Continuing Healthcare At Forest Hill

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review and interview, the facility failed to provide care and services to restore bladder function and treat urinary tract infections (UTI) timely. This affected four (#3, #11, #44 and #52) of four residents reviewed for UTI's, and one (#57) resident reviewed for an indwelling urinary catheter. The census was 75. Findings include: 1. Medical record review revealed Resident #3 was admitted on [DATE] with diagnoses including cerebral infarction and a history of urinary tract infections. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 was moderately impaired for daily decision-making and had no urinary infections within the last 30 days. Review of the progress note (dated 03/02/24 at 1:03 P.M.) revealed Resident #3 complained of burning with urination and a foul smelling odor (with urination). Nurse Practitioner (NP) #901 ordered a urinalysis and culture to be obtained on 03/04/24. No progress notes were documented on 03/03/24.…

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 review, review of infection control log, interviews, observations, and policy review the facility failed to ensure appropriate use of antibiotics and/or assessment were completed accurately. This affected five (Resident #12, #41, #48, #52, and #57) of nine reviewed for urinary tract infection and unnecessary medication review. Findings include. 1.Medical record review revealed Resident #52 was admitted to the facility on [DATE] with diagnosis including metabolic encephalopathy, urinary tract infection, Parkinson's, aphasia, cognitive communication deficit, obstructive and reflux uropathy, malignant neoplasm of prostate, sleep terrors, attention and concentration deficit, dementia, major depression, anxiety, spinal stenosis, lower back pain, gastro-esophageal reflux disease, hyperlipidemia, hypertension, pulmonary embolism, constipation, and benign prostatic hyperplasia without lower urinary tract symptoms. a. Review of Resident #52's orders and Medication Administration Records (MAR) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, interview, and policy review the facility failed to ensure residents call lights were readily assessable. This affected five residents (#47 Resident #3, #43, #48, #54) observed during the initial tour. Findings included: 1. Medical record review revealed Resident #47 was admitted to the facility on [DATE] with diagnosis including hunting disease, scoliosis, epilepsy, anxiety and depression. Observation on 10/21/24 at 4:11 P.M., revealed both of call lights in Resident #47's room were lying on the floor under the resident foot of bed. The resident was observed sitting in bed with back against the wall. There was a sign next to the door to remind the resident to use call light. Interview on 10/21/24 at 4:11 P.M., with the Administrator confirmed the call lights were on the floor. The Administrator placed the call lights next to the resident. Review of Resident #47's activity of daily living (ADL) deficit related to Huntington's plan of care dated 05/08/23 and revised…

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 shower schedules, and interview, the facility failed to ensure bathing preferences were honored. This affected one (Resident #178) of 14 residents interviewed related to choices. Findings include: Review of Resident #178's medical record revealed diagnoses including left hip fracture, depression, and type two diabetes mellitus. An assessment for Preference for Everyday Living (PELI) dated 10/07/24 revealed it was somewhat important for Resident #178 to choose between a tub bath, shower, bed bath or sponge bath. Resident #178 preferred a tub bath with no preference for bathing time. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #178 was able to make herself understood and was able to understand others. Resident #178 was assessed as cognitively intact. Review of an Interdisciplinary team (IDT) note dated 10/18/24 revealed Resident #178 required substantial/maximal assistance with bathing. Review of shower schedules revealed Resident #178…

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 review and interview, the facility failed to ensure advanced directives were accurate. This affected one (#59) of 24 residents reviewed for advanced directives. The census was 75. Findings include: Medical record review revealed Resident #59 was admitted on [DATE] with diagnoses including cerebral infarction. Review of the medical record revealed no Advanced Directive form for review. Review of the Baseline Care Plan (dated [DATE]) revealed Resident #59 was a Full Code (a medical directive that indicates that a resident should receive all possible medical care to save their life in the event of a medical emergency). Review of Nurse Practitioner #901's History and Physical (dated [DATE]) revealed Resident #59 was a Full Code. Review of the electronic medical record, including the Physician Orders as of [DATE], indicated Resident #59 was a DNR-CCA (Do-Not-Resuscitate Comfort Care Arrest which is a medical abbreviation that allows residents to receive aggressive interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure comprehensive information was conveyed to the receiving health care provider and documented as such in the medical record. This affected one (Resident #52) of two residents reviewed for hospitalization. Findings included: Record review revealed Resident #52 was initially admitted to the facility on [DATE] with diagnosis including metabolic encephalopathy, urinary tract infection, Parkinson's disease, cognitive communication deficit, attention and concentration deficit, dementia, major depression, anxiety, and benign prostatic hyperplasia without lower urinary tract symptoms. Review of Resident #52's census tab from 06/01/24 to 10/18/24 revealed the resident was transferred and admitted to the hospital on [DATE], 08/11/24, 09/26/24, and 10/13/24. The resident was transferred to the hospital on [DATE], however was not admitted to the hospital and returned to the facility. Further review of Resident #52's medical record revealed no documented…

