Autumnwood Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, and facility policy review revealed the facility failed to ensure dependent residents received proper grooming. This affected two (#56, #85) of four residents reviewed for assistance of daily living (ADL) care. The facility identified all residents residing in the facility as being dependent for ADL care. The facility census was 88.Findings include:Review of Resident #56's medical record revealed an admission date of 01/08/25. Diagnoses included Alzheimer's disease, dementia, suicidal ideations, anxiety, and amaurosis fugax (vision loss).Review of Resident #56's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a low cognitive function and required partial to moderate assistance regarding personal hygiene and showering.Review of Resident #56's most recent care plan revealed the resident suffered from an activity of daily living (ADL) self-care and mobility performance deficit related to severe cognitive impairment,…

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 provide bed hold notice to residents being sent to the hospital. This affected one (#6) of three residents reviewed for bed hold notices. The facility census was 80.Findings include:Review of medical record for Resident #6 revealed an admission date of 04/18/25. Diagnoses included chronic kidney disease stage III, low back pain, and malignant neoplasm of parotid gland. Review of the census line revealed Resident #6 was private pay.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact.Review of the nursing note dated 07/03/25 at 3:01 P.M. revealed Resident #6 was found on the floor of her bathroom lying on her side in front of the toilet. The resident was screaming out in pain during the transfer. The Certified Nurse Practitioner (CNP) was notified and a new order received to send the resident to the emergency room (ER) for evaluation.The nursing note dated…

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

Based on observation, staff interview, and review of facility policy, the facility failed to maintain the kitchen in a safe and sanitary manner. This had the potential to affect 77 residents in the facility, Resident #52 received no food by mouth and thus received no food from the kitchen. The facility census was 78. Findings include: Observation on 12/09/24 at 8:35 A.M. of the kitchen found Dietary Staff (DS) #534 was running dishes through the dishwasher. Coinciding interview with DS #534 revealed she was not aware if the dishwasher was a high temperature or chemical machine. Review of the dishwasher found it was labeled as a high temperature machine with the final rinse temperature should be 180 degrees Fahrenheit (F). Observation of the temperature gauge as DS #534 ran the dishwasher found it reached 164 degrees F for the wash and the gauge did not move off the 100 degree mark for the rinse. Observation and coinciding interview on 12/09/24 at 8:37 A.M. with Dietary Director (DD) #601 found when the dishwasher was run again the rinse gauge continued to read 100 degrees and did…

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

Based on observation, staff interview, review of the manufactures instructions for the dishwasher, review of dishwasher temperature logs, and review of facility policy, the facility failed to ensure the dishwashing machine was maintained in a safe operating condition. This had the potential to affect 77 residents in the facility, Resident #52 received no food by mouth and no food from the kitchen. The facility census was 78. Findings include: Observation on 12/09/24 at 8:35 A.M. of the kitchen found Dietary Staff (DS) #534 was running dishes through the dishwasher. Coinciding interview with DS #534 revealed she was not aware if the dishwasher was a high temperature or chemical machine. Review of the dishwasher found it was labeled as a high temperature machine with a final rinse temperature noted to be 180 degrees Fahrenheit (F). Observation of the temperature gauge as DS #534 ran the dishwasher found it reached 164 degrees F for the wash and the gauge did not move off the 100 degree mark for the rinse. Observation and coinciding interview on 12/09/24 at 8:37 A.M. with Dietary…

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 interviews, staff interviews, and review of facility policy, the facility failed to ensure the dryers in the facility laundry room were cleaned appropriately. This had the potential to affect all residents in the facility. Additionally, the facility failed to ensure a well-maintained environment. This affected two residents (Resident #24 and Resident #68) of two residents reviewed for environment. The facility census was 78. Findings include: 1. Observation on 12/10/24 at 12:02 P.M. revealed the walk-in vent area behind the facility's three industrial dryers were covered in lint. An interview on 12/10/24 at 12:02 P.M. with Laundry #502 verified these findings. An interview on 12/10/24 at 12:02 P.M. with Laundry #502 revealed Maintenance Supervisor #535 cleans the lint once per year. 2. Observation of Residents #24 and #68 room on 12/09/24 at 9:45 A.M. revealed above Resident #24's bed was a large brown stain on the ceiling. Interview with Residents #24 and #68 on 12/09/24 at 10:35 A.M. verified their ceiling had large brown stain. They stated the stain…

