Grande Lake Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff, resident, and resident representative interviews, and policy review; the facility failed to conducted care conferences. This affected two (#18 and #26) of two resident reviewed for care planning. The census was 36. Findings include: 1. Review of the medical record for Resident #18 revealed an initial admission date of 10/27/21, with re-entry admission on [DATE]. Diagnosis for Resident #18 included: altered mental status, muscle weakness, acute kidney failure, Parkinson's disease, dysphagia oropharyngeal phase, type two diabetes mellitus without complications, hypercalcemia, and major depressive disorder recurrent severe with psychotic symptoms. Review of the Minimum Data Set (MDS) Assessment, dated 12/15/22, revealed the resident was severely cognitively impaired. Review of the medical record, dated since 06/08/22 to date of survey, revealed no evidence of a care conferences being held. Interview on 02/06/23 at 2:39 P.M., with Resident #18's Representative verified they…

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 policy review, the facility failed to ensure a resident received the care and services for daily use of alcohol. This affected one (#17) of one resident reviewed for alcohol. The facility census was 36. Findings include: Review of medical record for Resident #17 revealed admission of 01/25/20, with diagnoses including unspecified convulsions, anxiety, insomnia, depression, migraine, atrial fibrillation, cerebral infarction with right sided hemiparesis/hemiplegia, and expressive language disorder. Review of Minimum Data Set (MDS) assessment dated [DATE], for Resident #17 revealed the mental status was unable to be assessed. Staff interviews revealed the resident independent for daily decision making. Resident #17 was assessed as independent for activities of daily living. Observation on 02/06/23 at 11:30 A.M., revealed two [NAME] Lite cans on over the bed table. One can noted to be open. Interview on 02/06/23 at 12:53 P.M., with Resident #17…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, and review of the policy, the facility failed to ensure fall interventions were in place for a resident at risk for falls. This affected one (#20) of three residents reviewed for falls. The facility census was 36. Findings include: Review of the medical record for Resident #20 revealed an admission date of 12/19/22, with medical diagnoses of unspecified dementia, acute on chronic respiratory failure with hypoxia, morbid obesity, weakness, pain in lower extremities, and cerebral infarction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 had impaired cognition and required extensive assistance of two people for bed mobility, transfers, dressing, toileting, and hygiene, and required supervision with one person assist for eating. Further review revealed Resident #20 fell two or more times without injury since the previous assessment. Review of a physician order dated 01/16/23 revealed Resident #20 needed a low bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and policy review, the facility failed to follow physician orders regarding tube feed administration. This affected one (#138) of one resident reviewed for tube feed. The facility census was 36. Findings include: Review of medical record for Resident #138 revealed admission of 02/01/23, with diagnoses of fusion of spine cervical region, spinal stenosis, unspecified cord compression, cerebral palsy, dysphagia, conversion disorder with seizures or convulsions, hypothyroidism, aphasia, pneumonitis due to inhalation of food and vomit, and anxiety. Review of Minimum Data Set (MDS) assessment dated [DATE] for Resident #138 revealed resident is rarely/never understood. Staff interview revealed resident is independent for daily decision making skills. Review of physician order dated 02/08/23 for Resident #138 revealed nepro at 45 milliliters (ml) per hour for 20 hours a day, off at 8:00 A.M. and on at 12:00 P.M. Observation on 02/08/23 at 3:04 P.M. of Resident #138…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to provide rationale for gradual dose reduction (GDR) not indicated. This affected one (#21) of five residents reviewed for GDR's. The facility census was 36. Findings include: Review of medical record for Resident #21 admitted on [DATE], with diagnoses including Alzheimer's with early onset, dementia, hypertension, adult failure to thrive, depression, and schizoaffective disorder. Review of Minimum Data Set (MDS) assessment dated [DATE], for Resident #21 revealed a Brief Interview for Mental Status (BIMS) score of five which indicated severe cognitive impairment. Resident #21 was independent for activities of daily living. Review of the form titled: CommuniCare: Psychotropic Medication Evaluation (Pharmacy and Therapeutics Committee), dated 02/09/22, for Resident #21 revealed GDR not indicated at this time, due since (pick one, note rational below). No rationale listed on GDR form. Review of the form titled: CommuniCare:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and policy review, the facility failed to administer medications per physician order. This affected one (#25) of three residents reviewed for medication administration. The facility census was 36. Findings include: Review of medical record for Resident #25 revealed admission date 09/22/21, with diagnoses including wernicke's encephalopathy, unspecified mood disorder, anxiety, bipolar disorder, and cognitive communication disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] for Resident #25 revealed a brief interview of mental status (BIMS) score of 14 which indicated cognitively intact. Observation on 02/07/23 at 7:34 A.M., during medication pass with Licensed Practical Nurse (LPN) #632 revealed the nurse administered Seroquel 50 milligrams (mg) and Seroquel 25 mg to Resident #25. Review of physician order dated 02/02/23 for Resident #25 revealed discontinue previous Seroquel order. Start Seroquel 25 mg by mouth twice daily for five days then…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interview, and policy review, the facility failed to ensure a resident was seen by a dentist timely. This affected one (Resident #23) of one resident reviewed for dental concerns. The facility census was 36. Findings include: Review of the medical record revealed Resident #23 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease with late onset, dementia in other diseases classified elsewhere severe with agitation, essential (primary) hypertension, hyperlipidemia, type two diabetes mellitus with diabetic neuropathy, acute kidney failure, acute kidney failure. Review of the Minimum Data Set (MDS) assessment, dated 12/09/22, revealed the resident was moderately cognitively impaired. Review of the care plan, dated 12/08/22, revealed the care plan was silent for dental needs. Review of the nurse's progress note, dated 09/17/22, revealed Resident #23 reported that while he was eating an apple four to five of his top teeth fell out. Resident's…