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

Based on medical record review and staff interview, the facility failed to ensure a discharge summary of a resident stay was completed following discharge from the facility. This affected one (Resident #75) of one residents reviewed for discharge. The facility census was 75. Findings include: Review of Resident #75's medical record revealed an admission date of 08/02/24 with diagnoses that included congestive heart failure, atherosclerotic heart disease, hypertension and hyperlipidemia. Further review of the medical record revealed on 08/16/24 Resident #75 was discharged to the assisted living facility connected to the facility. Review of the discharge summary revealed no evidence of completion by the nursing or dietary departments. On 10/28/24 at 10:41 A.M. interview with the Director of Nursing verified Resident #75's discharge summary was not completed thoroughly.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, review of shower schedules and interview, the facility failed to provide hygiene and/or grooming for three (Residents #29, #54, and #73) of 24 residents screened for hygiene/grooming. Findings include: 1. Review of Resident #73's medical record revealed diagnoses including metabolic encephalopathy (a condition in which brain function is disturbed by diseases or toxins in the body), Parkinson's disease, fracture of the fourth metacarpal of the left hand, and neurocognitive disorder. A baseline care plan dated 09/18/24 indicated Resident #73 was to be assisted with bathing as needed. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #73 was usually understood and usually understood others. Resident #73 was assessed as moderately cognitively impaired. No rejection of care was documented. Resident #73 required substantial/maximal assistance with bathing and partial/moderate assistance with personal hygiene. a. The medical record revealed 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 review, observations, interviews, and policy review the facility failed to ensure a decline in pressure ulcer was timely identified and adequately treated. This affected one (Resident #15) of two residents reviewed for pressure ulcers. Findings included: Medical record review revealed Resident #15 was admitted to the facility on [DATE] with diagnosis including cognitive communication deficit, heart failure, and vascular dementia. Review of Resident #15's current plan of care revealed the resident had pressure ulcers (left and right heel) related to mobility, dementia, edema, weakness, and chronic heart failure. Interventions included to monitor, document, and report to physician any changes in skin status (appearance, color, wound healing, signs and symptoms of infection and wound size). Notify nurse immediately of any new areas of skin breakdown noted during bath or daily care. Review of Resident #15's pressure ulcer assessment dated [DATE] revealed the left heel was a stage I (intact…

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 interviews the facility failed to implement interventions to prevent foot drop/contractures/limited range of motion. This affected two (Resident #30 and #59) of two residents reviewed for mobility/positioning. Findings included: 1. Medical record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including palliative care, encephalopathy, sequelae of cerebral infarction, hemiplegia and hemiparesis, aphasia, and depression. There was no evidence the resident's diagnoses list included contractures. Review of Resident #30's Physical Therapy (PT) notes dated 01/22/24 revealed the resident had functional limitation of the knee, hip, and ankle on the right lower extremity due to contractures. Review of Resident #30's Occupation Therapy (OT) notes dated 01/20/24 to 01/26/24 revealed gentle passive range of motion (PROM) and stretching was completed to bilateral upper extremities to increase ROM and to decrease the risk for further…

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 and interview, the facility failed to ensure fall prevention interventions were in place as ordered and fall investigations were completed after a fall. This affected two (#3 and #54) of four residents reviewed for accidents. The census was 75. Findings include: 1. Medical record review revealed Resident #3 was admitted on [DATE] with diagnoses including coronary artery disease, cerebral infarction, hemiplegia, anxiety disorder, depression and obsessive compulsive disorder. a. Review of the general note (dated 07/03/23) revealed a nurse had taken Resident #3 her breakfast tray and observed a dark purple/deep red bruise to her left eye. Resident #3 stated she fell out of bed and hit her face. Education was provided to the resident to utilize her call light and to ask for assistance. Review of the IDT (Interdisciplinary Team) Note dated 07/04/23 revealed Resident #3 reports she had a fall from bed. New intervention was a mat to the floor, on window side 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.