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, staff interview, and policy review, the facility failed to ensure shower preferences were honored. This affected one (#18) of one resident reviewed for showers. The facility census was 78. Findings include: Review of the medical record for Resident #18 revealed an admission date of 04/29/19. Diagnoses included bipolar disorder, type two diabetes mellitus, schizoaffective disorder, delusional disorder, and depressive disorder. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent on staff for showers and bathing. Review of the plan of care initiated 08/02/24 revealed the resident's personalized care preferences included a shower three times per week. The resident required physical assistance to total dependence for bathing and shower transfers with two staff with the mechanical lift. Review of the shower schedule revealed Resident #18 was scheduled for showers three times per week…

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, staff and resident interview, and policy review, the facility failed to ensure residents were provided quarterly statements for their personal funds. This affected one (#20) of one resident reviewed for personal funds. The facility identified 54 residents with personal funds accounts. The facility census was 78. Findings include: Review of medical record for Resident #20 revealed an admission dated of 09/11/17. Diagnoses included type two diabetes mellitus, bipolar disorder, Parkinson's disease, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the personal fund authorization form dated 07/09/18 revealed the resident authorized the facility to manage her personal fund account. Further review of the medical record revealed no documentation the resident was provided with quarterly statements for personal funds. Interview on 12/09/24 at 9:34 A.M., Resident #20 revealed the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, staff interview, and policy review, the facility failed to timely notify the physician and resident representative of a resident change in condition. This affected one (Resident #30) of two residents reviewed for change in condition. The facility census was 78. Findings include Review of the medical record for Resident #30 revealed an admission date of 08/05/24. Diagnoses included chronic obstructive pulmonary disease, heart failure, dementia, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of a nurses note dated 11/17/24 at 1:54 P.M. revealed the resident stated this morning she had gotten up in the middle of the night and moved her right ankle wrong. The resident complained of pain to the right ankle and foot. No swelling or bruising noted. The resident had two elastic bandages wrapping the ankle and the nurse removed one and rewrapped one so it was not too tight. The nurse got a leg…

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 maintain comfortable sound levels in the dining room on the secured unit. This affected one resident (#59) and had the potential to affect the 12 residents who resided on the secured unit. The facility census was 78. Finding include: Review of the medical record for Resident #59 revealed an admission date of 10/06/23. Diagnoses included Alzheimer's disease, anxiety disorder, muscle weakness, and dementia. Review of Resident #59's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine indicating Resident #59 was moderately cognitively impaired. Resident #59 required maximal assistance with toilet use, dressing and personal hygiene. Resident #59 required moderate assistance with bathing and supervision with eating. Resident #59 displayed rejection of care behaviors one to three days during the review period and wandering behaviors four to six days during the review period. Observation…

