Springfield Nursing & Independent Living

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, and policy review, the facility failed to ensure a resident was provided written notification prior to a room change. This affected one (#10) out of three residents reviewed for room changes. The facility census was 63. Findings include: Review of the medical record for Resident #10 revealed an admission date of 03/22/22 with medical diagnoses of cerebral infarction with left hemiplegia, aphasia, ischemic cardiomyopathy, obesity, congestive heart failure, and chronic kidney disease stage III. Review of the medical record revealed Resident #10 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the medical record for Resident #10's quarterly MDS assessment, dated 05/02/25, indicated Resident #10 had severely impaired cognition, not able to make needs known, and was dependent upon staff for all ADL's including eating. The MDS indicated Resident #10 did not receive any by mouth (PO) intake and received 51%-100% nutrition via…

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 Self-Reported Incidents (SRI), staff interviews, and policy review, the facility failed to thoroughly and timely investigate allegations of abuse. This affected two (#10 and #46) out of the three reviewed for abuse investigations. The facility census was 63. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 03/22/22 with medical diagnoses of cerebral infarction with left hemiplegia, aphasia, ischemic cardiomyopathy, obesity, congestive heart failure, and chronic kidney disease stage III. Review of the medical record revealed Resident #10 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the medical record for Resident #10 revealed a quarterly Minimum Data Set (MDS) assessment, dated 05/02/25, indicated Resident #10 had severely impaired cognition, not able to make needs known, and was dependent upon staff for all ADL's including eating. The MDS indicated Resident #10 did not receive…

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, review of the facility Minimum Data Set (MDS) policy, and review of the Long- Term Care Facility Resident Assessment Instrument 3.0 User (RAI) Manual, October 2024, the facility failed to complete significant change MDS as required. This affected one (#10) out of the three residents reviewed for change in condition. The facility census was 63. Findings include: Review of the medical record for Resident #10 revealed an admission date of 03/22/22 with medical diagnoses of cerebral infarction with left hemiplegia, aphasia, ischemic cardiomyopathy, obesity, congestive heart failure, and chronic kidney disease stage III. Review of the medical record revealed Resident #10 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the medical record for Resident #10 revealed an annual MDS, dated [DATE], which indicated Resident #10 was cognitively intact and required set-up assistance with eating. The MDS indicated Resident #10 was…

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

Based on medical record review and staff interview, the facility failed to ensure resident blood sugar levels were monitored as ordered. This affected one (#66) out of three residents reviewed for monitoring of blood sugar levels. The facility census was 63. Findings include: Review of the medical record for Resident #66 revealed an admission date of 04/09/25 with medical diagnoses of atrial fibrillation, hypertension, diabetes mellitus, and congestive heart failure. Review of the medical record revealed a discharge date of 04/23/25. Review of the medical record for Resident #66 revealed an admission Minimum Data Set (MDS) assessment, dated 04/15/25, which indicated Resident #66 was cognitively intact and required partial/moderate staff assistance with toilet hygiene, showers, supervision with transfers, and was independent with bed mobility. The MDS indicated Resident #66 received hypoglycemic medications. Review of the medical record for Resident #66 revealed a physician order dated 04/09/25 for Accu-Chek (fingerstick blood sugar monitoring) two times daily, if above 150 give…

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, observation, and policy review, the facility failed to properly measure pressure ulcers and ensure treatments were timely initiated for a pressure ulcer. This affected one (#07) out of the three residents reviewed for pressure ulcers. The facility census was 63. Findings include: Review of the medical record for Resident #07 revealed an admission date of 07/20/24 with medical diagnoses of adult failure to thrive, dementia, right hemiplegia, and paranoid schizophrenia. Review of the medical record revealed Resident #07 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the medical record for Resident #07 revealed a quarterly Minimum Data Set (MDS) assessment, dated 02/28/25, which indicated Resident #07 was cognitively intact and required set-up assistance with eating and substantial/maximum staff assistance with toilet hygiene, showers, bed mobility, and transfers. The MDS did not have documentation to support 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 and staff interview, the facility failed to provide cares/services to restore eating skills. This affected one (#10) out of three residents reviewed for rehabilitation services. The facility census was 63. Findings include: Review of the medical record for Resident #10 revealed an admission date of 03/22/22 with medical diagnoses of cerebral infarction with left hemiplegia, aphasia, ischemic cardiomyopathy, obesity, congestive heart failure, and chronic kidney disease stage III. Review of the medical record revealed Resident #10 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the medical record for Resident #10 revealed an annual Minimum Data Set (MDS), dated [DATE], which indicated Resident #10 was cognitively intact and required set-up assistance with eating. The MDS indicated Resident #10 was dependent upon staff for all Activities of Daily Living (ADL's). The MDS indicated Resident #10 received a by mouth intake and no documentation…