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

Based on review of a snack sign out sheet, observations, staff and resident interview and policy review, the facility failed to ensure residents received substantial bedtime snacks due to the time span of greater than 14 hours between the dinner meal and breakfast. The facility identified all 31 residents residing in the facility who received food from the kitchen. Facility census was 31. Findings include: Review of bedtime snack sign out sheets dated 10/1/19 through 1/03/20 revealed bed time snacks were documented as not passed on 11/01/19, 11/03/19, 11/04/19, 11/07/19, 11/10/19, 11/17/19, 11/20/19, 11/23/19, 11/24/19, 11/25/19 and 12/01/19. 12/10/19, 12/12/19, 12/14/19, 12/23/19, 12/25/19 and 12/26/19. Review of morning meeting notes dated 12/06/19, 12/15/19, 12/31/19 and 01/02/20 revealed Dietary Manager #420 had informed management during the morning meeting of bedtime snacks not being provided to residents. Interview with four residents (#3, #4, #24 and #27) during the resident council meeting on 01/03/20 at 10:04 A.M. revealed they did not receive bedtime snacks on a routine…

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 documentation/record review, staff interview and review of policy and procedures, the facility failed to establish and implement specific testing protocols for their water management program through the Legionella policy and procedure. This had the potential to affect all 31 residents residing in the facility. Facility census was 31. Findings include: Review facility Centers for Disease Control and Prevention (CDC) toolkit risk assessment for Legionella undated documented the facility was at increased risk for Legionella growth and spread. Further review documented the facility needed a water management program for the buildings hot and cold water distribution system. Review of CDC toolkit assessment for Legionella last revised 06/05/17 documented control measures should be applied where there are hazardous conditions for Legionella to possibly grow. Review of the facility Legionella policy and procedure revised 11/18/19 documented Water Management Plan documented the Center for Medicare and Medicaid (CMS) only requires the facility to consider the CDC toolkit and 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, staff and resident interview and policy review, the facility failed to ensure residents were free from involuntary seclusion when the facility used a coded secure entrance/exit door at the main entrance of the facility without providing the code to resident's who were cognitively intact, alert, oriented and independently mobile. This affected four (#4, #2, #10, #3) of four residents reviewed for involuntary seclusion. The facility identified 12 (#28, #9, #31, #15, #12, #25, #24, #27, #18, #26, #30 and #29) additional residents who were cognitively intact, alert, oriented and independently mobile who could potentially be affected by the secured entrance/exit door. The facility census was 31. Findings include: 1. Review of the medical record for Resident #4 revealed the resident was admitted to the facility on [DATE]. Diagnoses include coronary artery disease, depression, anxiety, mild cognitive impairment, obesity, urinary incontinence, symbolic dysfunction, weakness,…