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, interviews, and review of facility policy, the facility failed to ensure the comprehensive care plan was complete with current resident condition. This affected one (Resident #20) of two residents reviewed for comprehensive care planning. The census was 78. Findings include: Review of Resident #20's medical record revealed an admission date of 09/11/17. Diagnoses included bipolar disorder, chronic obstructive pulmonary disease, chronic respiratory failure, ataxia, Parkinson's, schizoaffective, and lymphedema. Review of Resident #20's quarterly Minimum Data Set, dated [DATE] revealed intact cognition. The resident required maximum assistance for lower body dressing and required oxygen therapy. Review of Resident #20's medical record revealed a physician's order for [NAME] hose (compression stockings) to be applied in the morning and removed at bedtime. Size regular medium. Review of Resident #20's care plan revealed no goals or interventions in place for the use 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, record review, staff interview, and resident interview, the facility failed to ensure a resident (#20) was provided compression stockings as physician ordered. This affected one (Resident #20) of one resident observed for compression stockings. The facility census was 78. Findings included: Review of Resident #20's medical record revealed an admission date of 09/11/17. Diagnoses included bipolar disorder, chronic obstructive pulmonary disease, chronic respiratory failure, ataxia, Parkinson's, schizoaffective, and lymphedema. Review of Resident #20's quarterly Minimum Data Set, dated [DATE] revealed intact cognition. The resident required maximum assistance for lower body dressing and required oxygen therapy. Review of Resident #20's care plan revealed the resident required diuretic therapy. Interventions included to watch for lower extremity swelling. Review of Resident #20's medical record revealed a physician's order for [NAME] hose (compression stockings) to be applied in the morning 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 observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure residents had their tube feed running at the ordered rate. This affected one resident (#52) of one resident reviewed. The facility identified one resident who received nutrition via tube feeding in the facility. The facility census was 78. Findings include: Review of Resident #52's medical record revealed an admission date of 08/31/24. Diagnoses included Parkinson's Disease, dysphagia, moderate protein calorie malnutrition, anxiety disorder, bipolar disorder, seizures, and osteoporosis. Review of Resident #52's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of eight indicating Resident #52 was moderately cognitively impaired. Resident #52 required maximal assistance with toilet use, dressing, bathing, and mobility. Resident #52 had a feeding tube and received 51% or more of his total calories through the tube feeding. Resident #52 displayed no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, resident interview, and policy review, revealed the facility failed to ensure medical staff completed accurate documentation regarding a resident's compression stocking application. This affected one (Resident #20) of one resident reviewed for documentation. The facility census was 78. Findings included: Review of Resident #20's medical record revealed an admission date of 09/11/17. Diagnoses included bipolar disorder, chronic obstructive pulmonary disease, chronic respiratory failure, ataxia, Parkinson's, schizoaffective, and lymphedema. Review of Resident #20's quarterly Minimum Data Set, dated [DATE] revealed an intact cognition. The resident required maximum assistance for lower body dressing. Review of Resident #20's care plan revealed the resident required diuretic therapy. Interventions included to watch for lower extremity swelling. Review of Resident #20's medical record revealed a physician's order for [NAME] hose (compression stockings) to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure resident's catheter collection bags were maintained off the floor and in a safe and sanitary manner. This affected two residents (#56 and #39) of two residents reviewed with indwelling catheters. In addition, the facility failed to ensure medications were administered in a safe and sanitary manner. This affected two residents (#56 and #69). The facility census was 78. Findings include: 1. Review of Resident #39's medical record revealed an admission date of 10/07/24. Diagnoses included urethral syndrome, urinary retention, chronic kidney disease, and breast and lung cancer. Review of Resident #39's Minimum Data Set (MDS) revealed she had intact cognitive function and required an indwelling Foley catheter. Review of Resident #39's most recent care plan revealed the resident required enhanced barrier precautions related to increased risk for multidrug-resistant organisms…

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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, cardiologist progress notes, policy review, and review of facility corrective action, the facility failed to adequately monitor the placement of a resident's cardiac defibrillator external heart monitor. This affected one (#57) of one resident reviewed for implanted defibrillators. The facility census was 79. Findings included: Review of Resident #57's medical record revealed an admission date of 12/02/22. Diagnoses included congestive heart failure, coronary artery disease, atrial fibrillation, and an implanted defibrillator. Review of Resident #57's quarterly Minimum Data Set assessment dated [DATE] revealed the resident had a moderately impaired cognitive level and required a maximum assist for transfers. Review of Resident #57's most recent care plan revealed he had a cardiac diagnosis which required monitoring, medications, 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 family and staff interview, interview with the Long Term Care Ombudsman, interview with hospital staff, record review, and policy review, the facility failed to provide the required documentation when a resident was initially transferred to the hospital for evaluation and treatment and the resident was later discharged from the facility. The facility also failed to ensure there was necessary reasons to transfer the resident to the hospital. This affected one (Resident #76) of three residents reviewed for discharges. The facility census was 75. Findings include: Review of Resident #76's closed medical record revealed an admission date of [DATE]. Medical diagnoses included Alzheimer's disease, spinal stenosis, congestive heart failure, and ischemic heart disease. Resident #76 was transferred to an acute, inpatient, geriatric psychiatric facility on [DATE] on a 72-hour involuntary hold placed by Certified Nurse Practitioner (CNP) #210. Resident #76 was previously hospitalized at the same facility from…

