Divine Rehabilitation And Nursing At Sylvania

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, and resident and staff interview, the facility failed to ensure range of motion exercises were provided as ordered by the physician. This affected one (#44) of one resident reviewed for contracture management in a facility census of 75. Findings include: Review of the medical record revealed Resident #44 was admitted to the facility on [DATE]. Diagnoses included encephalopathy, type II diabetes mellitus, congestive heart failure, right and left lower leg contracture, and adjustment disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had intact cognition, had bilateral lower extremity range of motion impairments, and dependent on staff for the completion of activities of daily living (ADL). On 04/22/24, a physician order was initiated to address Resident #44's contractures of the bilateral lower extremities. The physician ordered to provide gentle range of motion with all cares, two times a day related to contrature of muscle…

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 0Based on medical record review, observation, staff interview, review of hospital report, and review of the facility policy, the facility failed to timely report a fall and monitor a resident status post fall and failed to ensure a resident's fall interventions were in place for a resident at risk for falls. This affected two (#18 and #68) of three residents reviewed for falls. The facility census was 75. Findings include: 1. Review of the medical record revealed Resident #18 was admitted on [DATE]. Diagnoses included unspecified dementia, dysphagia oropharyngeal phase, cognitive communication deficit, type two diabetes mellitus without complications, major depressive disorder recurrent, hypothyroidism, and essential hypertension. Review of the Minimum Data Set (MDS) assessment, dated 01/03/25, revealed Resident #18 was moderately cognitively impaired. Resident #18 required partial/moderate assistance with toileting and had a history of falls. Review of the most recent care plan revealed Resident #18 was at risk…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure water was readily available for proper hydration. This affected one (#20) of two residents reviewed for hydration. The facility census was 75. Findings include: Review of the medical record for Resident #20 revealed an admission of 09/24/24. Diagnoses included aphasia, chronic obstructive pulmonary disease, chronic kidney disease, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 had severe cognitive impairment and required substantial assistance with activities of daily living (ADLs). Observation on 03/03/25 at 11:14 A.M. revealed Resident #20 was sitting in his geriatric chair at the nurse's station. Resident #20 had visible creases in his tongue were observed. There was no access to water present during this time. Observation on 03/04/25 at 11:30 A.M. revealed Resident #20 was in the memory care dining room in his geriatric chair, independently…

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, resident and staff interview, and review of facility policy, the facility failed to ensure oxygen equipment was maintained and applied as ordered by the physician. This affected one (#42) of two residents reviewed for respiratory services in a facility census of 75. Findings include: Medical record review revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD, morbid obesity, acute and chronic respiratory failure, shortness of breath, and congestive heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had intact cognition, had no behaviors or refusal of care, required substantial to maximal assistance with activities of daily living (ADL). and received oxygen therapy. On 10/02/24, physician orders included Auto C-Pap settings 8-20 cmH2O with full facemask and nasal mask with four liters (L) oxygen bled in, patient to wear at bedtime (HS) and with naps 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, staff interview, and review of a contract, the facility failed to document communication and assessments before and after dialysis, failed to monitor fluid intake and output, and monitor the resident's dialysis access port. This affected one (#75) of one resident reviewed for dialysis. The facility identified one resident as receiving dialysis services. The facility census was 75. Findings include: Review of the medical record for Resident #75 revealed an admission date of 02/13/25. Diagnoses included bilateral pleural effusion, and end stage chronic kidney disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #75 had intact cognition. Review of the care plan for dialysis, last revised 03/03/25, revealed Resident #75 attended dialysis three times per week on Mondays, Wednesdays, and Fridays. Interventions included monitoring a fluid restriction of 1,500 milliliters (ml) per day and monitor fluid intake and output, and monitor the dialysis access…

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 facility policy review, the facility failed to ensure the resident's prescribed pain medication was available to administer as physician ordered. This affected one (#60) of three residents reviewed for pain. The facility census was 75. Findings include: Review of the medical record revealed Resident #60 was admitted on [DATE]. Diagnoses included hemiplegia affecting left dominant side, acute cholecystitis, and chronic systolic congestive heart failure. Review of the Minimum Data Set (MDS) assessment, dated 01/23/25, revealed Resident #60 was cognitively intact and received scheduled and as needed pain medication. Review of the physician order, dated 11/26/24, revealed an order for tramadol oral tablet 50 milligram (mg) with instructions to give 50 mg by mouth every six hours for pain. Review of the Medication Administration Record (MAR), dated March 2025, revealed Resident #60 did not receive the physician order for tramadol four times 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 review of the medical record, review of pharmacy recommendations, staff interview, and policy review, the facility failed to ensure a physician responded timely to pharmacy recommendations. This affected three (#10, #15, #34) of five residents reviewed for unnecessary medications. The facility census was 75. Findings include 1. Review of the medical record revealed Resident #15 had an admission date of 11/05/14. Diagnoses included chronic obstructive pulmonary disease, schizophrenia, bipolar disorder, depressive disorder, anxiety and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had intact cognition. Review of pharmacy recommendations dated 04/23/24, 09/09/24, 11/25/24, and 01/23/25 revealed Resident #15 received Alendronate for the treatment of bone health but was not receiving a calcium supplement. The pharmacist made the same recommendation on 04/23/24, 09/09/24, 11/25/24, and 01/23/25 to initiate calcium carbonate 600 milligrams (mg)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure medications were administered per physician's orders resulting in a medication error rate exceeding five percent. 25 opportunities were observed with five medication errors, resulting in a medication error rate of 20 percent. This affected two (#37 and #64) of three residents reviewed for medications. The facility census was 75. Findings include: 1. Review of the medical record for Resident #37 revealed an admission date of 01/13/25. Diagnoses included chronic obstructive pulmonary disease, peripheral vascular disease, and metabolic encephalopathy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had intact cognition. Review of the physicians order for 03/2025 revealed Resident #37 had orders including for vitamin B1 (vitamin) 1,000 units, docusate sodium (stool softener) 100 milligrams (mg.), and magnesium oxide (antacid) 400 mg. Observation on 03/05/25 at…

