Swanton Valley Rehabilitation And Healthcare Cente

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the facility policy, the facility failed to notify the resident representative of changes of condition requiring as needed intramuscular injection for behavior. This affected one resident (#100) of one resident reviewed for notifications. The facility census was 82. Findings include: Review of the medical record for Resident #100 revealed he was admitted on [DATE] and discharged on 08/07/24. Resident #100 was admitted with diagnoses of Alzheimer's, dementia with behavioral disturbance, delirium, restlessness, and agitation. Review of the physician orders for 07/24 for Resident #100 revealed he was ordered geodon (used for agitation) 10 milligram (mg) intramuscular (IM) as needed (PRN), and Zyprexa (used for agitation) 10 mg IM PRN. Review of the Medication Administration Record (MAR) for 07/24 for Resident #100 revealed he was administered Zyprexa 10 mg IM on 07/04/24 at 5:35 P.M. for agitation and Geodon 10 mg IM on 07/22/24 at 8:59 P.M. and on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff schedule review, staff interview, review of the facility assessment the facility failed to maintain the services of a registered nurse for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 84 residents currently residing in the facility. The facility census was 84. Findings include: Review of the nursing staff information and staff schedule from 01/29/24 to 02/04/24 revealed no registered nurses (RN) were present working in the facility on 02/03/24 and 02/04/24. Review of the Facility assessment dated [DATE] stated staffing and staff assignments are determined by the Nursing Administration and Administrative leadership utilizing various reports to analyze the number of patients, velocity of expected admissions and discharges, diagnosis, the total number and type of tasks and services required of nursing, nursing assistants, and other ancillary personnel. Staff assignments are driven by the burden of care, patient location, and acuity.…

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, review of cleaning list, and review of policy, the facility failed to ensure a clean and sanitary kitchen, ensure all food items were dated when opened and contained used by dates. This had the potential to affect all 84 residents who received food from the kitchen. The facility census was 84. Findings include: Observation during the tour of the kitchen on 02/05/24 between 8:27 A.M. and 9:00 A.M., of the kitchen revealed a buildup of a black substance on around the baseboards of the kitchen, a dirty microwave with a variety of dried color splatter, dried patterns of dried substances on a variety of metal shelving, including a dried white splatter on the cart containing boxes of foil and plastic wraps and an air conditioner in the window next to the grill top with brown/yellow colored debris. Refrigerator with unlabeled and undated bowls (three) of a brown substance, 2 gallons of chocolate milk without open dates, and in the dry storage room revealed an onion on the floor below a wheeled cart that contained a pan of uncovered, undated cornbread.…

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, testing log review, staff interview, review of material data sheet for disinfectant, and policy review, the facility failed to maintain appropriate infection control practices when cleaning a resident's room in isolation precautions for Clostridium Difficile (C-Diff) infection; utilize proper hand hygiene; and failed to ensure water monitoring for Legionella was completed. This had the potential to affect all 84 residents. The facility census was 84. Findings include: 1. Record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, morbid obesity, pulmonary hypertension, lymphedema, hypertension, anxiety disorder, depression, insomnia. Resident #16 tested positive for C-diff on 01/27/24. Review of the care plan for Resident #16 revealed the resident had a C-diff infection and required contact isolation precautions with a goal for Resident #16 to have no complications related to the C-diff infection.…

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, policy review, and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) assessments. This affected four (#14, #23, #62 and #241) of twenty-one residents reviewed for assessments. The facility census was 84. Findings include: 1. Review of the medical record for Resident #241 revealed an admission date of 01/18/24, diagnoses included: chronic obstructive pulmonary disease, asthma, oropharyngeal dysphagia, neurocognitive disorder with Lewy bodies, dementia, hypertension, atrial fibrillation, depression, and COVID-19 upon admission. Review of the physician order dated 01/19/24 and timed 1:54 P.M., revealed Resident #241 was ordered a regular diet, pureed with nectar thickened liquids. Review of the care plan dated 01/19/24 identified Resident #241 had an activities of daily living self-care deficit, interventions included one person assist for eating. Resident #241 was also identified as having a dental problem related to missing teeth 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.