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

Based on family and staff interview, interview with hospital staff, record review, and policy review, the facility failed to provide the resident and the resident's representative of the appropriate written notice upon discharge. This affected one (Resident #76) of three residents reviewed for discharges. The facility census was 75. Findings include: Review of Resident #76's closed medical record revealed an admission date of 01/22/22. Medical diagnoses included Alzheimer's disease, spinal stenosis, congestive heart failure, and ischemic heart disease. Resident #76 was transferred to an acute, inpatient, geriatric psychiatric facility on 05/24/24 on a 72-hour involuntary hold placed by Certified Nurse Practitioner (CNP) #210. Review of Resident #76's Minimum Data Set (MDS) 3.0 discharge return anticipated assessment, dated 05/24/24, revealed the resident was identified with a memory problem and required modified independence with cognitive skills for daily decision making. Review of Resident #76's interdisciplinary progress notes revealed a note dated 05/24/24 at 2:48 P.M. which…

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 family and staff interview, interview with the Long Term Care Ombudsman, interview with hospital staff, record review, and policy review, the facility failed to allow Resident #76 to return to the facility following a therapeutic leave to an acute, inpatient, geriatric psychiatric facility. This affected one (Resident #76) of three residents reviewed for discharges. The facility census was 75. Findings include: Review of Resident #76's closed medical record revealed an admission date of [DATE]. Medical diagnoses included Alzheimer's disease, spinal stenosis, congestive heart failure, and ischemic heart disease. Resident #76 was transferred to an acute, inpatient, geriatric psychiatric facility on [DATE] on a 72-hour involuntary hold placed by Certified Nurse Practitioner (CNP) #210. Resident #76 was previously hospitalized at the same facility from [DATE] to [DATE]. Review of Resident #76's Minimum Data Set (MDS) 3.0 discharge return anticipated assessment, dated [DATE], revealed the resident 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 observation, staff interview, record review, and review of the facility policy, the facility failed to ensure fall interventions were in place. This affected one (#11) of three residents reviewed for falls. The facility census was 68. Findings include: Review of the medical record for Resident #11 revealed an admission date of 10/12/23. Diagnoses included congestive heart failure (CHF), osteoarthritis, and muscle weakness. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had intact cognition and displayed no rejection of care. Review of the Morse Fall Scale (assessment tool that predicts the likelihood that a patient/resident will fall) dated 10/12/23 revealed Resident #11 was at high risk for falls. The Morse Fall Scale dated 10/15/23 revealed Resident #11 was at moderate risk for falls. Review of the care plan updated 11/24/23 revealed Resident #11 was at risk for falls. Interventions included a low bed with a floor mat. Review of a nurse's progress note…

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, review of the staff schedules, and review of the facility unit staffing guidelines, the facility failed to ensure sufficient staff on the secured memory care unit to provide resident care. This directly affected two residents (#64 and #66) and had the potential to affect all 12 residents (#09, #12, #13, #19, #23, #54, #55, #59, #60, #63, #64 and #66) out of 12 residents residing on the secured memory care unit. The facility census was 73. Findings include: 1. Review of the medical record revealed Resident #64 was admitted on [DATE]. Diagnoses included major depressive disorder, anxiety disorder, Alzheimer's disease, vascular dementia, hypertension, interstitial pulmonary disease, Raynaud's syndrome, spinal stenosis, polyneuropathy, and osteoporosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was severely cognitively impaired and required extensive assistance with transfers, dressing, toilet use, personal hygiene,…

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, staff interview, and policy review, the facility failed to ensure foods kept in the refrigerator and freezer on the memory care unit were properly stored, labeled, and dated. This had the potential to affect 12 residents (#09, #12, #13, #19, #23, #54, #55, #59, #60, #63, #64 and #66) out of 12 residents residing on the secured memory care unit. The facility census was 73. Findings include: Observation on 09/26/22 at 9:54 A.M. of the kitchen area on the memory care unit revealed a reach in refrigerator and freezer combination. The refrigerator compartment revealed a container of applesauce dated 08/30/22, an undated and unlabeled package of luncheon meat in a plastic bag, an undated and unlabeled half-full pitcher of juice, a red cup with a lid containing an unknown liquid, undated and unlabeled, and a loosely covered bowel of butter with toast crumbs noted on the butter, undated and unlabeled. Additional observations revealed the refrigerator grates had food particles and dirt build-up and a sticky substance was spilled on the inside of the refrigerator.…

