Cumberland Pointe Care Center

Based on review of the facility Payroll Based Journal (PBJ) submission data for the first quarter of 2024, review of the facility assessment, and staff and resident interviews, the facility failed to maintain sufficient levels of direct care staff to meet the total care needs of all residents. This affected six residents (#46, #44, #2, #39, #28 and #51) and had the potential to affect all 65 residents residing in the facility. Findings include: Review of the facility PBJ submission data (staffing data submitted to the Centers for Medicare and Medicaid) revealed the facility was identified to have low weekend staffing during the first quarter (October through December of 2023) of 2024. Review of the facility assessment (last updated 01/21/24) revealed the facility provided staffing levels based on resident acuity levels for each side of the facility. These acuity levels help determine the number of direct care and indirect care needed based on the residents' needs instead of raw number or residents. Nurse managers/Interdisciplinary Team (IDT) were responsible for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of personnel records, policy review, review of time punches, and interview, the facility failed to ensure staff were adequately tested for signs of tuberculosis prior to resident contact and failed to maintain infection control protocols during medication administration and incontinence care. This affected Residents #10 and #15 and had the potential to affect all 65 residents. Findings include: 1. On 06/20/24 at 2:00 P.M., State Tested Nursing Assistant (STNA) #567 was observed providing incontinence care to Resident #15. After turning Resident #15 over to provide incontinence care to the buttocks, STNA #567 started cleaning from the top of the buttocks toward the vaginal area. After completing the care, multiple surfaces were touched including the bed remote and blankets while wearing the same gloves worn to provide incontinence care to the resident. On 06/20/24 at 2:13 P.M., STNA #567 verified she had not implemented appropriate incontinence care procedures when she cleaned…

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

Based on review of documents from the facility's food supplier and interview, the facility failed to ensure provisions were made to have water available in the event of an emergency. This had the potential to affect all 65 residents. Findings include: During the entrance conference on 06/17/24, the Administrator was asked what provisions the facility had made to ensure the availability of water in the case of an emergency. A document from the facility's food service supplier dated 11/01/23 was provided. The agreement indicated in the event that an emergency affected the facility, the food supplier might not be able to provide the facility with the recommended amount of water needed during an emergency situation and recommended the facility ensure they had an alternate vendor set up. On 06/18/24 at 11:59 A.M., the Administrator verified the facility had not made alternate arrangements for the provision of water in the event of an emergency.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, facility worksheet review, interviews and policy review the facility failed to ensure medication was properly secured and accessible only to authorized staff and failed to ensure insulin was dated upon opening and/or discarded after expiration. This affected five residents receiving insulin (Resident #23, #26, #29, #50, #63) but had the potential to affect all residents residing in the facility. The facility census was 65. Findings included: 1. Observation on [DATE] at 8:22 A.M., with Registered Nurse (RN) #563 revealed a ring of keys were hanging on the wall at the nurse's station, which was not a locked or secured area. The RN retrieved the keys off the wall and opened the medication room door and obtained insulin out of the refrigerator for a resident. The RN then hung the keys back on the wall at the nurse's station before she returned to the medication cart. The RN confirmed the keys were kept on the wall due to the A hall nurses had to share a key and there was only one medication…

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 a facility investigation, review of personnel files, medical record review and interview, the facility failed to ensure all residents were treated with dignity and respect. This affected one (Resident #36) of five residents reviewed for dignity. The facility census was 65. Findings include: Review of Resident #36's medical record revealed diagnoses including vascular dementia, depression, and impulse disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was able to make himself understood and was able to understand others. The MDS indicated Resident #36 was moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) score of eight (out of 15 total). On 06/18/24 at 10:05 A.M., during the review of State Tested Nursing Assistant (STNA) #546's personnel file with Human Resource (HR) Director #500, disciplinary action indicated STNA #546 was found cursing in a resident room and not being professional to co-workers. The discipline form…