Based on record review and staff interview, the facility failed to timely provide an Notice of Medicare Non-Coverage (NOMNC). This affected one (#188) of three residents reviewed for timely NOMNC's. The facility census was 84. Findings include: Review of the medical record for Resident #188 revealed an admission date of 03/16/23 and a readmission date of 12/12/23 and a discharge date of 01/04/24. Resident #188 discharged home with family. Review of the beneficiary notice worksheet provided by the facility during the annual survey revealed Resident #188 was discharged from skilled therapy services while using her Medicare Part A benefit on 01/03/24. Review of the notice provided to Resident #188 upon discontinuation of skilled services revealed the NOMNC notice was provided on 01/02/24. Interview on 02/08/24 at 8:01 A.M., with Director of Social Services #283 verified the NOMNC was not given to Resident #188, 48 hours before the end of coverage. DSS #283 stated the notice should have been given 48 hours before the end of coverage, but was not provided 48 hours ahead of time because…

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 resident interview, the facility failed to update resident care plans in a timely manner to reflect the resident's current needs. This affected two (#14 and #44) of 21 residents reviewed for accuracy of the care plan. This had the ability to affect all residents. The facility census was 84. Findings included: 1. Review of Resident #44's medical record revealed an admission date of 08/22/23. Diagnoses included Alzheimer's, diabetes mellitus, chronic kidney disease, sciatica, and transient ischemia accident (TIA). Review of Resident #44's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had no broken or loose-fitting teeth. Review of Resident #44's most recent care plan revealed she was at risk for a dental problem related to age. The plan was silent to being edematous and only having top dentures. Review of Resident #44's dietary notes dated 08/22/23 through 02/01/24 the dietician failed to refer to the fact that the resident was edematous.…

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 fall investigations, staff interview, and review of policy, the facility failed to facility failed to complete a thorough root cause analysis into why a resident continued to fall. In addition, the facility failed to implement effective fall interventions to prevent falls. This affected two (#62 and #65) of three residents reviewed for falls. The facility census was 84. Findings include: 1. Review of the medical record for Resident #62 revealed an admission date of 09/29/22 with diagnoses of Alzheimer's, dementia, hypertension, right femur fracture (10/09/23) and left femur fracture (11/08/23). Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #62 had impaired cognition and ambulated with a wheelchair. Resident #62 required substantial/maximal assistance when transferring from sitting to standing and from the chair to bed and to the toilet. Ambulation was not attempted due to medical condition or safety concerns. Resident #62…

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 policy the facility failed to provide appropriate care and services for oxygen therapy. This affected three residents (#23, #29 and #65) of three residents reviewed for oxygen therapy. The facility census was 84. Findings included: 1. Review of the medical record for Resident #65 revealed an admission date of 01/25/23, diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, hypothyroidism, and schizoaffective disorder. Review of the quarterly Minimum Data Set, dated [DATE] revealed Resident #65 was cognitively intact and required the use of oxygen therapy. Review of the care plan dated 01/26/23 revealed Resident #65 had an impaired respiratory status related to tobacco use and oxygen use. Interventions included administration of medications as ordered, assistance with activities of daily living as needed to reduce anxiety and respiratory fatigue, for resident to notify staff if having difficulty with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the policy, the facility failed to ensure blood pressure medications were administered per prescribed parameters. This affected one (#48) of five residents reviewed for medication administration. The facility census was 84. Findings include: Review of the medical record for Resident #48 revealed an admission date of 07/28/22 with a diagnosis of hypertension. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #48 had impaired cognition. Review of a current physician order dated 08/15/23 revealed Resident #48 was prescribed Lisinopril oral tablet, 10 milligrams (mg) one daily for hypertension. The medication should be held for a blood pressure (BP) less than 130. Review of the November 2023 Medication Administration Record (MAR) revealed Resident #48's blood pressure was documented at the time of the Lisinopril dose. Review of the MAR dated November 2023 revealed Resident #48's received Lisinopril ten times when his BP was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, review of policy, the facility failed to ensure gradual dose reductions were attempted for the use of psychotropic medications. This affected one (#54) of five residents reviewed for psychotropic medications. The facility census was 84. Findings include: Review of the medical record for Resident #54 revealed an admission date of 03/28/22, diagnoses included hemiplegia and hemiparesis following cerebral infarct affecting non dominant left side, mood affective disorder, major depressive disorder, anxiety disorder, suicidal ideation, visual hallucinations, nicotine dependence, and a history of cocaine dependence. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #54 was cognitively intact, exhibited no behavioral symptoms, had a psychiatric/mood disorders that included anxiety and depression, and was taking an antidepressant and had no gradual reduction attempted. Review of the care plan dated 03/29/22 revealed Resident #54 had impaired…