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

Based on observation and staff interview, the facility failed to ensure resident rooms and common areas were kept in good repair. This had the potential to affect all 73 residents of the facility. The facility census was 73. Findings include: 1. Observation on 09/26/22 at 9:41 A.M. of Resident #64's room revealed an area, approximately two inches in diameter, on the wall near the call light box of exposed, unpainted, drywall; two areas, one on each side of the window, approximately three inches long and a half inch wide of exposed, unpainted drywall; and a quarter size and two dime size areas of exposed, unpainted drywall on the wall near the thermostat. Interview on 09/26/22 at 9:44 A.M., the State Tested Nurse Aide (STNA) #482 verified the above findings. STNA #482 stated all staff were able to complete work orders for maintenance. STNA #482 was uncertain if a work order had been completed for the damage to Resident #64's room walls. 2 Observation on 09/29/22 at 8:36 A.M. of the sunroom, located on the 200 hall, revealed a ceiling crack, approximately 10 feet long, along 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, family and staff interview, and policy review, the facility failed to ensure notification was made to the physician, dietician, and the resident representative of a significant weight loss. This affected two residents (#04 and #34) out of two residents reviewed for notification of change in status. The facility census was 73. Findings include: 1. Review of the medical record revealed Resident #04 was admitted on [DATE]. Diagnoses included dementia, atherosclerotic heart disease, atrial fibrillation, hypertension, chronic diastolic (congestive) heart failure, chronic kidney disease, osteoarthritis, and other intervertebral disc degeneration. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 was severely cognitively impaired, required extensive assistance with personal hygiene, toilet use, and dressing, required supervision with eating and had weight loss of 5 percent (%) or more in the past month and was not on a prescribed weight loss…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and policy review, the facility failed to provide privacy for one resident (#40) out of three reviewed for pressure ulcer care. The facility census was 73. Findings Include: Review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included spastic hemiplegia, epilepsy, falls, and foot drop. Review of the 08/04/22 annual minimum data set (MDS) revealed Resident #40 was cognitively intact, had no behaviors or refusals of care, required extensive assist with bed mobility, toilet use, personal hygiene and was dependent for on staff for transfers. Resident #40 was coded as not having a pressure ulcer. Observation of incontinence care provided by State Tested Nursing Assistant (STNA) #502 and #503 on 09/28/22 at 10:02 A.M. revealed Resident #40's bed was against the wall and the resident's head of the bed was facing the outside wall where the room window was located. The staff laid the resident in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to develop a comprehensive plan of care to include a resident's pressure ulcer. This affected one resident (#64) out of 18 records reviewed for care plans. The facility census was 73. Findings include: Review of the medical record revealed Resident #64 was admitted on [DATE]. Diagnoses included major depressive disorder, anxiety disorder, Alzheimer's disease, vascular dementia, hypertension, interstitial pulmonary disease, Raynaud's syndrome, spinal stenosis, polyneuropathy, and osteoporosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was severely cognitively impaired, required extensive assistance with Activities of Daily Living (ADLs), was a risk for pressure ulcers and had one stage II pressure ulcer. Review of a Braden scale for predicting pressure sore risk dated 08/19/22 revealed Resident #64 had a score of 20, indicating the Resident was at high risk for developing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed ensure timely revision of the care plan. This affected one resident (#40) out of one reviewed for position/mobility out of 18 care plans reviewed. The facility census was 73. Findings Include: Review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included spastic hemiplegia, epilepsy, falls, and foot drop. Review of the 08/04/22 annual minimum data set revealed Resident #40 was cognitively intact, had no behaviors or refusals of care, required extensive assistance with bed mobility, toilet use, personal hygiene and was dependent on staff for transfers. A splint device was coded as zero days. Review of the care plans revealed Resident #40 had a care plan for his activities of daily living which included an intervention of a splint for the left hand which the resident would refuse to wear. The resident care plan had no documentation for the use of an ankle foot orthosis (AFO) to his…