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

Based on observations and staff interviews the facility failed to ensure resident rooms on the secure unit were clean, safe, and a homelike environment was maintained. This affected three residents (#47, #53, and #60) of six residents observed on the secure unit during the initial survey process. The census was 65. Findings included: 1. Observation on 06/17/24 at 10:15 A.M. of Resident #60's room revealed the electric outlet cover to the left of the resident's bed was noted to be missing. Observation on 06/24/24 at 4:15 P.M., of Resident #60's room with Housekeeping/Laundry Supervisor #525 revealed the electric outlet cover had been placed over the outlet, however the outlet cover did not cover the entire area cut out of the wall. The Supervisor reported the Life Safety Surveyor had already notified the facility of the concern regarding the missing cover; however, she would let the Administrator know the cover did not fit the entire electrical outlet properly. Interview on 06/25/24 at 7:52 A.M., with the Administrator confirmed the Housekeeping/Laundry Supervisor #525 notified her…

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 missing item reports, review of dental appointment visit lists, family interview, staff interview, and policy review, the facility failed to ensure a resident and her resident representative's concerns of missing dentures were addressed by the facility. This affected one (Resident #47) of two reviewed for personal property. The facility census was 65. Findings include: Review of Resident #47's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, dementia with behavioral disturbances, anxiety disorder, intermittent explosive disorder, and major depressive disorder. Review of Resident #47's ancillary consent form revealed the resident's representative consented to have her receive dental services as a resident with Medicaid, while in the facility. The consent form was signed on 10/21/21, around the time of her original admission. Review of Resident #47's consultation reports revealed she was last seen by the dentist 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.

Based on record review, staff interview, and policy review, the facility failed to ensure a resident had a new resident review completed after a newly diagnosed mental illness was added to their diagnoses. This affected one (Resident #5) of one residents reviewed for Preadmission Screening and Resident Review (PASRR) assessments. Findings include: Review of Resident #5's medical record revealed she was admitted to the facility from another nursing facility on 04/12/24. Her diagnoses included unspecified psychosis (05/02/24), delusional disorder (05/02/24), anxiety disorder (04/11/24), and vascular dementia with behavioral disturbance (05/28/24). Review of Resident #5's Pre-admission Screening and Resident Review (PASRR) identification screen dated 05/05/23 (completed at prior nursing facility) revealed the resident was indicated to have the diagnosis of dementia under section (D.) Medical Diagnoses. The only mental illness (MI) diagnoses included under section (E.) Indications of a Serious Mental Illness was a mood disorder. Review of a Preadmission Screening and Resident Review…

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 residents bowel movements were properly monitored and those residents who went without a bowel movement for greater than three days received appropriate intervention to promote a bowel movement to occur. This affected two (Resident #5 and #20) of five residents reviewed for unnecessary medications. Findings include: 1. Review of Resident #5's medical record revealed she was admitted to the facility on [DATE] with the diagnoses of vascular dementia with behavioral disturbances, unspecified psychosis, delusional disorder, anxiety disorder, cognitive communication deficit, difficulty walking, chronic pain, and constipation (passing less than three stools a week or having a difficult time passing stool). Review of Resident #5's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was able to make herself understood and was able to understand others. Her cognition was severely impaired. She was known to have delusions,…

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, interview, and consult notes review the facility failed to ensure Resident #4 was provided orthotic devices and/or restorative exercises for decreased range of motion (ROM) to the right lower extremity. This affected one (Resident #4) of two residents reviewed for positioning. The facility census was 65. Findings included: Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including history of falling, heart failure, sequelae of cerebral infarction, hemiplegia and hemiparesis following a cerebral infarction affecting right dominate side, muscle weakness, unsteadiness on feet, history of traumatic brain injury, osteoarthritis, dysphasia, need for assistance with personal care, epilepsy, and lack of coordination. Review of Resident #4's discontinued orders revealed on 08/16/18 an order was written that the resident may use a knee brace with ambulation at his request. The order was discontinued on 11/11/19. Further review of Resident #4'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, observation, staff interview and policy review, the facility failed to ensure a resident who was at risk for falls had fall prevention interventions implemented as per her plan of care. This affected one (Resident #47) of three residents reviewed for falls. The facility census was 65. Findings include: Review of Resident #47's medical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease, dementia with behavioral disturbances, anxiety disorder, intermittent explosive disorder, and a history of falls. Review of Resident #47's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any vision or hearing problems. Her speech was clear and she was able to make herself understood and was able to understand others. Her cognition was moderately impaired. Delusions were present and the resident was known to have verbal behaviors directed at others that occurred daily. She was also known 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, interview, and policy review the facility failed to ensure residents met criteria of antibiotic treatment. This affected one (Resident #17) of two reviewed for antibiotic stewardship. The facility census was 65. Findings included: Record review revealed Resident #17 was admitted to the facility on [DATE] with diagnosis including stage three kidney disease. Review of Resident #17's five-day Minimum Data Set (MDS) 3.0 Assessment revealed the resident was occasionally incontinent of bladder and frequently incontinent of bowel. Review of Resident #17's progress note dated 06/11/24 revealed the resident was having pain under the left breast that was not relieved with Tylenol. The resident agreed to go to the hospital to be checked out for peace of mind. Review of Resident #17's hospital note dated 06/12/24 revealed the facility sent resident to emergency room for chest/flank pain times for one week. The resident was alert and oriented times four and denies pain and reported he didn't know why…