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 food was prepared and appropriate to meet resident's needs and according to their assessment, physician order, and care plan. This affected two (#45 and #241) of two residents reviewed for nutrition and hydration. The facility census was 84. Findings include: 1. Review of the medical record for Resident #241 revealed an admission date of 01/18/24, diagnoses included chronic obstructive pulmonary disease, asthma, oropharyngeal dysphagia, neurocognitive disorder with Lewy bodies, dementia, hypertension, atrial fibrillation, and depression. Resident #241 also had COVID-19 upon admission. Review of the care plan dated 01/19/24 identified Resident #241 had an activities of daily living self-care deficit, interventions included one person assist for eating. Resident #241 was also identified as having a dental problem related to missing teeth with interventions in place for staff to provide assistance 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, resident and staff interview, and review of a shower list, the facility failed to offer alternatives to meet a resident's preference for bathing. This affected one (#1) of three residents reviewed for activities of daily living. The census was 82. Findings include: Review of Resident #1's medical record revealed the resident admitted to the facility on [DATE] with the diagnoses including, right pubis fracture, asthma, dysphagia, hypertension, end stage renal disease, dependence on renal dialysis, aggressive periodontitis, secondary hyperparathyroidism of renal origin, neurofibromatosis, rhabdomyolysis, and anemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was assessed with intact cognition, was dependent on staff for the completion of activities of daily living (ADLs), was occasionally incontinent of urine, continent of bowel, had no skin breakdown, and received dialysis. Review of a nursing plan of care dated 08/21/23 addressed 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 review of the facility's Self-Reported Incident, resident interview, staff interview, and review of facility policy, the facility failed to ensure residents were permitted the right to refuse showers. This affected one (Resident #1) of three residents reviewed for bathing. The facility census was 80. Findings include: Review of the medical record for Resident #1 revealed an admission date of 07/31/22. Diagnoses included muscle wasting, osteoarthritis, dementia with other behavioral disturbances, and major depressive disorder. Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of six, indicating Resident #1 was severely cognitively impaired. Resident #1 required extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. Resident #1 required physical help in part of the bathing activity. Resident #1 displayed no behaviors at the time of the review. Review of Resident #1's care plan revised 07/21/23…

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 medical record review, staff interview, and review of facility policy, the facility failed to ensure a physical restraint was not used as a behaviorial intervention without a physician order, prior assessment, or care plan support. This affected one (Resident #3) of three residents reviewed for restraints. The facility census was 80. Findings include: Review of Resident #3's medical record revealed an admission date of 11/02/22 and a readmission date of 01/23/23. Diagnoses included dementia with behavioral disturbance, multiple myeloma, anemia, and anxiety disorder. Review of Resident #3's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of eight, indicating Resident #3 was moderately cognitively impaired. Resident #3 required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. Resident #3 displayed no behaviors at the time of the review. Review of Resident #3's care plan revised 09/02/23 revealed supports and…