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

Based on observation, staff interview and policy review, the facility failed to ensure medications were dated when opened and the safe disposal of medications. This affected two of three medication carts inspected and had the potential to affect two residents (#19 and #48) the facility identified as cognitively impaired and independently mobile. The facility census was 75. Findings include: 1. Observation during medication administration on 03/05/25 at 7:50 A.M. revealed Licensed Practical Nurse (LPN) #312 placed a tablet of Lasix (diuretic) 40 milligrams (mg) in the medication cup and then stated that it was the wrong dose. LPN #312 then took the Lasix 40 mg tablet and threw it away in the trash can connected to the side of the medication cart. After the medications were prepared, LPN #312 spilled three medications on the cart. LPN #312 identified one of the medications as Senna (stool softener) and disposed of it in the trash connected to the medication cart. LPN #312 then went into Resident #37's room and administered his morning medication, leaving the other two medications on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, and staff interview, the facility failed to ensure a resident received his food preference of double portions. This affected one (#30) of three residents reviewed for meals. The facility census was 75. Findings include: Review of the medical record revealed Resident #30 was admitted on [DATE]. Diagnoses included hyperlipidemia, anxiety disorder, hypoglycemia, bipolar disorder, hypotension, and paranoid schizophrenia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 was cognitively intact and required set-up/clean-up assistance with eating. Review of the physician order dated 02/11/25 revealed Resident #30 received a regular diet, regular texture, regular/thin consistency, and double portions per the resident request. Interview on 03/03/25 at 10:13 A.M. with Resident #30 stated there was not enough food and he was often hungry. Resident #30 reported at times they give him extra food. Review of the dinner meal ticket…

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 Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff wore personal protective equipment (PPE) when providing care to residents in Enhanced Barrier Precautions (EBP). This affected one resident (#11). The facility identified 16 residents on EBP. The facility census was 75. Findings include: Review of the medical record for Resident #11 revealed an admission date of 12/30/20 with diagnoses of cerebral palsy and gastrostomy (an artificial opening into the stomach) status. Review of the significant change comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had intact cognition and required more than 51% of her nutrition and more than 501 milliliters (ml) of fluid daily through her gastrostomy tube. Review of the current physician order dated 03/03/25 revealed Resident #11 was on EBP for infection control. Review of the current care plan revealed Resident #11 was on EBP due to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of the manufacturer guidelines, the facility failed to ensure a mattress was compatible with a bed. This affected one (#70) of seven resident reviewed for accident hazards. The facility census was 75. Findings include: Review of the medical record for Resident #70 revealed an admission date of 11/13/24. Diagnoses include anoxic brain damage, tracheostomy status, and generalized idiopathic epilepsy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 had moderate cognitive impairment and was dependent on staff for all activities of daily living (ADLs). There was no documentation of Resident #70's assessment for a modified bed in the medical record. Observation on 03/03/25 at 10:23 A.M. revealed Resident #70's mattress did not fit the bed. A large gap between the end of the bed footboard and the mattress was noted. Interview on 03/04/25 at 2:58 P.M. with Maintenance Supervisor (MS) #375 stated he 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 medical record review, resident and staff interview, and policy review, the facility failed to timely notify a resident before a roommate change. This affected one (#85) of three residents reviewed for room changes. The facility census was 80. Findings included: Review of Resident #85's medical record revealed an admission date of 03/28/18. Diagnoses included multiple sclerosis, kidney cancer, and chronic kidney disease. Review of Resident #85's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident's was rarely understood. Review of Resident #22's medical record revealed an admission date of 11/11/20. Diagnoses included intellectual disabilities, schizophrenia, dementia, and bipolar disease. Review of Resident #22's quarterly MDS dated [DATE] she had moderately impaired cognition. Review of the document titled, Notice of Room Change, dated 09/21/24, revealed Resident #22 was informed that she would be moving into a room where Resident #85 resided. The form was silent to Resident #85 being…

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 review of policy, the facility failed to provide appropriate care, assessments, and ongoing monitoring of a pressure ulcer. This affected one (#9) of three residents reviewed for wounds. The facility census was 85. Findings include: Review of the medical record for Resident #9 revealed an admission date of 05/01/19, diagnoses included an unspecified injury of thoracic spinal cord, paralytic syndrome, protein calorie malnutrition, paraplegia, mood disorder, major depressive disorder, heart failure, and peripheral vascular disease. Resident #9 had an indwelling catheter and a colostomy and an unhealed stage IV pressure ulcer to the coccyx. Review of the annual Minimum Data Set (MDS) Assessment Resident #9 was cognitively intact, had functional impairments to bilateral upper and lower extremities, was dependent for transfers, toilet use, personal hygiene, and dressing. Review of the care plan for Resident #9 revealed a deficit in activities of daily living…

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, admission packet review, review of facility documents and review of facility policy, the facility failed to ensure a written discharge notice was provided to residents and their representatives for a facility-initiated discharge. This affected one (#1) of three residents reviewed for discharge. The facility census was 80. Findings Include: Review of Resident #1's medical record revealed an admission date of 07/18/23 and a discharge date of 02/24/24. Diagnoses included pleural effusion (fluid around his lungs), Alzheimer's disease, dementia, cough, edema, shortness of breath and altered mental status. Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of four indicating Resident #1 was severely cognitively impaired. Resident #1 required partial assistance from staff with toilet use, bathing, and dressing. Resident #1 displayed no behaviors at the time of the review. Review of Resident #1's care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to provide privacy during personal care and failed to ensure residents in a semi-private room had a means to maintain privacy. This affected three residents (#33, #69, and #83) of three residents observed for privacy. The facility census was 79. Findings included: 1. Review of Resident #69's medical record revealed an admission date of 06/15/22. Diagnoses included Alzheimer's disease, anxiety, and basal cell carcinoma. Review of Resident #69's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with impaired cognition, was dependent on staff for all activities of daily living (ADLs), and was always incontinent of bowel and bladder. Observation on 02/21/24 at 9:52 A.M. revealed State Tested Nurse Aide (STNA) #156 was performing incontinence care for Resident #69 with the door to the room closed. Resident #69 was lying on her bed which was located near the window. Further observation revealed Resident #72, 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 self-reported incident review, medical record review, staff interview, and review of a facility policy, the facility failed to submit the results of an investigation to the State Survey Agency in a timely manner. This affected one (#27) of one residents reviewed for neglect. The facility census is 79. Findings include: Review of the medical record revealed Resident #27 was admitted on [DATE]. Diagnoses included other hypertrophic osteoarthropathy, chronic obstructive pulmonary disease, type two diabetes mellitus with other diabetic arthropathy, and major depressive disorder recurrent. Review of the Minimum Data Set (MDS) assessment, dated 01/27/24, revealed the resident was significantly cognitively impaired. Review of a self-reported incident (SRI) created on 01/03/24 under the category of neglect, mistreatment, or abuse for Resident #27. Further review of the SRI revealed Resident #27 reported a staff member provided a shower that day, but Resident #27 did not want a shower. Review of the facility SRI…

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 staff interview, review of staffing schedules and payroll information, the facility failed to ensure staffing included Registered Nurse in-house coverage was provided daily for eight consecutive hours during a 24-hour period. This affected all 85 residents residing in the facility. The facility census in 85. Findings include: Review of facilit's master schedule obtained from payroll data between 08/13/23 and 11/13/23, noted the facility staffing assignments lacking Registered Nurse (RN) coverage of eight hours during a 24-hour period. These dates included the following: 08/24/23, 09/02/23, 09/03/23, 10/14/23, 10/28/23, 11/12/23. Interview on 11/16/23 at 11:47 A.M., with Human Resources Director #207 confirmed responsibility for developing and implementing facility nursing staff schedules. Review of nursing schedules and associated payroll information between 08/13/23 and 11/13/23, Human Resources Director #207 verified the absence of an RN scheduled for eight hours during a 24-hour period on 08/24/23, 09/02/23, 09/03/23, 10/14/23, 10/28/23, 11/12/23.