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 ensure residents received the pneumococcal vaccine per recommendation. This affected one (#59) of five residents reviewed for immunizations. The facility census was 65. Findings included: Record review revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including encephalopathy, dementia, hypertension, hyperlipidemia, hypothyroidism, and anxiety. Review of Resident #59's pneumococcal consent form dated 01/10/24 revealed the resident had already received the pneumococcal vaccine, however it was not checked which one was received or the date it was received. Review of Resident #59's immunization tab in the electronic medical record revealed the resident as not eligible for pneumococcal 13 or 20 vaccine. Interview on 06/18/24 at 11:03 A.M., and 2:28 P.M., with Infection Preventionist (IP)/Co-Director of Nursing (DON) #514 revealed she was not sure which vaccine the resident received and would need to call the family…

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, facility failed to provide showers to dependent residents scheduled per resident preference. This affected one resident (#73) of three residents reviewed for extensive activity of daily living (ADL) assistance. The facility census was 61. Findings included: Record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, stage four chronic kidney disease, tachycardia, muscle weakness, need for assistance with personal care, heart failure, pain, and gout. Review of the minimum data set (MDS) completed on 07/25/23 revealed Resident #73's cognition remained intact, he required extensive assistance of two people for bed mobility, transfers, and toileting, and required extensive assistance of one for hygiene and bathing. Review of a shower preference form signed by Resident #73 on 06/19/23 revealed Resident #73 preferred to have a shower twice a week. Review of nursing assistant…

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, facility policy and procedure review and interview the facility failed to maintain adequate levels of staffing to ensure all residents received necessary care and treatment, including timely bathing/showers and/or supervision to prevent elopement. This affected five residents (#35, #15, #38, #64 and #63) and had the potential to affect all 63 residents residing in the facility. Findings include: 1. On 07/19/22 at 10:29 A.M. interview with Resident #35 revealed concerns with the facility staffing. The resident reported staff response to call lights was sometimes slow. The resident elaborated and indicated call light response was usually within 20-25 minutes but sometimes took longer on the evening shift. Resident #35 stated one night the prior week there was only one nursing assistant for the entire building. On 07/21/22 at 8:57 A.M. interview with Human Resources (HR) manager #130 verified on night shift on 07/15/22 Temporary Nursing Assistant (TNA) #122 had to leave early at 9:45 P.M.…

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

Based on observation, record review, facility policy and procedure review and interview the facility failed to properly store and/or date opened medications. This had the potential to affect all 63 residents residing in the facility. Findings include: 1. On 07/20/22 at 7:49 A.M. observation of medication storage revealed six loose, unlabeled pills in the bottom of the second drawer of the A front medication cart. The six loose, unlabeled pills were in the compartment for Resident #58. An interview, at the time of the observation, with Registered Nurse (RN) #112 verified the six loose, unlabeled pills were not stored properly. On 07/20/22 at 10:22 A.M. interview with Director of Nursing (DON) #176 verified medications loose in the drawer of the medication cart were not an acceptable practice for properly storing medications. Review of the facility policy titled Medication Storage, dated 06/21/17 revealed medication and biologicals were to be stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. Remedi dispenses medication in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National emergency dated 03/13/20, review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, observation, record review, facility policy and procedure review and interview the facility failed to maintain proper infection control practices during resident care to prevent the spread of infection including COVID-19. This affected four residents (#36, #46, #117 and #218) and had the potential to affect all 63 residents residing in the facility. Findings include: 1. Review of Resident #218's medical record revealed an admission date of 07/08/22. The resident testing log for COVID-19 revealed the resident tested positive for COVID-19 on 07/14/22. Review of Resident #218's physician orders revealed an order, dated 07/14/22 for contact droplet (isolation)precautions every shift…