Based on medical record review and interview, the facility failed to ensure weekly weights were monitored for a resident who had significant weight loss. This affected one (Resident #73) of two residents reviewed for nutrition. Findings include: Review of Resident #73's medical record revealed diagnoses including Parkinson's disease, muscle wasting, neurocognitive disorder, and gastroesophageal reflux disease. A weight of 189.4 pounds was recorded on 09/20/24. A weight of 179.2 was recorded on 10/09/24 and 10/10/24. Review of a weight change note dated 10/10/24 at 12:49 P.M. indicated Resident #73 had a significant weight loss of 5% (10.2 pounds) in one month. Weight loss was likely due to fluid shifts from resolving edema. The note indicated Resident #73 would be added to the weekly weight list. No additional weights were located. On 10/23/24 at 12:30 P.M., Registered Nurse (RN) #541 provided a list of weekly weights dated 10/14/23 in which Resident 73's weight was recorded as 180.4. RN #541 verified the weight had been obtained on 10/23/24 as she was unable to locate a weight…

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, policy review and manufacturer guideline review the facility failed to ensure oxygen was administered per orders and respiratory equipment was stored properly. This affected two (Resident #15 and #229) residents of four residents reviewed for respiratory care. Findings include: 1. Record review revealed Resident #15 was admitted to the facility on [DATE] with diagnosis including heart failure, asthma, and anxiety. Review of Resident #15 Minimum Data Set (MDS) dated [DATE] revealed the resident utilized oxygen therapy and had asthma or chronic lung disease. Review of Resident #15's oxygen orders dated 09/20/24 revealed the resident was ordered oxygen at three liters per minute via nasal cannula continuously for congestive heart failure. Review of Resident #15's progress note dated 09/20/23 revealed the resident arrived via ambulette on a stretcher with three liters oxygen continuous via nasal cannula. Review of Resident #15's altered respiratory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to provide pain medication as ordered, obtain clarification regarding medication administration, and offer non-pharmacological interventions prior to the administration of pain medication ordered on an as needed basis. This affected two (Residents #29 and #178) of four residents reviewed for pain management. Findings include: 1. Review of Resident #29's medical record revealed diagnoses including osteoarthritis and type two diabetes mellitus. A care plan initiated 10/04/23 indicated Resident #29 was at risk for pain related to arthritis, depression, migraines, generalized discomfort and diabetes mellitus. An intervention dated 10/04/23 provided instructions to administer pain medication as ordered. Resident #29 had orders for the administration of tylenol 650 milligrams four times a day dated 08/21/24. Review of the September 2024 Medication Administration Record (MAR) revealed tylenol was not administered at midnight on 09/09/24 or 09/20/24 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 medical record review, policy review and interview, the facility failed to develop individualized comprehensive dementia care plans and policies related to dementia care. This affected one (#48) of one resident reviewed for dementia care. The census was 75. Findings include: Medical record review revealed Resident #48 was admitted on [DATE] with diagnoses including Alzheimer's disease, dementia and urosepsis. Review of the admission Minimum Data Set 3.0 assessment (dated 09/24/24) revealed Resident #48 was moderately impaired for daily decision-making and was receiving antipsychotic medications on a routine basis. Review of the electronic Physician Orders (dated 09/17/24) included to administer risperidone (antipsychotic) 0.5 milligrams twice a day for dementia and Memantine (treats dementia associated with Alzheimer's disease) 10 mg twice a day for dementia. On 10/21/24, the diagnosis for the use of risperidone was changed to restlessness, yelling out and impulsiveness; however, there was no documented…

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 review and interview, the pharmacist failed to identify irregularities in the medical record. This affected two (#3 and #48) of five residents reviewed for unnecessary medications. The census was 75. Findings include: 1. Medical record review revealed Resident #48 was admitted on [DATE] with diagnoses including Alzheimer's disease, dementia and urosepsis. Review of the admission Minimum Data Set 3.0 assessment (dated 09/24/24) revealed Resident #48 was moderately impaired for daily decision-making and was receiving antipsychotic medications on a routine basis. a. Review of the Physician Order (dated 09/18/24) revealed to repeat a complete blood count and obtain Vitamin D level in one week. Review of the Lab Results Report (dated 09/23/24) revealed the following abnormal lab values: red blood cell 2.92 M/cmm (normal 3.9-5.4), hemoglobin 9.4 g/dL (normal 12-16), hematocrit 26.9% (normal 36-48) and Vitamin D25-OH Total 8 ng/mL (normal 30-100). Review of the medical record…