Based on observations, staff interviews, and review of the facility policies, the facility failed to ensure the kitchen and food storage areas were maintained in a clean and sanitary manner. In addition, the facility failed to ensure staff sanitized their hands prior to and during meal service and did not sanitize the hands of the 17 residents in the memory care (#2, #5, #10, #13, #18, #22, #25, #27, #28, #43, #44, #45, #46, #60, #65, #82, and #84; Resident #62 did not eat lunch.) prior to their lunch meal. This had the potential to affect all residents except one resident (#11) who the facility identified as not accepting food by mouth. The facility census was 85. Findings include: 1. Observations on 11/13/23 at 8:50 A.M. of the kitchen and storage areas revealed the kitchen floor was dirty with a layer of debris, dirt, and dust especially along the wall and under the storage open cabinet. Observation of the walk in refrigerator revealed the shelving appeared to have a white mold like substance and the floor was dirty. Further observation of the walk in refrigerator revealed an…

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 reviews, review of the Certification And Survey Provider Enhanced Reports (CASPER) Report, staff interviews, review of staff schedules, and review of the administrator's job description, the facility failed to implement resources to ensure identified concerns were sufficiently corrected and resident needs were adequately met. This affected five residents (#9, #39, #63, #64, and #288) and had the potential to affect all 85 residents residing in the facility. Findings include: 1. Review of the Certification And Survey Provider Enhanced Reports (CASPER) Report, dated 11/03/23, revealed the facility had been cited at Data Tag F-689 (Free of accident hazards/Supervision/Devices) during the annual surveys in February 2018, March 2019, and July 2021. Additional concerns at Data Tag F-689 were identified during this recertification survey on 11/16/23. Review of the CASPER Report, dated 11/03/23, revealed the facility had been cited at Data Tag F-561 (Self-Determination) on March 2019 and July 2021. Additional concerns at Data Tag F-561 were identified during this…

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, record review, resident interviews, staff interviews, and policy review, the facility failed to ensure residents had daily access to their resident fund accounts. This had the potential to affect 54 (#1, #2, #3, #4, #6, #8, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #28, #29, #30, #31, #36, #37, #38, #40, #43, #44, #45, #46, #48, #50, #51, #53, #55, #56, #60, #61, #62, #65, #66, #69, #71, #72, #73, #74, #77, #78, #81, #82, and #388) of 54 residents with an open resident fund accounts. The facility census was 85. Findings include: Observation on 11/13/23 at 8:10 A.M., revealed the facility had a pink sign on the front desk stating, Banking hours 8:30 to 4:30. Review of the facility provided list revealed 54 (#1, #2, #3, #4, #6, #8, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #28, #29, #30, #31, #36, #37, #38, #40, #43, #44, #45, #46, #48, #50, #51, #53, #55, #56, #60, #61, #62, #65, #66, #69, #71, #72, #73, #74, #77, #78, #81, #82, and #388) residents had personal funds accounts. Interviews 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 and resident representative interview, staff interview, and facility policy, the facility failed to ensure care plan conferences were offered timely. This affected four (#13, #22, #24, and #47) of four residents reviewed for care plan conferences. The facility census was 85. Findings include: Review of the medical record revealed Resident #13 was admitted on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, cytomegaloviral disease, unspecified dementia without behavioral disturbance, atherosclerotic heart disease of native coronary artery without angina pectoris, hypothyroidism, aphasia, major depressive disorder, essential hypertension, and hyperlipidemia. Review of the Minimum Data Set (MDS) assessment, dated 08/31/23, revealed the resident was cognitively intact. Review of care conference progress notes, dated since admission, revealed Resident #13 had care conferences on 06/24/22, 09/29/22, 04/14/23,…

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 resident interviews, staff interviews, review of the facility policy, and record review, the facility failed to ensure the facility's arbitration agreement was thoroughly explained for complete understanding of the agreement upon the residents' admission to the facility. The facility also failed to ensure the staff responsible for the arbitration agreement was able to thoroughly explain the agreement for complete understanding. This affected five (#8, #11, #52, #69, and #78) of five residents reviewed for binding arbitration. This had the potential to affect the 59 residents who resided in the facility that entered into the binding arbitration agreement. (Residents #1, #4, #5, #6, #7, #8, #9, #11, #12, #13, #15, #16, #17, #18, #19, #20, #21, #24, #25, #28, #29, #30, #31, #35, #36, #37, #39, #40, #41, #42, #44, #45, #46, #48, #49, #50, #51, #52, #54, #55, #56, #57, #58, #62, #63, #64, #65, #66, #68, #70, #71, #73, #75, #80, #81, #82, #83, #289, and #388) identified to have signed arbitration agreements.…

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, resident and staff interviews, and policy review, the facility failed to maintain a clean and sanitary environment. This affected seven (Residents #13, #21, #47, #48, #63, #79, and #80) of 30 residents reviewed for clean and sanitary environment. The facility census was 85. Findings include: 1. Observation on 11/13/23 at 9:00 A.M. revealed peeling wall paper in the hallway leading to the employee break room, peeling and torn wall paper to the left of the water fountain just outside the main dining room, base board torn and pulled away from the wall to the right of the drinking fountain and a broken chair labeled do not use broken sitting in front of the water fountain. The drinking fountain was covered with dust and a crumbled tissue in the bowl of the fountain. Additional observation on 11/14/23 at 8:00 A.M. revealed no changes to the items identified on 11/13/23. Observations on 11/13/23 at 10:40 A.M. and on 11/14/23 at 11:00 A.M. of Resident #80's room revealed broken blinds with missing and cracked slates on the right side and in the middle of the blinds…