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 interview and policy review, the facility failed to administer medications as ordered resulting in two medication errors out of 27 medication opportunities or a 7.4 percent (%) medication error rate. The affected two (#42 and #53) out of three residents observed for medication administration. The facility census was 63. Findings included: Review of Resident #53's medical record revealed an admission date of 03/13/16. Diagnoses included hypertension, and transient cerebral ischemic attack. Review of Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #53 was alert and oriented. Review of plan of care dated 03/17/25 revealed that Resident #53 had diuretic therapy related to having hypertension. Intervention was to administer medication as ordered. Review of physician order dated 12/26/24 revealed that Resident #53 had an order for Verapamil HCL Extended Release 240 milligrams (mg). Review of Resident #42's medical record revealed admission date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to offer or provide Speech/Language Pathology (SLP) services. This affected one (#10) out of the three residents reviewed for rehabilitation services. The facility census was 63. Findings include: Review of the medical record for Resident #10 revealed an admission date of 03/22/22 with medical diagnoses of cerebral infarction with left hemiplegia, aphasia, ischemic cardiomyopathy, obesity, congestive heart failure, and chronic kidney disease stage III. Review of the medical record revealed Resident #10 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the medical record for Resident #10 revealed an annual Minimum Data Set (MDS), dated [DATE], which indicated Resident #10 was cognitively intact and required set-up assistance with eating. The MDS indicated Resident #10 was dependent upon staff for all Activities of Daily Living (ADL's). The MDS indicated Resident #10 received a by mouth intake and no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record reviews, staff interviews, observations, and policy review, the facility failed to follow infection control procedures during wound care and failed to ensure a resident was in Enhanced Barrier Precautions (EBP) as required. This affected one (#07) out of three residents reviewed for infection control procedures. The facility census was 63. Findings include: Review of the medical record for Resident #07 revealed an admission date of 07/20/24 with medical diagnoses of adult failure to thrive, dementia, right hemiplegia, and paranoid schizophrenia. Review of the medical record revealed Resident #07 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the medical record for Resident #07 revealed a quarterly Minimum Data Set (MDS) assessment, dated 02/28/25, which indicated Resident #07 was cognitively intact and required set-up assistance with eating and substantial/maximum staff assistance with toilet hygiene, showers, bed mobility, and transfers. The…

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

Based on observations, review of the menu, staff and resident interviews and policy review the facility failed to ensure the menu was followed and failed to let the residents know the menu changed. This had the potential to affect all 61 residents residing in the facility. The census was 61. Findings included: Review of the menu dated 05/19/24 revealed apple pork chop, onion roasted potatoes, dilled carrots, roll, and pumpkin crisp. Observation on 05/19/23 at 11:53 A.M. of the lunch meal revealed the residents were served an apple pork chop, mashed potatoes and gravy, dilled carrots, roll and a brownie. Interview with Dietary Manager DM #546 on 05/19/24 at 12:09 P.M. confirmed there was a menu change and she didn't let the residents know of the change. Dietary Manager #546 stated she didn't have the roasted potatoes or the pumpkin crisp. Dietary Manager #546 revealed she wasn't aware she had to let the residents know when a substitution was going to be made. Observation of her substitution list revealed there wasn't anything for this date. Dietary Manager #546 confirmed all 61…

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 interviews, and policy reviews, the facility failed to store food properly and maintain a sanitary kitchen. This had the potential to affect all 61 residents residing in the facility, as the facility reported every resident consumed food from the kitchen. The census was 61. Findings include: Observations on 05/19/24 at 8:25 A.M. revealed three white plastic tubs of cereal with white labels marked Cereal with no dates. There was also a gray trash can/bucket in the dry storage area that was filled with a few inches of water. The reach-in freezer had a plastic bag of hamburger patties open with no label or date, vegetarian burgers with no label or date, and a box of hamburger patties open with the inside plastic bag unsealed and no date. The walk-in refrigerator had a box of bacon thawing on the bottom shelf that was open with the inside plastic bag unsealed and a piece of bacon sticking out of the packaging. The ice machine had various red, yellow, and black stains on the inside of the lid and sides of the ice machine. The observations were confirmed by…