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, National Library of Medicine review and interview, the facility failed to address abnormal laboratory results. This affected one (Resident #48) of five residents reviewed for unnecessary medications. The census was 75. Findings include: Medical record review revealed Resident #48 was admitted on [DATE] with diagnoses including Alzheimer's disease, dementia and urosepsis. Review of the admission Minimum Data Set 3.0 assessment (dated 09/24/24) revealed Resident #48 was moderately impaired for daily decision-making. Review of the Physician Order (dated 09/18/24) revealed to repeat laboratory blood work including a CBC (complete blood count) and Vitamin D level in one week. Review of the Lab Results Report (dated 09/23/24) revealed the following abnormal lab values: red blood cell 2.92 M/cmm (normal 3.9-5.4), hemoglobin 9.4 g/dL (normal 12-16), hematocrit 26.9% (normal 36-48) and Vitamin D 25-OH Total 8 ng/mL (normal 30-100). Review of the medical record revealed no documented…

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 review and interview, the facility failed to ensure residents receiving antipsychotic medications had adequate indications of use and behavioral interventions. This affected one (#48) of five residents reviewed for unnecessary medications. The census was 75. Findings include: Medical record review revealed Resident #48 was admitted on [DATE] with diagnoses including Alzheimer's disease, dementia and urosepsis. Review of the admission Minimum Data Set 3.0 assessment (dated 09/24/24) revealed Resident #48 was moderately impaired for daily decision-making and was receiving antipsychotic medications on a routine basis. Review of the electronic Physician Orders (dated 09/17/24) included to administer risperidone (antipsychotic) 0.5 milligrams twice a day for dementia. On 10/21/24, the diagnosis for the use of risperidone was changed to administer risperidone for restlessness, yelling out and impulsiveness. Review of the medical record revealed no documented evidence the facility…

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 ensure residents were placed in contact isolation precautions as indicated. This affected one (Resident #78) of two residents reviewed for pressure ulcers. Findings included: Closed record review revealed Resident #78 was admitted to the facility on [DATE] for respite care (discharged from hospice on 05/07/24 to skilled services) with a diagnosis including malignant neoplasm of brain, anxiety, difficulty walking, cognitive communication deficit, delirium, insomnia, hemiplegia, hypertension, chronic ischemic heart disease, weakness, chronic ischemic heart disease, history of malignant neoplasm of the breast, and chronic obstructive pulmonary disease. Review of the emergency room report dated 05/23/24 revealed the resident was seen for hypokalemia (low potassium level) and decubitus skin ulcer. The female was a resident of a local skilled nursing facility who presents to the emergency room from the cancer center due to abnormal las. During the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, interview and policy review the facility failed to provide comprehensive, resident centered care related to edema and congestive heart failure. This affected one (Resident #24) of three records reviewed. Findings included: Record review revealed Resident #24 was admitted to the facility on [DATE] with a diagnosis of cerebrovascular disease, vascular dementia, Parkinson's Disease, congestive heart failure (CHF), cardiomegaly, and presence of cardiac pacemaker. Review of Resident #24's Minimum Data Set, dated [DATE] revealed no evidence the resident had behaviors including refusal of care. Review of Resident #24's current plan of care for congestive heart failure revealed no evidence to encourage the resident to elevate their lower extremities while sitting or in bed. Interventions included to monitor/document/report as needed any signs or symptoms of congestive heart failure (dependent edema of legs and feet and weight gain unrelated to intakes). 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 closed record review, policy review and interview the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of a pressure ulcer for Resident #78 within 30 days of admission. The facility failed to ensure adequate interventions and treatment were in place to promote healing and prevent deterioration of the ulcer. This affected one resident (#78) of two residents reviewed for pressure ulcers. The facility census was 74. Findings included: Review of Resident #78's hospice plan certification documentation dated 04/29/24 revealed skilled nursing to provide teaching related to altered skin integrity to include offloading, frequent position changes, keep skin clean and dry to prevent skin breakdown, and minimize friction and shearing. Medical equipment supplied gel mattress overlay. The resident was bedbound and able to bear weight. The resident received assistance with all activities of daily living (ADLS) except for 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 closed record review, interview, and policy review the facility failed to ensure antibiotic use was appropriate and criteria was met for the treatment of infections. This affected one resident (Resident #78) of two residents reviewed for pressure ulcers. Findings included: Closed record review revealed Resident #78 was admitted to the facility on [DATE] for respite care (discharged from hospice on 05/07/24 to skilled services) with a diagnosis including malignant neoplasm of brain, anxiety, difficulty walking, cognitive communication deficit, delirium, insomnia, hemiplegia, hypertension, chronic ischemic heart disease, weakness, chronic ischemic heart disease, history of malignant neoplasm of the breast, and chronic obstructive pulmonary disease. Review of the emergency room report dated 05/23/24 revealed the resident was seen for hypokalemia and decubitus skin ulcer. The female was a resident of a local skilled nursing facility who presents to the emergency room from the cancer center due to abnormal…