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 interview, staff interview, record review and review of policy, the facility failed to ensure residents were treated in a dignified manner. This affected two residents (#14 and #79) of four residents reviewed for dignity. The facility identified 18 resident smokers. The facility census was 85. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 05/13/20, with diagnoses including cerebral infarction, anemia, hypertension, congestive heart failure, and chronic respiratory failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had cognitive impairment and required substantial assistance for bed mobility. Observation on 11/13/23 at 11:29 A.M. revealed no linens on the bed of Resident #14, a bath blanket was underneath the middle section of Resident #14's body. Interview on 11/13/23, at the time of observation, with Resident #14 revealed the bed linens had been removed from the bed during the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview and policy review, the facility failed to ensure call lights were within reach and accessible. This affected two (#9 and #39) of 25 residents reviewed for call light placement. The facility census was 85. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 01/01/23, with diagnoses including chronic obstructive pulmonary disease, hypertension, type II diabetes mellitus, peripheral autonomic neuropathy, depression, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively intact, was dependent for mobility with limited range of motion to the right upper extremity due to a contracture for which a right resting hand splint with separators was worn at night for contracture management. Observation on 11/13/23 at 11:15 A.M., revealed Resident #9 lying in bed watching television with the over bed table to the right of the resident, the call light was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident interview and staff interview, the facility failed to ensure residents were provided with opportunities and assistive devices for out of bed activity. This affected one (#73) of 24 residents reviewed for the provision of choices. The facility census was 85. Findings include: Review of Resident #73's medical record revealed an admission date of 02/27/23, with the diagnosis including left hemiplegia, alcoholic cirrhosis, cerebral infarction, pyogenic arthritis, malnutrition, pain in right shoulder and left hip, anemia, atrial fibrillation, congestive heart failure, and urinary retention. Review of the minimum data set assessment dated [DATE] assessed Resident #73 with the ability to make needs known, intact cognition, no recorded refusal of care, range of motion impairment limitation to lower extremity, dependent on staff for activities of daily living including bed mobility and transfer, incontinent of bowel and bladder, received a mechanically altered diet,…

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, resident interview, staff interview and policy review, the facility failed to ensure they received approval in writing to access personal funds and keep the Medicaid regulated $50 each month for a Medicaid resident. This affected one (#22) of five residents reviewed for resident funds. The facility census was 85. Findings include: Review of the medical record for the Resident #22 revealed an admission date of 05/04/22, with diagnoses including femur fracture, vascular leuko encephalopathy, Alzheimer's disease, diabetes, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively impaired with a Brief Interview for Mental Status (BIMS) of 2 and required extensive assistance of one to two staff for mobility. The score is as follows: 13-15 = cognitively intact, 8-12 = moderately impaired, and 0-7 = severe impairment. Review of the BIMS assessments dated 05/08/22 to 11/07/23 revealed the resident's BIMS score ranged from one to three, with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure resident's advanced directives were clearly described and contained in medical records. This affected three (#33, #68, #81) of 24 residents reviewed for advanced directives and code status choices. The facility census was 85. Findings include: 1. Review of Resident #33's medical record revealed an admission date on 06/05/23, with diagnoses including cerebral infarction, congestive heart failure, and hypertension. Review of the minimum data set assessment dated [DATE] assessed Resident #33 with severe cognitive impairment, sometimes understands or is understood, moderately impaired vision without corrective lenses, hearing deficit, and required partial to moderate staff assistance to complete hygiene task and activities of daily living. Review of the medical record revealed on 06/06/23, a physician order was implemented for Advanced Directive: Do Not Resuscitate Comfort Care (DNRCC) DNRCC. No directions specified 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, Power of Attorney (POA) interview, staff interview, and policy review, the facility failed to ensure the physician and family were contacted after a change in condition with acute pain was identified. This affected one (#47) of two residents reviewed for a change in condition. The facility census was 85. Findings include: Review of the medical record for Resident #47 revealed an admission date of 05/19/20, with diagnoses including chronic obstructive pulmonary disease, heart failure, muscle weakness, depression insomnia, Review of the emergency contact list revealed Resident #47 had a friend listed at the emergency contact with notation of being the healthcare and financial power of attorney as well as a daughter and brother listed as additional contacts. Review of the physician orders dated 10/07/20 revealed an order for Tylenol tablet (acetaminophen) with instructions to given one tablet, 650 milligrams (mg) by mouth every 6 hours as needed for pain. Review of the 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 medical record review, staff interview and policy review, the facility failed to ensure beneficiary notices were completed. This affected two (#22 and #82) of four residents reviewed for beneficiary notices. The facility census was 85. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 05/04/22, with diagnoses including femur fracture, vascular leukoencephalopathy, Alzheimer's disease, diabetes, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively impaired and required extensive assistance of one to two staff for mobility. Review of the record revealed no evidence of a skilled nursing facility advanced beneficiary notification (SNF ABN) on file when skilled services ended on 09/07/23. 2. Review of the medical record for Resident #82 revealed an admission date of 07/18/23, with diagnoses including pleural effusion, Alzheimer's disease, dementia, weakness, and altered mental status. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based of medical record review, observation, staff interview, and policy review, the facility failed to ensure a resident's personal privacy was honored. This affected one (#80) of two residents reviewed for personal privacy. The facility census was 85. Findings include: Review of the medical record revealed Resident #80 was admitted on [DATE], with diagnoses including inclusion body myositis, essential primary hypertension, mixed hyperlipidemia, chronic tension, weakness, and repeated falls. Review of the Minimum Data Set (MDS) assessment, dated 10/26/23, revealed the resident was cognitively intact. Resident #80 had functional limitation in range of motion on both sides and utilized a wheelchair. Review of the care plan, dated 06/15/23, revealed Resident #80 required activities of daily living self-care performance due to body myositis and required assistance by one staff with bathing/showering as necessary and was dependent with transfers via Hoyer lift for two staff members. Observation on 11/14/23 at 10:00…

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, resident interview and staff interviews, the facility failed to ensure a resident's bed linens were changed when the linens became soiled and torn. This affected one (#47) of three residents reviewed for linens. The facility census was 85. Findings include Review of the medical record for the Resident #47 revealed an admission date of 05/19/20, with diagnoses including chronic obstructive pulmonary disease, heart failure, muscle weakness, depression and insomnia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had significant cognitive impairment and required limited one person assist for transfers and extensive assist of one staff for toileting and extensive assistance of two staff physical assist for personal hygiene. Observation on 11/13/23 at 10:11 A.M., of Resident #47 revealed the resident was sleeping in his bed and the bed sheets had numerous food stains from juice and likely coffee and what appeared to be urine stains. The linens also were…