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 Quality Assurance and Performance Improvement (QAPI) documentation, staff interview, and policy review, the facility failed to have the required members at QAPI meetings. This had the potential to affect all 61 residents residing in the facility. The facility census was 61. Findings include: Review of QAPI for January 2023, March 2023, June 2023, July 2023, and October 2023 revealed no sign in sheets noted for the meetings. Sign in sheets were located in the March and April 2024 QAPI documentation. No documentation of the medical director attending the meetings in March 2024 or April 2024. Interview on 05/22/24 at 1:27 P.M. with Administrator verified no sign in sheets were located for the QAPI meetings held in 2023. Administrator verified that the medical director did not attend the QAPI meetings in March 2024 and April 2024. Review of the QAPI committee provided by the facility revealed the committee members included but not limited to Administrator, Director of Nursing, Assistant Director of Nursing, Medical Director, and facility interdisciplinary team. Review of policy…

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

Based on record review, staff interviews, and policy review, the facility failed to have a developed water management plan in place. This had the potential to affect all 61 residents residing in the facility. The census was 61. Findings include: Review of the facility's water management binder revealed no water management plan, including a description and diagram of the water system or control measures to prevent Legionella. Interview on 05/21/24 at 10:05 A.M. with the Administrator confirmed the facility lacked a water management plan. Interview on 05/21/24 at 10:32 A.M. with Maintenance Director #573 revealed they only checked hot water temperatures and had no water management plan to follow. Review of the facility policy titled Legionella Surveillance, dated 01/12/24, revealed Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water system.

Based on observation, medical record review, staff and resident interview, and policy review, the facility failed to provide a homelike environment for the residents. This affected three (Residents #18, #21, #31) of three reviewed for homelike environment. This also affected 27 (Residents #56, #21, #07, #19, #110, #18, #05, #08, #55, #54, #25, #50, #22, #28, #43, #41, #45, #02, #210, #26, #44, #06, #37 #01, #03, #10, #51) of 27 residents who resided on the behavioral unit. The census was 61. Findings included: 1. Observation of the activity room for the behavioral unit on 05/19/24 at 2:10 P.M. revealed the seven window ledges were sticky and dusty. The seven window sills in the room were covered with a black substance. The three blinds in the room were covered with a sticky yellow substance. The floor under the two heaters in the room had a thick black substance under them. The baseboards had a black substance on them. There were three lights going down the west hall of the behavioral unit that had light coverings missing and some of the light bulbs were burned out. Also going down…

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 care conferences were provided quarterly for four (Residents #39, #21, #32, #33) of four reviewed for care conferences. The census was 61. Findings included: 1. Medical record review for Resident #39 revealed an admission date of 11/20/23 with a diagnosis of chronic obstructive pulmonary disease. Review of the quarterly MDS dated [DATE] revealed Resident #39 was cognitively intact. His functional status was set-up or clean-up assistance for eating and toileting. He was independent for bed mobility and transfers. Review of Resident #39's care conference history since 05/01/23 revealed he only had one care conference on 03/28/24. Interview with Resident #39 on 05/19/24 at 10:02 A.M. revealed he didn't know what a care conference was. Interview with the Social Services Designee (SSD) #592 on 05/20/24 at 2:53 P.M. confirmed there was only one care conference for Resident #39. 2. Medical record review 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 Review of medical records, late medication reports, physician orders, interview, and policy review the facility failed to ensure medications were administered in a timely manner and according to physician instruction. This affected four (Residents #13, #30, #31, and #33) of four residents reviewed for late medications. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 01/12/15 with diagnoses including but not limited to unspecified convulsions, dementia, mild intellectual disabilities, epilepsy, post-traumatic stress disorder, hypothyroidism, major depressive disorder, cognitive communication disorder, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had severe cognitive impairment. Resident #13 required supervision/touching assistance for ADLs. Review of the late medication report for 05/18/24, revealed the following medications due at 8:00 A.M. were not administered until 12:00 P.M. levothyroxine 50 mcg…

