with his curtain drawn. There was no accommodations for a roommate, because there was no bed A in the room. The space for bed A was being utilized as storage for the facility. Two large floor polishing machines, two Hoyer (mechanical) lifts, an extra wide wheelchair that does not belong to Resident #18 and various boxes were being stored in Resident #18's room Observation on 03/28/23 at 5:27 P.M., revealed Resident #18 had his curtain drawn…

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 policy, and staff interview, the facility failed to notify residents or resident representatives of facility policy for bed holds, to include amount of bed hold days used and left and potential cost liability. This affected two (#54 and #86) of three residents reviewed for hospitalization. The census was 100. Findings include: 1. Medical record review for Resident #54 revealed admission date 12/13/22. Diagnoses including diabetes mellitus 2 (DM2), chronic venous hypertension (idiopathic) with other complications of bilateral lower extremity, chronic obstructive pulmonary disease (COPD), heart failure, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had intact cognition. The MDS data revealed Resident #54 discharged with return anticipated on 12/23/22 and returned 12/28/22. Interview on 03/20/23 at 11:39 A.M., the Director of Nursing (DON) stated she was not able to locate any Bed Hold documentation for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interview and policy review, facility failed to ensure members of the interdisciplinary team (IDT) with the resident and/or resident representative reviewed and revised care plans at least quarterly. This affected two (#31 and #60) of two residents reviewed for care conferences. The facility census was 100. Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of 01/21/13. Diagnoses included diabetes, convulsions, dementia, contractures of bilateral knees, and edema. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was cognitively intact and was independent with mobility. Review of the medical record revealed there was no evidence of a care plan conference being held or the IDT reviewing the care plan during the second quarter of 2022. Review of the progress notes dated 07/21/22 revealed a care conference was held and the MDS Nurse #200 was the only staff member in attendance. Review of Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interviews and policy reviews, the facility failed to provide timely assistance with discharge planning for a resident requesting to discharge from the facility. This affected one (#48) of one resident reviewed for discharge planning. The facility census was 100. Findings include: Review of the medical record for Resident #48 revealed an admission date of 01/28/19. Diagnoses included non-traumatic cerebral hemorrhage, hemiplegia and hemiparesis, diabetes, epilepsy and cerebral edema. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact and required extensive assistance of two staff for bed mobility and transfers. Review of progress note dated 10/26/22 revealed the (previous) Administrator spoke with resident about discharge planning and sent a referral to a requested facility which was declined due to the requested facility doing renovations. Progress notes dated 03/30/23 revealed MDS Nurse #200 spoke with resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interview and policy review, the facility failed to ensure bathing was provided for dependent residents. This affected three (#64, #27, #48) of three residents reviewed for bathing. The census was 100. Findings included: 1. Medical record review for Resident #64 revealed an admission date of 09/26/19. Diagnoses included chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, obesity, and diabetes. Review of the care plan dated 09/20/22 revealed Resident #64 has an activities of daily living (ADLs) deficit related to impaired mobility and morbid obesity. Her preference for bathing was a bed bath and Mondays and Thursdays. Review of bathing from 12/23/22 through 03/28/23 revealed out of 28 opportunities Resident #64 received 19 bed baths. There were no refusals. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #64 was cognitively intact. Her functional status was extensive assistance for bed mobility, toilet…

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 and resident interview, the facility failed to ensure a resident was provided with incontinence supplies to prevent the potential for infections and skin impairments. This affected one (#48) of two residents reviewed for bowel and bladder incontinence during the annual survey. The census was 100. Findings included: Review of Resident #48's medical record revealed an admission date of 01/28/19, with diagnoses including nontraumatic intracerebral hemorrhage, deep vein thrombosis, diabetes and obesity. Review of annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #48 was cognitively intact. Resident #48 functional status was extensive assistance with two-person assistance with bed mobility and toilet use. Resident #48 was frequently incontinent of bowel and bladder. Review of the care plan dated 01/05/23 revealed Resident #48 was at risk for bowel and bladder incontinence related to impaired mobility. Interview with Resident #48 on 03/28/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews and policy review, the facility failed to ensure a complete an accurate medical record was maintained for a resident. This affected one (#48) of 33 total resident records reviewed. The facility census was 100. Finding include Review of the medical record for Resident #48 revealed an admission date of 01/28/19. Diagnoses included non-traumatic cerebral hemorrhage, hemiplegia and hemiparesis, diabetes, epilepsy and cerebral edema. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact and required extensive assistance of two staff for bed mobility and transfers and required total dependence for bathing. Review of hospital records dated 07/08/17 revealed resident had a transverse fracture of shaft of humerus with nonunion. The document also stated a resident had a bone matrix putty implanted into the right arm. Review of the facility medical record found no evidence or documentation mentioning a right upper arm…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview and review of facility policy,the facility failed to update the care plan when a resident's fluid restriction was discontinued. This affected one (Resident #94) of one resident reviewed for hydration. The facility also failed to conduct quarterly care conferences for three Residents (#22, #72, and #109) of five residents reviewed for participation in care planning. The census was 121. Findings include 1. Review of the medical record revealed Resident #94 was admitted to the facility on [DATE]. Diagnoses included schizophrenia, polydipsia, hypertension, generalized anxiety disorder, and convulsions. Review of the comprehensive assessment dated [DATE] revealed the resident had moderate cognitive impairment. Resident #94 was independent in activities of daily living with set up help only. Review of physician orders revealed Resident #94 received a regular diet with regular food texture and thin consistency fluids. A fluid restriction consisting of 2000 cubic centimeters…

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 interview, and review of directions for sani cloth bleach germicidal disposable wipes the facility failed to follow appropriate infection control procedures for the cleaning of the blood glucose monitoring machine after each use to prevent the spread of infections. This affected one (Resident #102) of two residents reviewed for blood glucose monitoring. The facility identified 10 Residents (#9, #16, #36, #37, #48, #49, #53, #54, #56, and #96) who received blood glucose monitoring on the 200 hallway. The facility census was 121. Findings include: Review of the medical record revealed Resident #102 was admitted on [DATE] with pertinent diagnosis of: type two diabetes mellitus, hypertension, hyperlipidemia, cerebral infarction, chronic obstructive pulmonary disease and convulsions. Observation of a blood sugar glucose monitoring check on 01/29/20 at 9:20 A.M. revealed Licensed Practical Nurse (LPN) #301 was preparing to check the blood sugar for Resident #102. 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 nterview, and review of facility guidelines the facility failed to accurately assess residents in the Pre-admission Screening/Resident Review (PASRR) process. This affected two Resident's (#66 and #109) of four residents reviewed for PASRR's. The census was 121. Findings include: 1. Review of the medical record for Resident #66 revealed an admission date of 11/14/19 with diagnoses including bipolar disorder, depression, and hypertension. Review of Resident #66's PASRR dated 11/14/19 revealed the resident was marked as having a diagnosis of panic or other severe anxiety disorder. Further review of Resident #66's PASRR dated 11/14/19 revealed the residents diagnosis of bipolar disorder was not included on the PASRR. Interview with Social Services Director (SSD) #205 on 01/28/20 at 3:52 P.M. verified Resident #66 had a diagnosis of bipolar disorder and it was not included on the PASRR dated 11/14/19. During the interview, Director of Social Services #205 verified the residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and review of facility guidelines, the facility failed to notify the state mental health authority and state intellectual disability (ID) authority after a significant change. This affected one (Resident #109) of four residents screened for Pre-admission Screens/Resident Reviews (PASRR). The census was 121. Findings include: Review of Resident #109's medical record revealed and admission dated of 02/16/18. Diagnoses included convulsions, schizoaffective disorder, epilepsy, and major depressive disorder. Review of Resident #109's census information revealed she admitted to hospice services on 01/03/20. Review of Resident #109's Significant Change Minimum Data Set (MDS) dated [DATE], revealed she had a moderate cognitive impairment and received hospice services. Further review of Resident #109's medical record revealed a PASRR dated 10/31/19. Resident #109's diagnoses of epilepsy, an ID-related condition, was not on the PASRR. The medical record lacked evidence a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and review of facility policy the facility failed to address frequent urinary tract infections (UTIs) on the comprehensive care plan. This affected one (Resident #10) of 22 residents reviewed for comprehensive care plans. The census was 121. Findings include: Review of the medical record for Resident #10 revealed an admission date of 07/13/16 with diagnoses including hemiplegia/hemiparesis, cerebral infarction, and diabetes mellitus type two. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #10 was coded as always incontinent of bowel and required extensive staff assistance with toileting. Review of Resident #10's active physician orders revealed an order dated 11/27/19 for Macrobid, an antibiotic, 100 milligram (mg) capsule by mouth once per day due to frequent UTIs. The physician order for Macrobid dated 11/27/19 did not include a stop date. Review of Resident #10's Medication Administration Record (MAR) dated January 2020 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of closed medical record, interview with facility staff, and review of facility policy, the facility failed to develop a post-discharge plan of care that addressed discharge needs, goals, treatment preferences, caregiver support as well as referrals made to address post-discharge needs. This affected one (Resident #119) of one resident reviewed for appropriate discharge planning. The census was 121. Findings include: Review of Resident #119's closed medical record revealed she admitted to the facility on [DATE]. She discharged to home on [DATE]. Diagnoses included cerebral infarction, dysphagia, major depressive disorder, and delusions. Review of her Minimum Data Set (MDS) dated [DATE] revealed she discharged home to the community. She had a moderate cognitive impairment. She required extensive assistance from staff with bed mobility, transfers, toilet use, and personal hygiene. She was totally dependent on staff for bathing and required limited assistance with eating. Further 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview with facility staff, the facility failed to provide set-up assistance with eating. This affected one (Resident #109) of three residents reviewed for activities of daily living (ADLs). The facility identified 100 residents who required at minimum set-up assistance with eating. The census was 121. Findings include: Review of Resident #109's medical record revealed she admitted to the facility 02/16/18. Diagnoses included chronic obstructive pulmonary disease, type 2 diabetes, schizoaffective disorder, and schizoaffective disorder. Review of Resident #109's significant change Minimum Data Set (MDS), dated [DATE], revealed the resident had a moderate cognitive impairment and required supervision and one person physical assist with eating. Resident #109 received hospice services. Review of Resident #109's physician orders revealed on 08/29/18 she was ordered a regular diet, with ground meat texture, and regular texture per request. Review of Resident #109'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, observation, resident and staff interviews, and review of the facility's policy the facility failed to provide fluids when a fluid restriction was discontinued. This affected one (Resident #94) of one resident reviewed for hydration. Facility census was 121. Findings include Review of the medical record revealed Resident #94 was admitted to the facility on [DATE]. Diagnoses included schizophrenia, polydipsia, hypertension, generalized anxiety disorder, and convulsions. Review of the comprehensive assessment dated [DATE] revealed the resident had moderate cognitive impairment. Resident #94 was independent in activities of daily living with set up help only. Review of physician orders revealed Resident #94 received a regular diet with regular food texture and thin consistency fluids. A fluid restriction consisting of 2000 cubic centimeters (cc) per 24 hours was ordered on 01/23/19 with fluids to be given as follows: Dietary provided 420 cc of fluid with breakfast, 480 cc with lunch,…

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 interview, and manufacturers recommendations review the facility failed to ensure residents were free from significant medication errors. Staff failed to ensure insulin lispro Humalog Kwikpen was primed prior to use according to manufacturer's recommendations. This may cause the resident to get too much or too little insulin. This affected one (Resident #49) of two residents observed for insulin administration. The facility census was 121. Findings include: Medical record review revealed Resident #49 was admitted on [DATE] with pertinent diagnosis of dementia without behavioral disturbance, hypertension, osteoarthritis, hyperlipidemia, major depressive disorder, diabetes mellitus, muscle weakness, and insomnia. Review of the 11/11/19 quarterly Minimum Data Set (MDS) assessment revealed the resident was moderately cognitively impaired and required extensive assistance for bed mobility, transfer, dressing, toilet use and personal hygiene. She used a walker and a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical record, observation, resident and staff interview, and review of facility policy the facility failed to ensure medications were not left at a residents bedside. This affected one (Resident #95) of five residents observed for medication administration. Facility census was 121. Findings include: Review of the medical record revealed Resident #95 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included acute kidney failure, hypertension, generalized anxiety disorder, and atherosclerotic heart disease. Review of the admission observation tool dated 06/30/19 revealed Resident #95 did not wish to self administer medications. Review of the comprehensive assessment dated [DATE] revealed the resident was cognitively intact. Resident #95 required limited to extensive assistance for activities of daily living. Observation on 01/28/20 at 8:31 A.M. revealed a medication cup containing pudding and a medication was sitting on Resident #95's over bed table. 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.