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, review of self-reported incidents (SRI), staff interview, and policy review, the facility failed to thoroughly investigate an allegation of injury of unknown origin and abuse. This affected one (#61) of three residents reviewed for abuse. The facility census was 85. Findings include: Review of the closed medical record for Resident #61 revealed an admission date of 09/15/23 and discharged on 11/08/23. Diagnoses for Resident #61 included fracture of unspecified part of the neck of left femur subsequent encounter for closed fracture with routine healing, vascular dementia severe, hematemesis, epilepsy, anxiety disorder, and insomnia. Review of the Minimum Data Set (MDS) assessment, dated 09/24/23, revealed the resident was severely cognitively impaired and required extensive one person assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene. Review of the Self-Reported Incident (SRI), dated 11/03/23, revealed Resident #61 was discovered to have an injury to the pelvic area with the aide and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure the resident, or their representative, received written transfer information. This affected one (#86) of one resident reviewed for hospitalization. The facility census was 85. Findings include: Review of the closed medical record revealed Resident #86 was admitted on [DATE] with re-entry on 10/11/23 and discharged on 10/13/23. Diagnoses for Resident #86 included Huntington's disease, depression, post-traumatic stress disorder, restless leg syndrome, and neuromuscular dysfunction of bladder. Review of the nursing progress note dated 10/13/23 revealed Resident #86 had pulled the catheter out fully while the balloon to catheter was still inflated. Resident #86 was bleeding from the groin area. Emergency services were contacted, and notification was provided to the physician and emergency contact. A further record review revealed transfer information was not provided to the resident or the resident representative.…

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 bed hold information was provided to resident upon hospitalization. This affected one (#86) of one resident reviewed for hospitalization. The facility census was 85. Findings include: Review of the closed medical record revealed Resident #86 was admitted on [DATE] with re-entry on 10/11/23 and discharged on 10/13/23. Diagnoses for Resident #86 included Huntington's disease, depression, post-traumatic stress disorder, restless leg syndrome, and neuromuscular dysfunction of bladder. Review of the nursing progress note dated 10/13/23, revealed Resident #86 had pulled the catheter out fully while the balloon to catheter was still inflated. Resident #86 was bleeding from the groin area. Emergency services were contacted, and notification was provided to the physician and emergency contact. A further record review revealed transfer information was not provided to the resident or the resident representative. 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 observation, medical record review, and staff interview, the facility failed to ensure an accurate Minimum Data Set Assessment (MDS) was completed. This affected one (#81) of 25 residents reviewed for accurate MDS assessments. The facility census was 85. Findings include: Review of the medical record for Resident #81 revealed an admission date of 09/01/23, with diagnoses including hypertension, dementia, glaucoma, cataract, and insomnia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #81 was cognitively impaired, had adequate hearing, speech was clear, and the resident was understood and understands others, vision was moderately impaired. Review of the active diagnoses revealed no vision diagnoses. Review of the visual function care assessment areas (CAA) which triggered in the MDS secondary to the inability to complete visual assessment secondary to cognitive loss, noted visual deficits related to glaucoma, cataracts and macular degeneration with blindness…

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 an accurate and updated Pre-admission Screening and Resident Review (PASARR) was completed. This affected one (#21) of two residents reviewed for PASARR. The facility census was 85. Findings include: Review of the medical record for the Resident #21 revealed an admission date of 08/29/17, with diagnoses including bilateral osteoarthritis of knee, muscle weakness, depression, anxiety, and unspecified psychosis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had mild cognitive impairment with a BIMS of 12. Residents mobility was not assessed in the MDS, but resident required supervision with mobility. Review of physician order dated 07/28/23 revealed an order for fluvoxamine maleate tablet for depression. A physician order dated 09/08/23 revealed an order for trazadone oral tablet for depression. The physician order dated 10/20/23 revealed an order for Cymbalta oral capsule for depression. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, record review and policy review, the facility failed to ensure an oxygen care plan was developed for Resident #52 and a vision care plan was developed for Resident #81. This affected two (#52 and #81) of 25 resident care plans reviewed. The facility census was 85. Findings include 1. Review of the medical record for Resident #52 revealed an admission date of 08/02/23. Diagnoses included complete traumatic amputation at knee level, vascular disease, diabetes and chronic viral hepatitis c. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 was cognitively impaired and required extensive assistance of one to two staff members for mobility and activities of daily living. Review of the plan of care dated 10/26/23 revealed Resident #52 did not have any care plan category or interventions for oxygen use. Review of physician orders for 11/13/23 for Oxygen via nasal cannula at two liters per minute continuous. Facility had no prior…

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, manufacturer's instruction review, and facility policy, the facility failed to ensure nursing staff worked within their scope of practice. This affected two (#288 and #78) of five resident reviewed for medication administration. The facility census was 85. Findings include: Review of the medical record revealed Resident #288 was admitted on [DATE]. Diagnoses included acidosis, arteriovenous fistula, unspecified cirrhosis of liver, anemia, chronic kidney disease, hyperlipidemia, type two diabetes mellitus, and essential primary hypertension. Review of the Minimum Data Set (MDS) assessment, dated 11/4/23, revealed the entry assessment had been completed. Review of physician orders, dated 11/05/23, revealed an order for Resident #288 to receive Humalog Kwickpen subcutaneous solution pen-injector 100 unit/milliliter (ml) with instructions to inject as per sliding scale: if 151-200 provide 2 units, if 201-250 provide 4 units, if 251-300 provide 6 units, if 301-350…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the medical record for Resident #52 revealed an admission date of 08/02/23. Diagnoses included complete traumatic amputation at knee level, vascular disease, diabetes, and chronic viral hepatitis c. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 was cognitively impaired and required extensive assistance of one to two staff members for mobility and activities of daily living. Review of the plan of care dated 10/26/23 revealed Resident #52 had an ADL self-care deficit related to amputation with interventions for one to two staff to assist with bathing and provide a bed bath if not able to shower. Review of the shower sheets revealed dated 09/01/23 to 11/13/23 revealed resident last had his hair washed on 10/12/23. Resident #52 was noted to not need nails trimmed on 11/13/23 according to the shower sheets. Shower sheets made no mention of residents' nails being cleaned or trimmed during this period of time. Interview and observation on 11/13/23 at 10:28 A.M., with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interview, physician interview, and policy reviews, the facility failed to ensure clear physician instructions for blood sugars above or below parameters, physician and nursing staff had no barriers to communication, and a resident with a change in condition was treated and monitored appropriately. This affected one (#288) of one residents reviewed for insulin. In addition, the facility failed to properly assess and monitor change in condition for Resident #47 related to acute pain. The facility census was 85. Findings include: 1. Review of the medical record revealed Resident #288 was admitted on [DATE]. Diagnoses included acidosis, arteriovenous fistula, unspecified cirrhosis of liver, anemia, chronic kidney disease, hyperlipidemia, type two diabetes mellitus, and essential primary hypertension. Review of the Minimum Data Set (MDS) assessment, dated 11/04/23, revealed the entry assessment had been completed. Review of physician orders, dated 11/05/23, revealed…