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 residents with limited range of motion (ROM) received restorative therapy to maintain function or prevent decline in ROM. This affected four residents (#4, #8, #12 and #57) of five residents reviewed for range of motion. Findings include: 1. Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, history of falling, and need for continuous supervision. Further review of Resident #8's medical record revealed no evidence the resident was receiving restorative therapy. Review of Resident #8's activity of daily living (ADL) plan of care, initiated 03/30/22 revealed the resident was at risk for developing complications associated with decreased ADL self-performance. Interventions included to encourage resident to slow down and look before propelling wheelchair. The resident self-propelled…

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

Based on observation, record review, review of shower schedules and interview the facility failed to ensure Resident #15, #38 and #64 were provided baths/showers according to their preference. This affected three residents (#15, #38 and #64) of 13 residents interviewed regarding their ability to make choices for bath/shower preferences. Findings include: 1. Review of Resident #15's medical record revealed diagnoses including end stage renal disease, morbid obesity, type 2 diabetes mellitus, depression, and heart disease. A quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/12/22 revealed Resident #15 was moderately cognitively impaired, was able to make herself understood and was able to understand others. The assessment indicated no rejection of care and dependency on staff for bathing. On 07/18/22 at 3:01 P.M. interview with Resident #15 revealed she would like to be bathed every other day but stated she received one bath every week or two. Review of a shower preference sheet revealed Resident #15 wanted two bed baths a week on day shift with a preference for morning.…

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

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure timely physician notification for Resident #54's related to significant weight changes and for Resident #14 related to a low blood glucose level. This affected two residents (#14 and #54) of two residents reviewed for physician notifications. Findings include: 1. Review of Resident #54's medical record revealed an admission date of 5/28/22 with diagnoses including congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and hypertension. Review of Resident #54's plan of care, dated 06/24/22 revealed the resident had a potential for alteration in nutrition and hydration related to being overweight, diuretic use, diabetes mellitus, chronic kidney disease, hypertension and COPD. The resident goals included no significant weight changes and to maintain skin integrity. Interventions included assess and report signs of edema to physician, notify the physician/nurse practitioner/family/interdisciplinary team for weight changes and obtain weights as…

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 provide a bed hold notification to Resident #17 as required. This affected one resident (#17) of two residents reviewed for hospitalization. Findings include: Review of Resident #17's medical record revealed diagnoses including chronic obstructive pulmonary disease, bipolar disorder, insomnia, and right sided weakness and paralysis following a stroke. A nursing note, dated 04/03/22 at 12:22 A.M. revealed Resident #17 had reported having a stomach ache early in the evening and requested Phenergan (medication to prevent vomiting) without effect. While Resident #17 was being re-assessed she felt warm and had an axillary (under the arm) temperature of 104.0 degrees. Her pulse was 122 and oxygen saturation was 91% on room air. Resident #17 requested to go to the hospital and the physician gave an order to send her to the hospital. A nursing note, dated 04/03/22 at 10:28 A.M. revealed the hospital reported Resident #17 was being admitted to the hospital for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to provide timely restorative nursing services to maintain or improve the ambulatory abilities of Resident #36 following the resident's discharge from physical therapy. This affected one resident (#36) of three residents reviewed for activities of daily living. Findings include: Review of Resident #36's medical record revealed diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, morbid obesity, generalized muscle weakness and muscle wasting and atrophy. Review of a Physical Therapy (PT) evaluation, dated 04/06/22 revealed Resident #36 was referred due to experiencing a fall in the facility with a resultant decline in functional mobility. PT was to address balance, bed mobility, transfers, gait and strength to enable Resident #36 to return to his prior level of function and reduce the risk of falls. At the time of evaluation Resident #36 ambulated five feet with a front wheeled walker with contact guard assistance. A PT…