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

Based on observation, record review, staff interview, and policy review, the facility failed ensure the medication error rate was less than five percent as evidenced by two medication errors out of 28 opportunities observed, resulting in a 7.14 percent (%) medication error rate. This affected one (Resident #7) of three residents observed for medication administration. The census was 80. Findings include: Medical record review for Resident #7 revealed an admission date of 09/10/22 with a diagnosis of high blood pressure. Review of Resident #7's most current physician orders for September 2023 revealed carvedilol 3.125 Milligrams (mg) used for high blood pressure and cetirizine 5 mg used for allergies. Observation on 09/05/23 at 7:52 A.M. of Licensed Practical Nurse (LPN) #162 providing medication administration to Resident #7 revealed LPN #162 pulled and administered carvedilol 6.25 mg and cetirizine 10 mg (double doses of both medications). Interview on 09/05/23 at 12:27 P.M. with LPN #162 verified Resident #7 was ordered carvedilol 3.125 mg and LPN #162 administered carvedilol 6.25…

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, staff interview, and policy review, the facility failed ensure residents were free from significant medication errors. This affected one (Resident #7) of three residents observed for medication administration. The census was 80. Findings include: Medical record review for Resident #7 revealed an admission date of 09/10/22 with a diagnosis of high blood pressure. Review of Resident #7's most current physician orders for September 2023 revealed carvedilol (heart medication) 3.125 Milligrams (mg) used for high blood pressure. Observation on 09/05/23 at 7:52 A.M. of Licensed Practical Nurse (LPN) #162 providing medication administration to Resident #7 revealed LPN #162 pulled and administered carvedilol 6.25 mg (double the amount ordered). Interview on 09/05/23 at 12:27 P.M. with LPN #162 verified Resident #7 was ordered carvedilol 3.125 mg and LPN #162 administered carvedilol 6.25 mg. Review of facility policy titled, Administering Medications, undated, revealed medications shall be administered in a safe and timely manner and as prescribed. 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 observation, staff interviews, review of facility policy, and review of Centers for Disease and Control (CDC) guidelines, the facility failed to ensure staff followed infection control guidelines and all required Personal Protective Equipment (PPE) had been utilized during the coronavirus 2019 (COVID-19) pandemic to prevent transmission of the virus. The county positive rate was listed as high. The practice had the potential to affect all residents residing in the facility. The facility census was 78. Findings include: 1. Review of Resident #222's medical record revealed an admission date of 09/28/21. Diagnoses included COVID-19, congestive heart failure, and hypertension. Review of Resident #222's COVID-19 test dated 09/24/21 revealed the resident tested positive for COVID-19. Observation on 10/04/21 at 12:06 P.M. revealed Resident #222 was in an isolation room. There was no signage observed outside of the resident's room indicating the resident was under isolation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, and review of facility policy the facility failed to ensure call lights were accessible to residents. This affected one (#53) resident reviewed for call lights. In addition, the facility failed to have the dining room available for dining service. This affected three (#26, #219, and #223) residents reviewed for dining services. The facility census was 78. Findings include: 1. Review of Resident #53's medical record revealed an admission date of 11/22/18 and a readmission date of 01/06/21. Diagnoses included chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, and spinal stenosis. Review of the quarterly Minimum Data Set, dated [DATE] revealed Resident #53 was mildly cognitively impaired. Observation on 10/04/21 at 11:16 A.M. of Resident #53 revealed the Resident was sitting in her recliner, which was positioned approximately halfway down the wall. To the left of the recliner was a table and the Resident's bed was on the other…