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 medical record, observation, staff interview and facility policy the facility failed to ensure fall interventions were in place. This affected one (#22) of three residents reviewed for falls. The facility census was 85. Findings include: Review of the medical record revealed Resident #22 was admitted on [DATE]. Diagnoses included unspecified fracture of lower end of left femur subsequent encounter for closed fracture with routine healing, progressive vascular leukoencephalopathy, Alzheimer's disease, type two diabetes mellitus with unspecified complications, mixed hyperlipidemia, hypomagnesemia, dementia in other disease classified elsewhere, pruritus, vitiligo, dermatitis, essential (primary) hypertension, and diverticulitis of intestine. Review of the Minimum Data Set (MDS) assessment, dated 08/07/23, revealed the resident was severely cognitively impaired and required extensive one person assistance for transfers and locomotion on and off the unit, required extensive two person…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure an indwelling urinary catheter was appropriately secured and maintained to prevent infections. This affected one (#77) of one resident reviewed for indwelling catheter maintenance and care. Facility census 85. Findings include: Review of the medical record revealed Resident #77 had an admission date of 04/26/23. Diagnoses included type two diabetes mellitus, chronic kidney disease stage three, obstructive and reflux uropathy, atrial fibrillation and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident required supervision for toileting hygiene. The resident was noted with an indwelling urinary catheter. Review of the physician orders dated 11/13/23 revealed the resident had an order for an indwelling urinary catheter. Observation on 11/13/23 at 9:34 A.M., revealed Resident #77's catheter drainage bag was resting…

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 policy, the facility failed to ensure physician ordered weights were obtained and accurate, and failed to ensure significant changes in weight were evaluated and addressed. This affected one (#63) of two residents reviewed for nutritional status. The facility census was 85. Findings include: Review of Resident #63's medical record revealed an admission date of 06/16/23. Diagnoses included type II diabetes mellitus, encephalopathy, heart disease, hypothyroidism, hypertension, and major depressive disorder. Review of Resident #63's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 was cognitively intact and required supervision for eating. Review of the care plan dated 06/22/23 revealed Resident #63 had a nutritional problem or a potential for nutritional problems related to diabetes mellitus, depression, variable weight fluctuations and variable meal intake. Interventions included observing, recording, and reporting any signs or symptoms of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interviews, record review and policy review, the facility failed to ensure oxygen had an active order, the tubing had been changed timely, and had proper humidification of oxygen. This affected two (#52 and #14) of three residents reviewed for respiratory care. The facility census was 85. Findings included: 1. Review of the medical record for the Resident #52 revealed an admission date of 08/02/23. Diagnoses included complete traumatic amputation at knee level, vascular disease, diabetes, and chronic viral hepatitis c. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 was cognitively impaired with a BIMS of 9 and required extensive assistance of one to two staff members for mobility and activities of daily living. Review of the plan of care dated 10/26/23 revealed Resident #52 did not have any care plan category or interventions for oxygen use. Review of physician orders for 11/13/23 for Oxygen via nasal cannula at two liters per…

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, physician interview and policy review, the facility failed to ensure residents care was supervised by a physician when the physician was unable to have effective communication with the nursing staff to provide direct orders for residents. This affected two (#9 and #288) of two residents for a change in condition. The facility census was 85. Findings include: 1. Review of the medical record revealed Resident #288 was admitted on [DATE]. Diagnoses included acidosis, arteriovenous fistula, unspecified cirrhosis of liver, anemia, chronic kidney disease, hyperlipidemia, type two diabetes mellitus, and essential primary hypertension. Review of the Minimum Data Set (MDS) assessment, dated 11/4/23, revealed the entry assessment had been completed. Review of physician orders, dated 11/05/23, revealed an order for Resident #288 to receive Humalog Kwickpen subcutaneous solution pen-injector 100 unit/milliliter (ml) with instructions to inject as per sliding scale: if 151-200…

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 policy, the facility failed to ensure newly admitted residents were seen and evaluated by a physician within the first 30 days of admission. This affected three (#39, #63 and #64) of 25 residents reviewed for physician services. The facility census was 85. Findings include: 1. Review of Resident #39's medical record revealed an admission date of 08/07/23. Diagnoses included cerebral infarction, type II diabetes mellitus, acute respiratory failure with hypoxia, hypertension, chronic kidney disease, bell's palsy, and hemiplegia to the left, nondominant side. Review of Resident #39's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had moderate cognitive impairment. Review of Resident #39's Physician Visit notes revealed Resident #39 was seen by the Nurse Practitioner on 09/01/23, 10/11/23, 10/12/23, 10/13/23, 10/30/23, 11/07/23 and 11/13/23. No visits from the physician were found. There was no evidence in Resident #39's medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure medications to address psychiatric diagnosis were monitored for effectiveness and specific treatment outcome for specified condition. This affected one (#16) of five resident sampled residents reviewed for unnecessary medications. The facility census was 85. Findings include: Review of Resident #16's medical record revealed an admission dated 11/05/14, with the diagnosis including, schizophrenia, bipolar disorder, obsessive compulsive disorder, major depression, anxiety disorder, insomnia, lumbosacral disc degeneration, malnutrition, anemia, chronic obstructive pulmonary disease, and cachexia. According to the minimum data set assessment dated [DATE] Resident #16 was assessed ability to make needs known, intact cognition, required set-up assistance for the completion of activities of daily living, independent with toileting, continent of bowel and bladder, utilized a walker for mobility, at risk 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.

Based on observation, medical record review, staff interview, and review of policy, the facility failed to ensure medications were appropriately stored and secured. This affected one (#68) of one resident observed with medications unattended at the bedside. The facility census was 85. Findings include: Review of the medical record revealed Resident #68 had an admission date of 08/03/22. Diagnoses included rhabdomyolysis, chronic obstructive pulmonary disease, depression, and anxiety. Review of the physician orders dated 06/25/23 revealed Resident #68 had an order for DuoNeb Solution 0.5-2.5 (3) milligrams (mg)/milliliter (ml), one inhalation orally via nebulizer three times a day for chronic obstructive pulmonary disease. Observation on 11/13/23 at 1:39 P.M., in Resident #68's room revealed there were two plastic vials of DuoNeb solution left on the bedside table. Interview on 11/13/23 at 1:42 P.M., Licensed Practical Nurse (LPN) #220 verified the medications were left at the bedside. LPN #220 verified there was no order for the medication to be left at the bedside and the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure newly admitted residents were seen and evaluated by a physician within the first 30 days of admission. This affected three (Residents #10, #19, and #23) of 17 residents reviewed for physician services. The facility census was 83. Findings include: 1. Review of Resident #10's medical record revealed an admission date of 09/16/23 and a discharge date of 10/31/23. Diagnoses included kidney cancer, bone cancer, type II diabetes, major depressive disorder, chronic kidney disease, and chronic right humerus fracture. Review of Resident #10's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact. Review of Resident #10's Physician Visit notes revealed Resident #10 was seen by the Nurse Practitioner on 09/26/23, 10/03/23, 10/05/23, 10/06/23, and 10/10/23. No visits from the physician were found. There was no evidence in Resident #10's medical record that Resident #10 was…