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 ensure resident's were offer and administer the influenza and pneumococcal vaccine. This affected five (#6, #11, #84, #7 and #33) out f five residents reviewed for immunizations in the infection control task. The facility census was 31. Findings include: 1. Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include chronic obstructive pulmonary disease, atrial fibrillation, chronic kidney failure, congestive heart failure, hypertension, anemia and Stage IV pressure ulcer to the sacrum. Review of the resident's immunization record revealed no evidence the resident had been offered or received the pneumonia vaccine. 2. Review of Resident #11's medical record revealed the resident was admitted to he facility on 10/07/19 and readmitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), diabetes type II, hypertension, gastro esophageal reflux…

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 resident and staff interviews the facility failed to arrange appropriate transportation to a wound clinic for one resident (#11) of three residents reviewed for pressure and non pressure ulcers. The facility census was 31. Findings include: Resident #11 was admitted to the facility on [DATE] with a readmission of 12/15/19. Diagnoses included chronic obstructive pulmonary disease, diabetes type II, hypertension, gastro esophageal reflux disease, hypothyroidism, atrial fibrillation, major depression , urine retention, and morbid obesity. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was 14 out of 15 revealing no cognitive deficits. He required extensive assist of two staff for bed mobility and toileting. The resident did not transfer or ambulate. Review of the quarterly MDS assessment, dated 10/07/19, revealed the resident scored a 15 out of 15 on the BIMS assessment indicating no cognitive…

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 the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) included the explanation of estimated cost. This affected two (#19 and #31) out of three residents review for beneficiary protection notification. The facility census was 31. Findings include: 1. Review of medical record for Resident #19 revealed an admission date of 10/21/19 with diagnosis including acute kidney failure, tachycardia, iron deficiency, chronic kidney disease, hypertension, hypothyroidism and muscle weakness. Review of physician order dated 11/18/19 Resident #19 documented physical therapy recertification complete for five time a week for one week to address therapy active training, gait training and patient caregiver education. Review of SNFABN documented Physical Therapy services were to end on 11/23/19. Resident #19 refused to sign the notice on 11/20/19. Resident #19 wasn't informed of the estimated cost as part of the SNFABN notification requirements. 2. Review of medical record for Resident #31 revealed and admission…

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 ensure residents were provided written notification of transfer upon transfer from the facility. This affected one (#11) of five residents reviewed for hospitalizations. The facility census was 31. Findings include: Review of Resident #11's medical record revealed the resident was admitted to he facility on 10/07/19. Diagnoses included chronic obstructive pulmonary disease, diabetes type II, hypertension, gastro esophageal reflux disease, hypothyroidism, atrial fibrillation, major depression, urine retention and morbid obesity. Further review of Resident #11's medical record revealed the resident was transferred to the hospital and hospitalized on [DATE] and returned to the facility on [DATE]. Resident #11 was admitted to the hospital again on 12/08/19 and readmitted [DATE]. Review of the medical record revealed no reason for the transfers to the hospital on [DATE] and 12/08/19 given to resident and representative 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 closed medical record review and staff interview, the facility failed to ensure a Discharge-return not anticipated Minimum Data Set (MDS) assessment was completed and submitted within 14 days to Center for Medicare & Medicare Services (CMS) database. This affected one (#1) out of one resident reviewed for resident assessments based on information submitted to CMS. The facility census was 31. Findings include: Review of closed medical record documented Resident #1 was admitted to the facility on [DATE] with diagnosis including hypothyroidism, hypertension, history of falls, hyperlipidemia, constipation, atrial fibrillation and muscle weakness. Review of census record documented Resident #1 was discharge from the facility on 09/29/19 and moved to the assisted living in the same building. Review of discharge-return not anticipated MDS for Resident #1 dated 09/29/19 was not completed until 01/02/19 and was not submitted to the CMS database until 01/03/19. On 01/03/20 at 10:15 A.M. an interview with MDS…

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, resident and family interview and policy review, the facility failed to ensure residents and responsible parties were provided personalized care planning conferences on admission and on a quarterly basis. This affected two (#2 and #21) of two residents reviewed for care planning. Facility census was 31. Findings include: 1. Review of the medical record for Resident #2 revealed the resident was admitted to the facility on [DATE]. Diagnoses include non displaced trimalleolar fracture ( fracture of the ankle including the ankle bone and the lower part of the tibial bone) of left lower leg, morbid obesity, right heart failure, depression, diabetes mellitus type II, diabetic neuropathy, chronic obstructive pulmonary disease, persistent mood disorder, ischemic heart disease, urine retention, neurogenic dysfunction of bladder, bipolar, hyperlipidemia, hypertension and anxiety. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had 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, observation, and staff interview the facility failed to assess and implement interventions for a resident who was exhibiting exit seeking behaviors. Additionally, the facility failed to implement physician orders fall interventions for a resident at risk for falling. This affected two (#33 and #7) out of three residents reviewed for accidents and hazards. The facility census was 31. Findings include: 1. Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, congestive heart failure, major depressive disorder, schizophrenia and asthma. Review of the nursing admission Assessment, dated 12/09/19 revealed there was on documentation indicating if the resident was at risk elopement risk. Review of the admission minimum data set (MDS) assessment, dated 12/12/19, revealed the resident scored a four out of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident has…