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 the State Tested Nurse Aide (STNA) shower documentation, staff interview, and policy review, the facility failed to ensure dependent residents received showers as scheduled. This affected two residents (#64 and #66) out of three residents reviewed for activities of daily living (ADLs). The facility census was 73. Findings include: 1. Review of the medical record revealed Resident #64 was admitted on [DATE]. Diagnoses included major depressive disorder, anxiety disorder, Alzheimer's disease, vascular dementia, hypertension, interstitial pulmonary disease, Raynaud's syndrome, spinal stenosis, polyneuropathy, and osteoporosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was severely cognitively impaired and required extensive assistance with transfers, dressing, toilet use, personal hygiene, and physical help in bathing. Review of a plan of care focus area initiated 02/25/22 revealed Resident #64 was unable to carry out…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure planned fall interventions were implemented. This affected two residents (#04 and #37) out of four resident reviewed for falls. The facility census was 73. Findings include: 1. Review of Resident #37's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, hypertension, long-term use of insulin, obstructive sleep apnea, unspecified psychosis, bipolar disorder, anxiety, and depression. Review of Resident #37's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. The resident required extensive assistance of one staff for bed mobility, dressing, eating, toilet use, and personal hygiene. Review of Resident #37's fall risk assessments dated 03/22/20, 06/21/20, 09/05/20, 11/30/20, 02/27/21, 05/30/21, 08/29/21, 08/30/21, 11/29/21, 11/30/21, 02/26/22, 05/29/22, 07/16/22, 07/30/22,…

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 medial record review, staff interview and review of facility policy, the facility failed to ensure weights were monitored per facility policy and failed to track meal intakes as care planned. This affected one (#4) of two residents reviewed for nutrition. In addition, the facility failed to ensure weights were obtained per physician order. This affected one (#34) of two residents reviewed for nutrition. The facility census was 73. Findings include: 1. Review of the medical record revealed Resident #04 was admitted on [DATE]. Diagnoses included dementia, atherosclerotic heart disease, atrial fibrillation, hypertension, chronic diastolic (congestive) heart failure, chronic kidney disease, osteoarthritis, and other intervertebral disc degeneration. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 was severely cognitively impaired, required extensive assistance with personal hygiene, toilet use, and dressing, required supervision with eating and had weight loss 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 medical record review, observation, and staff interview, the facility failed to ensure oxygen was applied per physician order. This affected one resident (#33) of two residents reviewed for respiratory care. The facility census was 73. Findings include: Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included displaced segmental fracture of shaft of humerus, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, Parkinson's disease, depression, and muscle weakness. Review of Resident #33's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired. The resident required extensive assistance of one staff for bed mobility, transfers, ambulation, dressing, toilet use, and personal hygiene. The resident used oxygen. Review of Resident #33's physician orders for September 2022 identified orders for oxygen at three liters per minute via nasal cannula, every shift, and oxygen at two…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to timely act on pharmacy recommendations. This affected two residents (#28 and #03) out of eight residents reviewed for unnecessary medications. The facility census was 73. Findings Include: Review of Resident #28's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, schizoaffective disorder, chronic kidney disease, and diabetes mellitus type two. Review of the quarterly minimum data set (MDS) dated [DATE] revealed Resident #28 was cognitively intact, had behaviors directed toward others four to six days of the review period, required extensive assistance with dressing, limited assist with toilet use and bed mobility and supervision with transfers, eating, and personal hygiene. Resident #28 had seven days of injections: insulin, an antipsychotic, an antidepressant, an antianxiety, a diuretic and an opioid medication. The last gradual dose reduction was attempted on 12/28/21 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 and staff interview, the facility failed to ensure access and availability of therapy records in a resident's medical record. This affected one resident (#04) out of one resident reviewed for therapy services. The facility census was 73. Findings include: Review of the medical record revealed Resident #04 was admitted on [DATE]. Diagnoses included dementia, atherosclerotic heart disease, atrial fibrillation, hypertension, chronic diastolic (congestive) heart failure, chronic kidney disease, osteoarthritis, and other intervertebral disc degeneration. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 was severely cognitively impaired, required extensive assistance with transfers, personal hygiene, toilet use, and dressing, and had one fall with no major injury. Review of the plan of care focus area revised 06/28/22 revealed Resident #04 was at risk for falls related to side effects of medication, unsteady gait, decreased balance and 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.