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

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 ensure a resident's transportation was arranged and provided for a scheduled medical appointment. This affected one (Resident #10) of four residents reviewed for transportation services. The facility census was 83. Findings include: Review of Resident #10's medical record revealed an admission date of 09/16/23 and a discharge date of 10/31/23. Diagnoses included kidney cancer, bone cancer, type II diabetes mellitus, major depressive disorder, chronic kidney disease, and chronic right humerus fracture. Review of Resident #10's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact. Resident #10 required extensive assistance from staff with transfers and did not display behaviors at the time of the review. Review of Resident #10's Facility Referral Packet dated 09/09/23 revealed Resident #10 had pain in his upper rights arm with chronic weakness and cancer. Resident #10…

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, resident interview, staff interview, and policy review, the facility failed to ensure dependent residents were assisted with nail care. This affected two (#54 and #55) of three residents reviewed for activities of daily living. The facility census was 92. Findings included: 1. Review of Resident #54's medical record revealed an admission date of 02/27/23. Diagnoses included hemiplegia left side post cerebral vascular accident, congestive heart failure, and cirrhosis of the liver. Review of Resident #54's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he had no cognitive impairment. The resident required extensive assistance for bed mobility, bathing, and personal hygiene. Observation of Resident #54 on 10/06/23 at 8:32 A.M., revealed he had long, unkept fingernails. Interview with Resident #54 on 10/06/23 at 8:32 A.M., revealed he wished to have his fingernails trimmed but it was difficult to find someone to complete the task. 2. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of immunization records, staff interview, review of policy, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure residents were offered pneumococcal vaccinations per CDC recommendations. This affected five (#1, #3, #58, #59, and #60) of five residents reviewed for pneumococcal vaccinations. In addition, the facility failed to ensure a resident was offered the influenza vaccination. This affected one (#58) of five residents reviewed for influenza vaccination. The facility census was 93. Findings include: 1. Review of Resident #58's medical record revealed an admission date of 01/12/23. Diagnoses included spinal stenosis, morbid obesity, chronic obstructive pulmonary disease (COPD), dysphagia, hypertension, heart failure, atherosclerotic heart disease, congestive heart failure (CHF), dementia, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #58 was severely cognitively…

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 immunization records, staff interview, review of policy, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure a resident was offered the COVID-19 vaccinations. This affected one (#58) of five residents reviewed for COVID-19 vaccinations. The facility census was 93. Findings include: Review of Resident #58's medical record revealed an admission date of 01/12/23. Diagnoses included spinal stenosis, morbid obesity, chronic obstructive pulmonary disease (COPD), dysphagia, hypertension, heart failure, atherosclerotic heart disease, congestive heart failure (CHF), dementia, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #58 was severely cognitively impaired. Review of Resident #58's current immunization record located in the electronic medical record (EMR) revealed no documentation the resident had been offered or received COVID-19 vaccines. Interview on 08/25/23 at…

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

Based on observation, staff interview, and review of facility policy, the facility failed to label and date open foods. This had the potential to affect all residents, except for one (#52), identified by the facility as having nothing by mouth. The facility census was 79. Findings include: 1. Observation on 07/12/21 at 8:55 A.M. of the refrigerator revealed four small, covered bowls containing salad and 12 covered soufflé cups containing various salad dressings. The bowls of salad and salad dressings were unlabeled and undated. Interview on 07/12/21 at 9:02 A.M. with Dietary Manager (DM) #387 verified the salad and dressings were unlabeled and undated. DM #387 stated the salads were left over from 07/10/21. 2. Observation on 07/12/21 at 8:56 A.M. of the freezer revealed two packages of pancakes that were soft to the touch. One of the packages of pancakes was split open, exposing the pancakes to the freezer. The package was unlabeled and undated. Interview at the time of the observation with Dietary Aide (DA) #376 verified the pancakes in the freezer were soft and one package was…

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

Based on observation, resident and staff interview, medical record review, and review of an example of a menu food choice document, the facility failed to allow residents to make choices related to their breakfast foods. This affected a total of seven residents, one (#32) resident reviewed for choices and affected five (#6, #19, #28, #44, and #60) additional residents interviewed for food choices. The census was 79. Findings included: Review of Resident #32's medical record revealed an admission date of 04/15/21. Diagnoses included acute respiratory failure, unspecified atrial fibrillation, congestive heart failure, essential hypertension, acute kidney failure, and hepatic failure. Review of Resident #32's comprehensive Minimum Data Set (MDS) assessment completed, 04/21/21, revealed Resident #32 had intact cognition. Interview on 07/12/21 a 1:43 P.M., Resident #32 stated the nursing staff ask him what he wants for lunch and supper the day before each planned meal and there are two choices to pick from. However, Resident #32 stated he does not get to choice what he wants 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.

Based on observation, medical record review, resident interview, resident representative interview, staff interview, review of monthly activity calendar, and facility policy review, the facility failed offer appropriate and scheduled activities to residents. This affected six residents, one resident (Resident #4) reviewed for activities and five additional residents (#6, #28, #60, #44, and #19) interviewed. The facility census was 79. Findings include: Review of the medical record for Resident #4 revealed an admission date of 06/30/20. Diagnosis included atherosclerotic heart disease, edema, atrial fibrillation, obstructive sleep apnea, venous insufficiency, type two diabetes mellitus with diabetic neuropathy, age-related osteoporosis, hyperlipidemia, hypertension, pulmonary hypertension, anxiety disorder, and major depressive disorder recurrent. Review of the annual Minimum Data Set (MDS) assessment, dated 07/02/21, revealed Resident #4 was severely cognitively impaired. Activity preferences revealed activities were somewhat important and included favorite activities and going…