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 ensure physician ordered pre and post dialysis evaluations were completed. This affected one (#16) out of one resident reviewed for dialysis. The facility identified two resident currently receiving dialysis treatment. Findings include: Review of medical record for Resident #16 revealed an admission date of 11/14/19 with diagnosis including diabetes type two, obesity, and stage renal disease, anemia, fluid volume overload, atrial fibrillation, dependency on renal dialysis, non compliance with renal dialysis, liver disease, hypertension and congestive heart failure. Review of physician order dated 11/14/19 documented Resident #16 is to receive dialysis treatment on Mondays, Wednesdays and Fridays. Review of admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #16 was cognitively intact and currently received dialysis treatment. Review of comprehensive care plan for dialysis documented an intervention…

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, and staff interview, the facility failed to administer Coumadin (anticoagulant) as ordered by the physician. This affected one (#7) out of five residents reviewed for unnecessary medication. The facility census was 31. Findings include: Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include heart failure, chronic obstructive pulmonary disease, diabetes, atrial fibrillation, poly arthritis and anxiety disorder. Review of the quarterly minimum data set (MDS) assessment, dated 10/09/19, revealed the resident scored an eight out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident received, insulin, antianxiety, diuretic and anticoagulant medication all seven days of the assessment. Review of the plan of care, dated 10/25/19 documented the resident was at risk for abnormal bleeding or hemorrhage due to anticoagulant use related to atrial fibrillation. The goal stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and policy review, the facility failed to ensure monthly medication reviews were completed for Resident #7 and failed to ensure pharmacy recommendations were followed up on for Resident #3. This affected two (#7 and #3) out of five residents reviewed for unnecessary medications. The facility census was 31. Findings include: 1. Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including heart failure, chronic obstructive pulmonary disease, diabetes, atrial fibrillation, poly arthritis and anxiety disorder. Review of the quarterly minimum data set (MDS) assessment, dated 10/09/19, revealed the resident scored an eight out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The assessment stated the resident received, insulin, antianxiety, diuretic and anticoagulant medication all seven days of the assessment. Review for the monthly pharmacy visits revealed there…

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 notify the physician of the results of a urine culture and sensitivity resulting in the use antibiotic which the organism was not sensitive to. This affected one (#6) of five residents laboratory results reviewed during review of unnecessary medications. The facility census was 31. Findings include: Resident #6 was admitted to the facility on [DATE]. Diagnoses include chronic obstructive pulmonary disease, atrial fibrillation, chronic kidney failure, congestive heart failure, hypertension, anemia and Stage IV pressure ulcer to the sacrum. Review of the quarterly minimum data set (MDS) assessment, dated 10/09/19, revealed the resident's Brief Interview for Mental Status (BIMS) score was an eight out 15 indicating severe cognitive impairment. The resident required extensive assistance of two staff for bed mobility and transfers. He is no ambulatory and no longer propels his wheelchair on or off the unit. He has a suprapubic catheter 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 medical record review, staff interviews, and policy review the facility failed to implement antibiotic stewardship policy to ensure a resident received optimal antibiotic therapy. This affected one (#6) out of five resident reviewed for unnecessary medications. The facility census as 31. Findings include: Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include chronic obstructive pulmonary disease, atrial fibrillation, chronic kidney failure, congestive heart failure, hypertension, anemia and Stage IV pressure ulcer to the sacrum. Review of the quarterly minimum data set (MDS) assessment, dated 10/09/19, revealed the resident's Brief Interview for Mental Status (BIMS) score was an eight out of 15 indicating severe cognitive impairment. The resident required extensive assistance of two staff for bed mobility and transfers. He is no ambulatory and no longer propels his wheelchair on or off the unit. He has a suprapubic catheter in place He is…

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.