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 ensure the residents were offered and/or administered the Coronavirus Disease 2019 (COVID-19) vaccine. This affected (#32, #110, #58 and #19) of five reviewed for the COVID-19 vaccinations during the annual survey. The census was 61. The facility also failed to ensure staff were offered COVID-19 vaccinations. Findings included: 1. Medical record review for Resident #32 revealed an admission date of 01/31/19. Medical diagnoses included chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #32 was cognitively intact. His functional status was set-up or clean-up assistance for eating, toileting, bed mobility and transfers. Review of the medical record from 07/01/23 through 05/19/24 revealed there wasn't any evidence of education, consent or medication administration for COVID-19 vaccination. Interview with Resident #32 on 05/22/24 at 11:08 A.M. revealed he had not…

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 ensure all residents were treated with dignity and respect. This affected one (#1) of one resident reviewed for dignity and respect. The facility census was 61. Findings include: Review of the medical record for Resident #1 revealed an admission date of 07/20/12. Diagnoses included unspecified psychosis not due to a substance or known physiological condition, bipolar two disorder, schizoaffective disorder, aphasia, post traumatic seizures, other specified intracranial injury without loss of consciousness, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had severe cognitive impairment and was non-verbal. No behaviors were noted on the assessment. Resident #1 was assessed to require setup assistance for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy reviews, the facility failed to develop a care plan for smoking and activities. This affected one (Resident #55) of five residents reviewed for care planning. The facility census was 61. Findings include: Review of the medical record for Resident #55 revealed an admission date of 06/27/23. Diagnoses included unspecified dementia, unspecified severity, with other behavioral disturbance, mild protein-calorie malnutrition, anxiety disorder, myelodysplastic syndrome, heart failure, alcohol dependence with unspecified alcohol-induced disorder, adult failure to thrive, and major depressive disorder recurrent severe with psychotic symptoms. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 had severely impaired cognition. Resident #55 was assessed to require supervision for bathing, dressing, and personal hygiene, and was independent for eating, oral hygiene, toileting, bed mobility, and transfer. Review of the plan…

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 complete discharge summaries. This affected two (Residents #57 and #59) of two residents reviewed for discharge. The facility census was 61. Findings include: 1. Review of the closed medical record for Resident #57 revealed an admission date of 01/12/24 and a discharge date of 05/09/24. Diagnoses included malignant neoplasm of central portion of right female breast, chronic obstructive pulmonary disease, anxiety disorder, posttraumatic stress disorder, major depressive disorder, dementia, and hypokalemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 had moderately impaired cognition. Resident #57 was assessed to require setup assistance for eating oral hygiene, and personal hygiene, supervision for toileting, bathing, and dressing, and was independent for bed mobility and transfer. Review of the progress note dated 05/09/24 revealed Resident #57 discharged home. 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 observation, medical record review, staff and resident interview, and policy review, the facility failed to ensure a resident who couldn't perform Activities of Daily Living (ADL) independently was provided with bathing, beard trimming, and nail trimming, This affected one (Resident #32) of three reviewed for ADL care. The census was 61. Findings included: Medical record review for Resident #32 revealed an admission date of 01/31/19 with a diagnoses of chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was cognitively intact. His functional status was set-up or clean-up assistance for eating, toileting, bed mobility, and transfers. Review of the care plan dated 05/01/24 revealed Resident #32 had a self-care deficit for ADLs. He has been supervision for all ADLs but at times required hands on assistance. The resident used a powered wheelchair to move about the facility. He refused showers at times. Review of shower sheets…

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 policy review, the facility failed to assess side rails and/or enabler bars for entrapment risk. This affected one (Resident #33) of two residents reviewed for side rails/enabler bars. The facility census was 61. Findings include: Review of medical record for Resident #33 revealed an admission date of 08/26/22 with diagnoses including but not limited to epidural hemorrhage with loss of consciousness, major depressive disorder, hypertension, psychosis, type two diabetes, paranoid schizophrenia, and dementia with behavioral disturbance. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 had severe cognitive impairment. Resident #33 required extensive assistance for activities of daily living. Review of assessments revealed no side rail and/or enabler bar assessments completed. Observation on 05/21/24 at 1:49 P.M. of enabler bar on Resident #33's bed revealed approximately three and half to four inch gap between the enabler bar and mattress. Interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review the facility failed to assess the use of side rails/enabler bars. This affected two (#33 and #58) of two residents reviewed for side rails/enabler bars. The facility census was 61. Findings include: 1. Review of medical record for Resident #33 revealed admission date of 08/26/22 with diagnoses including but not limited to epidural hemorrhage with loss of consciousness, major depressive disorder, hypertension, psychosis, type two diabetes, paranoid schizophrenia, and dementia with behavioral disturbance. Review of minimum data set (MDS) dated [DATE]. Resident #33 had a brief interview of mental status (BIMS) score of three which indicated severe cognitive impairment. Resident #33 required extensive assistance for activities of daily living. Review of care plan dated 04/24/24 revealed at risk for falls with intervention of mobility bar to right side of bed when in bed to assist with mobility. Review of assessments revealed no side rail and/or enabler bar…