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 received treatment to a non-pressure related skin issue as ordered by the advanced level provider. This affected one resident (#5) of three residents reviewed for wounds. Findings include: A review of Resident #5's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included heart failure, atherosclerotic heart disease (ASHD), peripheral vascular disease, major depressive disorder, and anxiety disorder. A review of Resident #5's care plans revealed she had an active care plan in place for a friction abrasion on her right great toe and left middle toe. The care plan was initiated on 11/25/23. The interventions included keeping the skin clean and dry and to monitor/ document the location, size, and treatment of skin injury. The interventions did not include the need to provide any treatments as ordered. A review of Resident #5's Skin Grid for Non-Pressure assessments dated 11/25/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to maintain adequate staffing levels to provide bathing for residents. This affected five residents (Residents #2, #16, #52, #56 and #278) of five residents reviewed for bathing with the potential to affect all 69 residents. The facility census was 69. Findings include: On 05/07/23 at 8:30 A.M. the survey team entered the facility to conduct the annual survey. There were four licensed nurses and one State Tested Nursing Assistant (STNA) on duty to provide care for 69 residents currently residing in the facility. 1. Review of Resident #2's medical record revealed she was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side. Review of the shower schedules for the North Hall (100 hall) revealed Resident #2 was to received showers on Wednesdays and Saturdays. Review of Resident #2's scheduled bathing documentation in STNA documentation from…

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

Based on resident interview, observation, staff interview and policy review, the facility failed to ensure food was served at appropriate temperatures. This had the potential to affect all but one resident (Resident #4) identified as not receiving nutritional services from the dietary department. The facility census was 69. Findings include: Interview with Resident #124 on 05/07/23 at 11:29 A.M. revealed concerns with cold food served by the facility. Test tray and food service observation on 05/09/23 revealed the following: The main course served was turkey ala king. 11:58 A.M., food tray line began in the kitchen with North Unit first cart. 12:05 P.M., test tray prepared and placed onto the North Unit cart first cart. 12:06 P.M., North Unit first cart out of the kitchen and delivered to the North Unit. 12:08 P.M., North Unit first cart arrived to the North Unit. 12:12 P.M., two staff members begin passing meal trays. 12:32 P.M., two resident meal trays (Residents #9 and #38) and test tray left in North Unit 1st cart. 12:33 P.M., staff begin passing meals trays from North Unit…

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 garbage was properly secured inside the dumpster and not lying on the ground outside the dumpster. This had the potential to affect all residents within the facility. The facility census was 69. Findings include: Observation during the initial kitchen tour on 05/07/23 from 9:00 A.M. to 9:15 A.M. revealed two bags of trash lying on the ground next to the dumpster outside of the kitchen. Interview with the Dietary Manager (DM) #166 on 05/07/23 at 9:13 A.M. verified trash is not to be outside the dumpster and should be placed within the dumpster. Review of the facility policy Housekeeping with a review date of 04/18 indicated the dumpster are is to be kept clean at all times, free of debris, rodents and standing water.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review the facility failed to wear appropriate personal protective equipment (PPE) when the COVID-19 county transmission level was high, failed to maintain Resident #21's urine bag off the floor, failed to ensure ice scoops during ice pass on the North Hall (100 hall) were placed in a sanitary location when not in use, failed to ensure a nurse did not handle medications with her bare hands, and failed to ensure residents who were on enhanced barrier precautions had appropriate PPE for staff to wear when providing care. This affected four residents (Resident #21, #62, #66 and #224) observed for infection control procedures and had the potential to affect all 69 residents residing in the facility Findings included: 1. Observation on 05/07/23 at 8:30 A.M. upon entrance into the facility of signage at front entry revealing the COVID-19 county transmission level was high and staff were to wear masks and eye protection. Observation on 05/07/23 at 8:32 A.M. 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 interview, record review and policy review the facility failed to ensure showers were provided as scheduled and per resident preference. This affected five Residents (#2, #16, #52, #56, and #278) of five residents reviewed for activities of daily living. The facility census was 69. Findings included: 1. Review of Resident #2's medical record revealed she was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, chronic obstructive pulmonary disease, unspecified heart failure, essential hypertension and chronic gout. Review of Resident #2's annual MDS 3.0 assessment, dated 08/10/22, revealed it was very important for her to choose between a tub bath, shower, bed bath or sponge bath. Review of Resident #2's plan of care, dated 08/12/21, revealed her hygiene preference was a shower and the resident would maintain cleanliness. Interventions included offer shave and nail trim on shower days and as needed…