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 and staff interview, the facility failed to ensure signs detailing resident care needs were visible from the hall. This affected one (Resident #24) of two residents reviewed for dignity. The facility census was 78. Findings include: Review of Resident #24's medical record revealed an admission date of 04/23/20. Diagnoses included cerebral infarction, type two diabetes mellitus with hyperglycemia, and major depressive disorder. Review of the quarterly Minimum Data Set, dated [DATE] revealed Resident #24 was cognitively impaired. Further review revealed Resident #24 required extensive one person physical assistance with personal hygiene. Review of the plan of care revised 10/05/21 revealed Resident #24 required assistance or was dependent for staff with activities of daily living (ADL) care in bathing, grooming, personal hygiene, dressing, eating, and toileting. Interventions included one person physical assistance with oral/dental care. Observation on 10/04/21 10:10 A.M. of Resident #24's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to report allegations of misappropriation. This affected one (Resident #5) of two residents reviewed for personal property. The facility census was 78. Findings Include: Review of Resident #5's medical record revealed an admission date of 10/06/15 and a readmission date of 01/13/21. Diagnoses included multiple sclerosis, type two diabetes, and major depression. Review of Resident #5's Minimum Data Set, dated [DATE] revealed Resident #5 was cognitively intact. Resident #5 displayed no behaviors during the review period. Review of Resident #5's inventory list dated 05/27/21 revealed Resident #5 had four cameras noted on his inventory list. Review of the facility's Self Reported Incidents (SRIs) revealed no incident was reported for the missing camera and camera accessories. Review of Resident #5's progress notes revealed no documented report of Resident #5's missing a camera. Interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to report allegations of misappropriation. This affected one (Resident #5) of two residents reviewed for personal property. The facility census was 78. Findings Include: Review of Resident #5's medical record revealed an admission date of 10/06/15 and a readmission date of 01/13/21. Diagnoses included multiple sclerosis, type two diabetes, and major depression. Review of Resident #5's Minimum Data Set, dated [DATE] revealed Resident #5 was cognitively intact. Resident #5 displayed no behaviors during the review period. Review of Resident #5's inventory list dated 05/27/21 revealed Resident #5 had four cameras noted on his inventory list. Review of the facility's Self Reported Incidents (SRIs) revealed no incident was reported for the missing camera and camera accessories. Review of Resident #5's progress notes revealed no documented report of Resident #5's missing a camera. Interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview and review of resident council minutes, the facility failed to ensure residents received vision services in a timely manner. This affected one (Resident #32) of two residents reviewed for vision services. The facility census was 78. Findings Include: Review of Resident #32's medical record revealed an admission date of 03/13/21. Diagnoses included type two diabetes, major depressive disorder, and anxiety disorder. Review of Resident #32's Minimum Data Set (MDS) dated [DATE] revealed Resident #32 was cognitively intact. Review of Resident #32's Health Care Services Consent Form dated 03/22/21 revealed Resident #32 accepted optometry services. Review of Resident #32's progress notes and scanned documents revealed Resident #32 had no vision appointments completed or scheduled. Interview on 10/04/21 at 10:04 A.M. with Resident #32 revealed she had been in the facility since March 2021, had concerns with her vision, had signed the consent 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, resident observation, and staff interview, the facility failed to ensure pressure relieving devices were in place as ordered by the physician. This affected one (Resident #15) of one resident reviewed for pressure ulcers. The facility census was 78. Findings Include: Review of Resident #15's medical record revealed an admission date of 07/08/21. Diagnoses included chronic kidney disease, diabetes with foot ulcer, and muscle wasting and atrophy. Review of Resident #15's Minimum Data Set assessment dated [DATE] revealed the resident had intact cognition. The assessment listed the resident as at risk for pressure ulcers. Review of Resident #15's most recent care plan revealed the resident had actual pressure ulcers to the left heel, right heel, left lateral ankle, and left medial foot. Interventions included to provide a pressure redistribution therapeutic device as ordered. Review of Resident #15's physician order dated 09/28/21 revealed an order for off-loading bilateral heel boots…