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, resident and staff interviews and review of facility policy, the facility failed to ensure resident room temperatures were maintained to ensure a comfortable environment for the residents. This affected two (#1 and #3) out of four residents reviewed for comfortable room temperatures. Facility census was 63. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 02/22/21. Diagnoses included cerebral infarction, anxiety, hypertension, and acute kidney injury. Review of the annual Minimum Data Set (MDS) 3.0 assessment for Resident #3, dated 11/01/23, revealed the resident had mildly impaired cognition. Review of the plan of care for Resident #3 revealed the resident had potential for altered cardiac status related to hypertension with goal to remain free from complications related to altered cardiac status. Interventions include, but not limited to, monitor for chest pain, blood pressure, nausea and vomiting, shortness of breath,…

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, staff interview, review of personnel files, review of witness statements, and review of the facility's abuse policy, the facility failed to ensure Bureau of Criminal Investigation (BCI) background checks were completed during the employees hiring process. This affected one resident (#52) of the three residents reviewed for abuse. The facility also failed to ensure their abuse policy was implemented when an allegation of resident abuse was reported. This affected one resident (#52) of three residents reviewed for abuse. The facility census was 59. Findings Include: 1. Review of the personnel file for Housekeeper #301 revealed she was hired on 01/29/23 and terminated on 08/18/23 for violating the facility's abuse policy due to shouting at a resident. The personnel file revealed no documented evidence of a BCI background check being completed during Housekeeper #301's hiring process. A BCI background check was completed on 08/25/23 which was after Housekeeper #301 had been terminated from employment for violating the facility's abuse policy. Review of 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.

Based on medical record review, staff and resident interview, review of witness statements, review of the facility's self-reported incidents (SRIs) and review of the facility's abuse policy, the facility failed to ensure an allegation of verbal abuse was reported to the state agency. This affected one resident (#52) of three residents reviewed for abuse. The census was 59. Findings include: Review of medical record for Resident #52 revealed an admission date of 06/30/23 and the resident's diagnoses included Schizophrenia. Review the admission Minimum Data Set (MDS) assessment 3.0 for Resident #52 dated 07/11/23, revealed the resident was cognitively intact. Review of a progress note dated 08/17/23 for Resident #52, revealed no documented evidence of an argument between Housekeeper #301 and the resident. Review of the SRI's submitted by the facility revealed no documented evidence of an SRI being initiated to the state agency for an allegation of staff to resident abuse on 08/17/23. Review of a witness statement authored by Activities Director (AD) #62 dated 08/18/23, revealed 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, observation, staff interviews and policy review the facility failed to ensure incontinence care was provided correctly. This affected two residents (#11 and #31) of three residents reviewed for incontinence care. The census was 59. Findings include: 1. Review of medical record for Resident #11 revealed an admission date of 01/08/21 with diagnoses of seizures, aphasic, and cerebrovascular attack (stroke). Review of the quarterly Minimum Data Set (MDS) assessment 3.0 dated 07/01/23 for Resident #11, revealed the resident had severely impaired cognition. The resident required extensive assistance for toileting was always incontinent of bowel and bladder. Review of the care plan for Resident #11 dated 07/09/23 revealed the resident exhibited episodes of incontinence for bowel and bladder due to impaired cognition. Observation of incontinence care provided by State Tested Nursing Aide (STNA) #124 for Resident #11 on 09/27/23 at 2:36 P.M. revealed STNA #124 stood the resident up in the…