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 review and interview, the facility failed to ensure resident wishes for life saving procedures were clearly designated in the medical record. This affected one resident (Resident #31) of 31 residents reviewed for advance directives. The census was 69. Findings include: Review of Resident #31's medical record revealed diagnoses including cerebral infarction, multiple sclerosis, history of traumatic brain injury, chronic obstructive pulmonary disease and depression. A plan of care dated 09/17/20 indicated Resident #31 was a full code (the facility staff will provide emergent measures in an attempt to resuscitate the resident. It may involve chest compressions, electrical shocks, and emergency medications that act to temporarily keep blood moving to essential organs). An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #31 was cognitively intact. A physician order dated 04/18/23 indicated a code status of Do Not Resuscitate Comfort Care (DNRCC) (permits…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and interview, the facility failed to ensure Resident #59 was invited to participate in care plan conferences and failed to ensure the resident's activity interests had not changed since admission and the activity program provided was meeting the resident's individual needs. This affected one resident (Resident #59) of two residents reviewed for involvement in care planning. The census was 69. Findings include: Review of Resident #59's medical record revealed diagnoses including Parkinson's disease, protein-calorie malnutrition, anxiety disorder, type two diabetes mellitus with diabetic nephropathy (diabetic kidney disease), sleep apnea, hypertension, and depression. a. On 05/07/23 at 11:28 A.M., Resident #59 stated she had not been informed of any care plan/conference meetings. Documentation revealed a care conference was held 08/18/22 with Resident #59 and responsible party attending. A care conference was held 11/09/22 with the responsible party attending. There was no evidence…

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, record review and policy review the facility failed to ensure activities were provided on the weekends to meet the resident needs. This affected one resident (Resident #9) of two residents reviewed for activities. The facility census was 69. Findings include: Review of Resident #9's medical record revealed an admission date of 06/25/19 with diagnoses including unspecified dementia, weakness, attention and concentration deficit, and tremors. Review of Resident #9's plan of care, dated 07/09/19, revealed she was at risk for a decline in her activities of daily living function related to decreased mobility, weakness, and tremors. Interventions included provide physical assistance with oral hygiene and teeth brushing due to tremors. Review of Resident #9's plan of care, dated 07/19/19, revealed she had an alteration in activity participation related to behaviors, impaired decision making, and impaired mobility. She needed assistance to activities. Interventions included arrange 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, policy review and interview the facility failed to ensure antipsychotic medication use was appropriate. This affected three residents (Resident #19, #21 and #67) out of five residents reviewed for unnecessary medications. The facility census was 69. Findings include: 1. Review of Resident #19 medical record revealed Resident #19 was admitted to the facility on [DATE] with admitting diagnoses including encephalopathy and unspecified dementia with behavioral disturbance. Review of Resident #19 physician medication listing revealed Resident #19 was ordered on admission [DATE]) Aricept (cognition enhancing medication) 5 milligrams (mg) daily for dementia and Seroquel (antipsychotic medication) 25 milligrams (mg) twice daily for dementia with behaviors which include aggression, hitting, and yelling. On 01/21/23 the physician attempted a gradual dose reduction for Seroquel, decreasing the dosage to 12.5 mg twice daily for dementia with behaviors. Further review revealed no physician…

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

Based on observation, medical record review, medication information review, interview, and policy review the facility failed to ensure the medication administration error rate was not greater than five percent. Two medication errors out of 25 opportunities were observed resulting in an eight percent medication error rate. This affected two (Residents #4 and #16) of seven residents observed for medication administration. Findings include: 1. On 05/08/23 at 11:07 A.M., Licensed Practical Nurse (LPN) #107 was observed administering medication to Resident #16. One and one half tablets of Simethicone (used to relieve symptoms of gas) 80 milligrams (mg) was administered for a total of 120 mg. Review of the physician orders revealed simethicone 125 mg every six hours. LPN #107 verified she was administering 120 mg of simethicone as she prepared the medication prior to administration. Review of the facility's policy, Administration and Documentation of Medications (revised October 2022), revealed prior to and during administration, the nurse must observe the right dose was administered 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.