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

Based on observation, record review, review of shower schedules and interview the facility failed to ensure Resident #15, #38 and #64, who were dependent on staff for bathing were provided baths/showers according to their preference and schedule. This affected three residents (#15, #38 and #64) of 13 residents interviewed regarding their ability to make choices for bath/shower preferences. Findings include: 1. Review of Resident #15's medical record revealed diagnoses including end stage renal disease, morbid obesity, type 2 diabetes mellitus, depression, and heart disease. A quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/12/22 revealed Resident #15 was moderately cognitively impaired, was able to make herself understood and was able to understand others. The assessment indicated no rejection of care and dependency on staff for bathing. On 07/18/22 at 3:01 P.M. interview with Resident #15 revealed she would like to be bathed every other day but stated she received one bath every week or two. Review of a shower preference sheet revealed Resident #15 wanted two bed baths 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 observation, record review and interview the facility failed to ensure weight monitoring was completed as ordered for Resident #54, who had a diagnosis of congestive heart failure and failed to ensure a comprehensive and individualized bowel regimen was implemented for Resident #17 as ordered. This affected two residents (#17 and #54) of five residents reviewed for quality of care and/or nutrition. Findings include: 1. Review of Resident #54's medical record revealed an admission date of 05/28/22 with diagnoses including congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and hypertension. Review of Resident #54's recent weights revealed the resident had experienced a significant weight gain. On 06/16/22 the resident weighed 176 pounds and on 06/20/22 his weight was 191 pounds. Record review revealed an order, dated 07/01/22 to obtain daily weights. Record review revealed the facility failed to obtain weights for Resident #54 as ordered on 07/02/22, 07/05/22, 07/06/22, 07/07/22, 07/10/22, 07/11/22, 07/12/22 and 07/15/22. On 07/20/22 at 8:36 A.M.…

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 interview the facility failed to provide adequate supervision to Resident #63 to prevent the resident from leaving the facility unsupervised and failed to ensure fall safety interventions were in place for Resident #55 as planned to prevent injury associated with fall risk. This affected two residents (#55 and #63) of seven residents reviewed for accidents. Findings include: 1. Review of Resident #63's closed medical record revealed diagnoses including dementia with behavioral disturbance, type 2 diabetes mellitus, wandering, Alzheimer's disease, impulsiveness and anxiety disorder. Review of a hospital emergency department provider note, dated 06/21/22 revealed Resident #63 had fallen a couple days prior to the hospital visit while hiking along the road trying to get to North Carolina. Resident #63 was at a different nursing home with several attempts of leaving this nursing home. The nursing home was attempting to place Resident #63 in a more secure facility when 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 observation, record review, review of the dietitian job description, nutrition best practice review, facility policy and procedure review and interview the facility failed to ensure the dietitian or qualified dietary employee timely assessed and addressed a significant weight gain for Resident #8. In addition, the facility failed to ensure weight changes were timely communicated to the resident's physician. This affected one resident (#8) of two residents reviewed for food choices. Findings include: Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, Crohn's disease, depression, gastro-esophageal reflux disease, hypokalemia, vitamin D deficiency, hypocalcemia and absence of other specified parts of the digestive tract. Review of Resident #8's potential for alteration in nutrition plan of care revealed interventions and goals included no unplanned significant weight changes and notify physician and family of weight changes. 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 record review and interview the facility failed to ensure laboratory testing was obtained for Resident #57 as ordered by the physician. This affected one resident (#57) of six residents reviewed for unnecessary medication use. Finding include: Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including osteomyelitis of vertebra, sacral, and sacrococcygeal region and stage four pressure ulcer of the sacral region. Review of Resident #57's physician's orders revealed an order, dated 07/01/22 for a Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) every Friday related to antibiotic use until 08/12/22. The resident had an order for the antibiotic, Cefepime two grams intravenously every Tuesday, Thursday, and Saturday for osteomyelitis until 08/11/22. A plan of care revealed Resident #57 was at risk for alteration in skin integrity. Interventions included laboratory testing as ordered. Review of Resident #57's laboratory testing results revealed 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.