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

Based on observation, staff interview, chemical supply technician interview, and policy review, the facility failed to maintain equipment and store food and supplies in a manner to prevent the potential spread of food borne illness. This had the potential to affect all 60 residents residing in the facility. Findings include: 1. Observation on 05/23/22 at 8:25 A.M. revealed a large standing fan in the kitchen, coated in a dark grey furry substance, facing the tray line, and in the on position. Staff were observed preparing breakfast trays from the tray line. Interview on 05/23/22 at 8:29 A.M., [NAME] #22 verified the fan was dirty, on, and facing the food on the tray line. 2. Observation on 05/25/22 at 9:07 A.M. revealed a large standing fan, in the on position, facing the three-compartment sink and clean, drying dishes. The fan was observed to be coated in a grey, furry substance. Interview at the time of the observation with Food Service Supervisor (FSS) #21 verified the fan was dirty, on, and facing clean dishes. 3. Observation on 05/23/22 at 8:31 A.M. revealed four milk crates…

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, interview and policy review, the facility failed to ensure residents were placed in appropriate transmission based precautions upon admission. This had the potential to affect 32 residents (#01, #03, #04, #05, #07, #10, #13, #15, #16, #18, #21, #24, #25, #26, #29, #31, #32, #37, #38, #39, #44, #45, #46, #49, #50, #51, #54, #58, #60, #463, #464, and #465) residing on the East Unit. In addition the facility failed to ensure medications were not handled with bare hands prior to administration. This affected two residents (#42 and #50) of three residents observed for medication administration. The facility census was 60. Findings include: 1. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE]. Diagnoses included unspecified anemia, major depressive disorder, unspecified acute kidney failure, and unspecified cerebral infarction. Review of most recent Minimum Daily Set (MDS) assessment dated [DATE] revealed Resident #58 had moderately…

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 and resident interview and policy review, the facility failed to ensure female residents did not have facial hair. This affected one resident (#36) of eight female residents (#42, #36, #33, #08, #41, #35, #56 and #06) observed on the memory care unit. The facility census was 60. Findings included: Review of Resident #36's medical record revealed an admission date of 11/16/11. Diagnoses included metabolic encephalopathy, dysphagia, cognitive communication deficit, extrapyramidal and movement disorder, diabetes, chronic kidney disease and hypertension. Review of Resident #36's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) was unable to be completed. The MDS revealed the resident required extensive one-person assistance for bed mobility, transfer, dressing, personal hygiene, and toilet use. Review of Resident #36's plan of care revealed the resident had a self-care deficit related to cognitive impairment 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 medical record review, observation, staff and resident interview, and policy review the facility failed to ensure the call light was within easy reach of residents. This affected one resident (#24) of 24 residents reviewed. The facility census was 60. Findings include: Review of medical record for Resident #24 revealed admission date of 05/11/21. Diagnoses included stroke, hemiparesis and hemiplegia affecting right dominant side, flaccid hemiplegia left non dominant side and type two diabetes mellitus with diabetic neuropathy. The comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 required extensive two-person assistance for bed mobility, extensive one person assistance for eating, toilet use, personal hygiene and total dependence for transfers. A care plan for self-care deficit related to right and flaccid hemiplegia requiring assistance. Interventions included the need to evaluate for adaptive equipment. Observation on 05/23/22 at 11:18 A.M., revealed Resident #24's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to ensure a resident's code status was accurately documented in the resident's record. This affected one resident (#49) out of 24 residents reviewed for code status. The facility census was 60. Findings include: Review of the medical record revealed Resident #49 admitted to the facility on [DATE]. Diagnoses included bipolar disorder, unspecified dementia without behavioral disturbance, major depressive disorder, malignant neoplasm of unspecified site of unspecified female breast, atrial fibrillation, chronic obstructive pulmonary disease, schizoaffective disorder, glaucoma, and insomnia. Review of Resident #49's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and Resident #49 required supervision with bed mobility, transfers, and toilet use. Resident #49 required limited assistance with dressing and Resident #49 also required extensive assistance with personal hygiene. 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 2. Review of the medical record of Resident #57 revealed an admission date of 01/02/19. The resident transferred to another facility on 04/01/22 and returned to the facility, following a hospital stay, on 04/12/22. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, anxiety, major depressive disorder, essential hypertension, epilepsy, osteoarthritis, moderate protein-calorie malnutrition, polyneuropathy, schizoaffective disorder, dementia with behavioral disturbance, type two diabetes mellitus, and chronic atrial fibrillation. Review of the comprehensive MDS assessment dated [DATE] revealed the resident's cognition was not assessed. The resident required extensive assistance of two staff for bed mobility and toilet use, and was totally dependent on two staff for transfers. The resident was independent after setup for eating. The resident was assessed as having no dental problems, including no broken natural teeth. Review of the Dental Summary Report dated 07/21/21 revealed the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed notify the state mental health authority with a significant change pre-admission screening and resident review (PASARR) for a resident with a change in their mental health condition. This affected one resident (#49) out of two residents reviewed for significant change PASARR. The facility census was 60. Findings include: Review of the medical record revealed Resident #49 admitted to the facility on [DATE]. Diagnoses included bipolar disorder, unspecified dementia without behavioral disturbance, major depressive disorder, malignant neoplasm of unspecified site of unspecified female breast, atrial fibrillation, chronic obstructive pulmonary disease, schizoaffective disorder, glaucoma, and insomnia. Review of Resident #49's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and Resident #49 required supervision with bed mobility, transfers, and toilet use. Resident #49 required limited…