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 semi-private resident rooms were equipped with full visual privacy. This affected six (#2, #14, #43, #45, #73, and #78) residents observed on the secured neighborhood. The census was 79. Findings include: Observation on 07/12/21 between 10:27 A.M. and 12:03 P.M. revealed residents and resident rooms on the secured neighborhood of the facility. Observation of room [ROOM NUMBER] and room [ROOM NUMBER] revealed the bedroom had no privacy curtains. Resident #45 and Resident #73 were observed to be roommates in room [ROOM NUMBER] and Resident #14 and Resident #43 were roommates in room [ROOM NUMBER]. Additionally, room [ROOM NUMBER] did not have a privacy curtain for Bed A and the room was shared by Resident #2 and Resident #78. None of the three resident rooms had any other mechanisms in place to ensure the residents in room [ROOM NUMBER], #316, and #323 had full visual privacy. Observations on 07/13/21 between 3:00 P.M. and 3:36 P.M., 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 observation, resident interview, and staff interview, the facility failed to ensure residents had a sanitary and homelike environment. This affected 21 residents, Resident #283 and 20 (#2, #3, #5, #14, #17, #21, #35, #36, #38, #42, #43, #45, #58, #63, #73, #75, #76, #78, #80, and #81) residents who resided on the secured neighborhood. The census was 79. Findings include: 1. Observation on 07/12/21 at 11:31 A.M. of Resident #283's room revealed the right closet door was off of the sliding track, leaning inside the closet, and partially behind the left door. The right side of the closet remained partially obstructed. The left side closet door could not be opened due to the position of the right closet door leaning behind the left door. Interview on 07/12/21 at 5:07 P.M. of Registered Nurse (RN) #314 verified Resident #283's closet door was broken. RN #314 stated she had not noticed the broken door and would follow up with maintenance. RN #314 then asked Resident #283 how long the door had been broken 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, resident and staff interview, and medical record review, the facility failed to ensure a resident's call light was positioned in a manner to allow for freedom of use. This affected one (#42) of four residents observed for call light placement on the secured neighborhood. The census was 79. Findings include: Review of Resident #42's medical record revealed an admission date of 01/12/21. Diagnoses included dementia with behavioral disturbances, anxiety disorder, muscle weakness, major depression, and hypothyroidism. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 07/05/21, revealed Resident #42 was assessed with severely impaired cognition, required extensive two-plus person assistance with bed mobility and transfers, and was assessed with no impairment of her upper extremities. Review of a fall risk care plan dated 06/17/21 revealed an intervention to ensure Resident #42 had the call light within reach and staff should encourage the resident to use the call light for assistance as needed. It was also documented Resident #42 needed prompt…

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, review of resident trust accounts, staff interview, and review of facility policy, the facility failed to convey personal funds to the resident within 30 days of discharge. This affected one (#284) resident reviewed for conveyance of personal funds. The facility census was 79. Findings include: Review of the medical record for Resident #284 revealed an admission date of 12/23/16 and a discharge date of 11/20/20. Diagnoses included cerebral infarction, type II diabetes mellitus, chronic obstructive pulmonary disease and anxiety disorder. Review of the Resident Fund Management Service Authorization and Agreement To Handle Resident Funds, dated 12/27/16, revealed Resident #284 authorized the facility to establish and manage a interest bearing resident fund. Review of the quarterly statement, printed 07/15/21, revealed Resident #284 was discharged from the facility on 11/20/20 and the trust account was closed on 02/04/21. Additional review of trust account records revealed two checks, one dated 01/22/21 in the amount of $1027.00 and one dated 02/03/21 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.

Based on medical record review, resident interview, resident representative interview, staff interview, and review of the facility policy, the facility failed to offer resident and/or representative participation in care plan conferences. This affected two (#39 and #71) of two residents reviewed for comprehensive care plan conferences. The facility census was 79. Findings include: 1. Review of Resident #39 medical record revealed an admission date of 12/11/19. Diagnosis included metabolic encephalopathy, hyperlipidemia, psychosis, schizoaffective disorder, and dementia without behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/20/21, revealed the resident was moderately cognitively impaired. Review of Resident #39's record review revealed a care conference was held on 03/12/20, 09/10/20, and 1/21/21. Interview on 07/12/21 at 11:16 A.M. with Resident #39's resident representative revealed care plan conferences are not occurring. Interview on 07/13/21 at 2:02 P.M. with Social Services #324 revealed while Resident #39's representative was…

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

Based on observation, staff interview, medical record review, and facility policy review, the facility failed to ensure resident safety while smoking. This affected one (Resident #37) of six residents who smoke. The facility census was 79. Findings include: Review of the medical record review for Resident #37 revealed an admission date of 04/27/21. Diagnoses included schizophrenia and intellectual disabilities. Review of the quarterly Minimum Data Set assessment, dated 06/30/21, revealed the resident was moderately cognitively impaired. Review of Resident #37's care plan, dated 04/28/21, revealed the resident was a smoker. Interventions included the resident requires a smoking apron while smoking. Review of Smoking Safety Screen, dated 04/29/21, revealed Resident #37 must have a smoking apron and supervision while smoking. Observation on 07/13/21 at 8:59 A.M. revealed Resident #37 outside smoking and not wearing a smoking apron. Interview on 07/13/21 at 9:03 A.M. with Administration #405 verified Resident #37 was not wearing a smoking apron while smoking. Review of facility policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to change oxygen supplies for one (#51) of three residents reviewed for respiratory care. The facility census was 79. Findings include: Review of the medical record review for Resident #51 revealed the resident was admitted on [DATE]. Diagnoses included acute respiratory failure, cerebral infarction, dysphagia, toxic encephalopathy, anxiety disorder, and chronic systolic (congestive) heart failure. Review of the quarterly Minimum Data Set (MDS) assessment, dated 5/25/21, revealed the resident was moderately cognitively impaired. The resident receives oxygen treatment. Review of the physician orders, dated 03/15/21, verified to change all nebulizer tubing and components, date and initial each component. An additional order dated 03/15/21, verified to change all oxygen tubing, date and initial all tubing, including wheelchair tubing. Observation on 07/12/21 at 10:36 A.M. revealed Resident #51 in 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.

Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to complete side rail assessments prior to installation on the bed for two (#34 and #64) of two residents reviewed for side rails. The facility census was 79. Findings include: 1. Review of the medical record for Resident #34 revealed an admission date of 03/25/21. Diagnoses included cerebral infarction, muscle weakness, and left hemiplegia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/01/21, revealed Resident #34 was moderately cognitively impaired and required extensive two person assist with bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of a physician order, dated 03/25/21 revealed Resident #34's preference of bed rails as needed to increase independence with bed mobility. Review of the plan of care, initiated 03/25/21, revealed Resident #34 was at risk for Activities of Daily Living (ADL) self-care performance deficit related to aggressive behavior, fatigue, limited mobility and stroke. Interventions included half…

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, medical record review, and review of a facility policy, the facility failed to ensure medications were administered as ordered by the physician which resulted in a medication error rate of 11.11%. The deficient practice affected two (#52 and #62) of five residents observed during medication administration with four errors occurring out of 36 opportunities. The census was 79. Findings include: 1. Review of Resident #62's medical record revealed an admission date of 04/23/21. Diagnoses included atrial fibrillation, anxiety disorder, diabetes mellitus type II, hypertension, and low back pain. Review of Resident #62's physician orders revealed an order dated 04/23/21 for the antidepressant Lexapro 10 milligrams (mg) by mouth daily, an order dated 04/23/21 for the supplement Vitamin D 2000 units by mouth daily, and an order dated 04/24/21 for the anti-hypertension medication metoprolol 75 mg by mouth twice daily. Further review of all medications revealed these medications were to be given along with other medications in the morning and were…

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.