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 pharmacy recommendations, review of pharmacy email correspondence, staff interview, and review of the facility policy, the facility failed to ensure pharmacy recommendations were reviewed timely by the physician. This affected two (#10 and #49) of five residents reviewed for pharmacy recommendations. The facility census was 78. Findings include: 1. Review of Resident #49's medical record revealed an admission date of 10/17/19 and a readmission date of 07/17/21. Diagnoses included chronic obstructive pulmonary disease, atherosclerotic heart disease of native coronary artery without angina pectoris, and occlusion and stenosis of unspecified carotid artery. Review of a physician order dated 08/01/21 revealed Resident #49 was prescribed clopidogrel bisulfate tablet, an antiplatelet medication, 75 milligrams (mg) one tablet by mouth in the morning. Review of the Medication Administration Record (MAR) from 08/01/21 through 10/06/21 revealed Resident #49 received clopidogrel…

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 a pharmacy recommendation form, staff interview, and review of facility policy the facility failed to provide medications as ordered by the physician. This affected two (#49 and #70) of four residents reviewed for medication administration. The facility census was 78. Findings include: 1. Review of Resident #49's medical record revealed an admission date of 10/17/19 and a readmission date of 07/17/21. Diagnoses included chronic obstructive pulmonary disease, atherosclerotic heart disease of native coronary artery without angina pectoris, and occlusion and stenosis of unspecified carotid artery. Review of the significant change Minimum Data Set, dated [DATE] revealed Resident #49 was severely cognitively impaired. Review of the plan of care revised 09/23/21 revealed Resident #49 was at high risk for abnormal bleeding due to anticoagulant (medications used to prevent blood clots) therapy. Interventions included administer medications as prescribed by the physician. 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 medical record review, staff interview, and review of facility policy, the facility failed to ensure laboratory tests were completed as ordered. This affected one (Resident #10) of five residents reviewed for unnecessary medications. The facility census was 78. Findings include: Review of the medical record for Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, depression, and vitamin D deficiency. Review of a physician recommendation form dated 05/21/21 revealed the resident received Vitamin D 50,000 units by mouth. A recommendation was made to the physician by the pharmacist for a Vitamin D level to be drawn every six months. The recommendation form to check a Vitamin D level was marked as agree by the physician and was signed by the physician on 07/16/21. Review of physician orders dated 02/14/19 revealed Resident #10 was to receive Ergocalciferol (Vitamin D), 50,000 units by mouth once weekly. The medication was reordered on 07/19/21.…

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 interview, staff interview, the facility failed to ensure residents received timely dental services. This affected one (Resident #32) of two residents reviewed for dental services. The facility census was 78. Findings Include: Review of Resident #32's medical record revealed an admission date of 03/13/21. Diagnoses included type two diabetes, major depressive disorder, and anxiety disorder. Review of Resident #32's Minimum Data Set (MDS) dated [DATE] revealed Resident #32 was cognitively intact. Review of Resident #32's care plan revised 06/15/21 revealed supports and interventions for self-care deficit, resistance to care, impaired cognitive function, depression, and potential for oral/dental health problems. Review of Resident #32's Health Care Services Consent Form dated 03/22/21 revealed Resident #32 accepted dentistry services. Review of Resident #32's progress notes and scanned documents revealed Resident #32 had no dental appointments completed or scheduled.…

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

Based on observation and staff interview, the facility failed to ensure resident bathrooms were free of peeling paint. This affected two (#24 and #29) of two residents reviewed for physical environment. The facility census was 78. Findings include: 1. Observation on 10/04/21 at 10:10 A.M. of Resident #24's bathroom revealed an approximately three inch area of peeling paint under the wall register vent, peeling paint along the top of the register vent, and an approximately 2 inch area of peeling paint to the lower left of the vent. 2. Observation on 10/04/21 at 11:10 A.M. of Resident #29's bathroom revealed an area approximately 12 inches long and three inches wide of peeling paint located on the wall between the sink and wall register vent. Interview on 10/04/21 3:47 P.M. of Licensed Practical Nurse (LPN) # 345 verified the peeling paint in Resident #24 and #29's bathrooms. Interview on 10/06/21 at 7:55 A.M. of Maintenance Supervisor (MS) #376 revealed he was aware of the peeling paint in Resident #24 and #29's bathrooms. MS #376 stated he was the only maintenance staff at 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.