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, review of the manufacturers installation recommendations, and policy review, the facility failed to ensure a resident had a care plan for assist bars. This affected one resident (#15) out of 15 residents reviewed for care plans. The facility census was 60. Findings include: Review of the medical record revealed Resident #15 admitted to the facility on [DATE] with diagnoses including anxiety disorder, chronic obstructive pulmonary disease, hyperlipidemia, major depressive disorder, muscle weakness, other abnormalities of gait and mobility, constipation, insomnia, edema, and paranoid schizophrenia. Review of Resident #15's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and Resident #15 was independent with bed mobility, transfers, dressing, eating, and toilet use. Resident #15 required supervision with personal hygiene. Review of Resident #15's undated care plan revealed Resident #15 did…

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, and policy review, the facility failed to ensure care plans were revised for dental and safety interventions. This affected two residents (#11 and #16) out of 15 residents reviewed for care planning. The facility census was 60. Findings include: 1. Review of the medical record of Resident #11 revealed an admission date of 04/19/16. Diagnoses included alcohol dependence with alcohol-induced persisting dementia, major depressive disorder, schizoaffective disorder, dementia with behavioral disturbance, hyperlipidemia, bipolar disorder, constipation, cognitive communication deficit, essential hypertension, and benign prostatic hyperplasia. Review of the quarterly MDS assessment dated [DATE] revealed the Resident #11 had impaired cognition. The resident was assessed as not having any behaviors during the assessment period. The resident required supervision for bed mobility, transfers, and toilet use, and was independent with eating. 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 observation, medical record review, staff interview, and policy review the facility failed to ensure a physician ordered fall preventions were implemented. This affected one resident (#36) of 15 residents reviewed during the annual recertification. The facility census was 60. Findings include: Review of Resident #36's medical record revealed an admission date of 11/16/11. Diagnoses included metabolic encephalopathy, dysphagia, cognitive communication deficit, extrapyramidal and movement disorder, diabetes, chronic kidney disease and hypertension. Review of Resident #36's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) was unable to be completed. The MDS revealed the resident required extensive one-person assistance for bed mobility, transfer, dressing, personal hygiene, and toilet use. The resident was independent with set-up for eating. Review of Resident #36's plan of care dated 01/06/22 revealed the resident was at risk for falls related to weakness 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, review of manufacturers instructions, and policy review, the facility failed to ensure a resident's assist bars were installed per manufacture instructions. This affected one resident (#15) out of 15 residents reviewed for care plans. The facility census was 60. Findings include: Review of the medical record revealed Resident #15 admitted to the facility on [DATE] with diagnoses including anxiety disorder, chronic obstructive pulmonary disease, hyperlipidemia, major depressive disorder, muscle weakness, other abnormalities of gait and mobility, constipation, insomnia, edema, and paranoid schizophrenia. Review of Resident #15's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and Resident #15 was independent with bed mobility, transfers, dressing, eating, and toilet use. Resident #15 required supervision with personal hygiene. Review of Resident #15's undated care plan revealed Resident #15…

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 and staff interview, the facility failed to maintain the facility in a clean manner and in good repair. This had the potential to affect 38 of 38 residents who reside in the [NAME] Wing. The total facility census was 76. Findings include: Observations on 07/22/19 at 10:45 A.M. in room [ROOM NUMBER], revealed a window that was missing blinds and the parking lot was visible through the window. During an interview on 07/24/19 at 01:46 P.M., with Maintenance Supervisor (MS) #21, verified room [ROOM NUMBER]'s window was missing blinds. Observation on 07/22/19 at 11:08 A.M. in room [ROOM NUMBER], revealed the closet door was off the tracks and very difficult to move. During an interview on 07/24/19 at 01:48 P.M. with MS #21, verified room [ROOM NUMBER]'s closet door was off the track and very difficult to move. Observation on 07/22/19 at 11:35 A.M., revealed the activity room mini-refrigerator had a strong odor, had a dried substance covering the bottom, and a spoiled mighty shake and apple…

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 interviews, the facility failed to maintain a call light within reach for one resident. This affected one (#58) of 18 residents reviewed for accommodation of needs. The total facility census was 76. Findings include: Review of the record for Resident #58 revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, dysphagia, anxiety, and major depressive disorder. Review of Resident #58's Minimum Data Set (MDS) dated [DATE], revealed he had a Brief Interview of Mental Status (BIMS) score of 10, indicating a moderate cognitive impairment. The MDS also revealed he required set-up assistance with bed mobility, extensive assistance with transfers, toilet use and personal hygiene. Review of Resident #58's care plan dated 01/29/19, revealed Resident #58 was at risk for falls and staff should maintain his call light within reach. Observations on 07/24/19 at 10:27 A.M., revealed Resident #58 was sleeping in bed with his call…

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 the closed records, review of facility policy and staff interview, the facility failed to provide written notice of transfer for one resident. This affected one (#84) of three closed records reviewed for written transfer notices. The total facility census was 76. Findings include: Review of the record for Resident #84 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, bipolar disorder, psychosis, major depressive disorder, insomnia, and schizoaffective disorder. Resident #84 discharged on 06/22/19, to a mental health hospital related to aggressive behaviors. Review of the form titled, Letters of Guardianship, dated 01/26/19, revealed Resident #87 was incompetent and had a legal guardian appointed for an indefinite time period. Review of a nursing note dated 06/22/19, revealed Resident #87 was exhibiting aggressive behaviors including attempting to flip a dining room table and pushing chairs into staff. Law enforcement was called to take Resident #87 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure one residents care plan had been reviewed and revised to meet the needs of the resident. This affected one (#58) of 18 residents reviewed for updated care plans. The total facility census was 76. Findings include: Review of Resident #58's record revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, dysphagia, anxiety, and major depressive disorder. Review of Resident #58's Minimum Data Set (MDS) dated [DATE], revealed he had a Brief Interview of Mental Status (BIMS) score of 10, indicating a moderate cognitive impairment. The MDS also revealed he required set-up assistance with bed mobility, extensive assistance with transfers, toilet use and personal hygiene. Resident #58's care plan dated 01/29/19, revealed he was on 15 minute checks for 72 hours, was an extensive assist for bed mobility, and was at risk for nutrition/hydration related to a history of refusing his dietary supplement…

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 activities of daily living (ADL's) care was provided for one resident. This affected one (#18) of 19 residents reviewed for ADL's care. The total facility census was 76. Findings include: Review of Resident #18's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included diverticulitis, gastrostomy status, gastro-esophageal disease, and dysphagia. Resident #18's annual Minimum Data Set (MDS) dated [DATE], revealed Resident #18 was severely cognitively impaired and totally dependent on staff for all ADL's. Observation on 07/23/19 at 08:28 A.M., revealed a strong foul odor in Resident #18's room. The observation also revealed brown emesis that had dried onto his beard, a wash-cloth that had been placed under his chin, and was also dried onto his hospital gown and bed sheet. Interview on 07/23/19 at 8:30 A.M. with State Tested Nurse Aide (STNA) #71, revealed Resident #18 was totally dependent on staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy and staff interview, the facility failed to ensure pharmacy recommendations were reviewed and addressed for two residents. This affected two (#24 and #41) of six residents reviewed for pharmacy recommendations. The total facility census was 76. Findings include: 1. Review of the record for Resident #24 revealed the resident was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, insomnia, dementia without behavioral disturbance, major depressive disorder, and unspecified psychosis. Review of Resident #24's care plan revealed Resident #24 was on psychotropic medications including an anti-depressant, hypnotic, and a mood stabilizer to manage symptoms of psychosis, depression, and insomnia. The care plan indicated the physician should review the medications for ongoing need and the pharmacy should review the medications per facility policy. Review of a pharmacy consultation report dated 11/20/18, revealed Resident #24 was receiving Fluoxetine…

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.