Foundation Park Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, review of the Centers for Disease Control (CDC) recommended guidelines for indwelling urinary catheter insertion and maintenance, and policy review, the facility failed to provide an indwelling urinary catheter (IUC) securement device. This affected one (#42) of one resident reviewed for indwelling urinary catheters. The facility identified one resident with an indwelling urinary catheter. The facility census was 87.Findings include:Review of the medical record revealed Resident #11 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia, unspecified severe protein calorie malnutrition, obstructive and reflux uropathy, and benign prostatic hyperplasia with lower urinary tract symptoms.Review of the admission Minimum Data Set (MDS) assessment for Resident #11, dated 02/22/26, revealed a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive deficits. Further review of the MDS revealed Resident #11…

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

Based on observation, record review and staff interview, the facility failed to ensure residents received enteral nutrition (tube feeding) as ordered by the physician. This affected one (#22) of two residents reviewed for tube feedings. The facility census was 87.Findings include:Review of the medical record for Resident #22 revealed an admission date of 7/31/19 with diagnoses of unspecified dementia, hemiplegia, gastrostomy status, dysphagia, and epilepsy.Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/17/25, revealed Resident #22 was rarely/never understood, had a gastrostomy tube, and relied on enteral nutrition to meet 51 percent (%) or more of his fluid and nutrition needs.Review of the current physician order dated 06/13/25 revealed Resident #22 received Isosource HN (high nitrogen) (a tube feeding formula) at 80 milliliters (ml) per hour. Observation on 03/10/26 at 1:09 P.M. revealed Resident #22 had tube feeding Fibersource HN running at 80 ml per hour. Further observation revealed the tube feeding bag was dated 03/10/26 at 4:00 A.M. Concurrent interview…

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, record review, and policy review, the facility failed to ensure a resident was receiving oxygen therapy per physician orders. This affected one (#56) of one resident reviewed for respiratory. The facility identified six residents who required supplemental oxygen. The facility census was 87.Findings include:Review of Resident #56's medical record revealed an admission date of 04/24/25. Diagnoses included vascular dementia, emphysema, Raynaud's syndrome, and peripheral vascular disease. Review of Resident #56's quarterly Minimum Data Set assessment, dated 01/07/26, revealed the resident required continuous oxygen therapy. Review of Resident #56's most recent care plan revealed she had emphysema and had a history of shortness of breath on exertion, when sitting, and laying flat. Interventions included oxygen per nasal canula per physician orders. Review of Resident #56's medical record revealed a physician's order dated 04/25/25 to apply oxygen at two liters per minute per nasal canula every shift for chronic respiratory deficit/shortness 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, staff interview and policy review, the facility failed to secure a provider agreement with a hemodialysis provider prior to the current annual survey. Additionally, the facility failed to ensure collaborative communication was shared between the facility and the hemodialysis center. This affected one (#12) of one resident reviewed for dialysis. The facility identified one resident receiving dialysis services The facility census was 87. Findings include: Review of the medical record revealed Resident #12 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia with other behavioral disturbances, end stage renal disease, type two diabetes, and hypertensive chronic kidney disease. Review of the Resident #12's care plan for end stage renal disease, revised 11/13/25, revealed interventions, including the assessment of central line site used for hemodialysis, to be completed every shift. Dialysis on Tuesdays, Thursdays and Saturdays. Resident to leave 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.

Based on observation, medical record review, resident representative interview, and staff interview, the facility failed to ensure specific interventions were provided to address triggers and care for post-traumatic stress disorde (PTSD). This affected one (#10) of one resident reviewed for PTSD care and treatment. The facility census was 87. Findings include:Review of the medical record revealed Resident #10 admitted to facility on 08/14/25. Diagnoses included dementia, type 2 diabetes mellitus, lumbar vertebra fracture, neurocognitive disorder with Lewy bodies, hypertension, PTSD, depression, transient ischemic attack, and cerebral infarction. Review of the Minimum Data Set assessment, dated 02/13/26, Resident #10 had severely impaired cognition, delusions, rejection of care one to three days during assessment period, and received antipsychotic and antidepressant medications. On 08/14/25 a Social History and Assessment was completed and signed by Social Services Director #408. Diagnoses included PTSD. No additional documentation contained in the medical record indicated the cause…

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

Based on record review and staff interview, the facility failed to ensure nutrition assessments were completed accurately and updated with new diet orders. This affected one (#65) for four residents reviewed for food and nutrition. The facility census was 87. Findings include:Review of the medical record for Resident #65 revealed an admission date of 06/07/23. Diagnoses included dementia, type 2 diabetes mellitus, epilepsy, anxiety, and traumatic brain injury. Review of the quarterly Minimum Data set (MDS) assessment, dated 02/11/26, revealed Resident #65 was rarely/never understood and was dependent on staff for eating.Review of the current physician order, initiated 12/14/23, revealed Resident #65 should receive a cream cookie twice daily for nutritional adequacy.Review of Resident #65's progress notes, dated 01/01/26 through 03/12/26, revealed no incidents or concerns regarding eating, swallowing, or choking.Review of the Speech Language Pathology Evaluation and Plan of Treatment, dated 01/07/26, revealed Resident #65 was referred for therapy due to pocketing food.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 medical record review, staff interview, review of facility documentation, and review of facility policy, the facility failed to ensure the physician and responsible party were timely notified when a resident was discovered unresponsive on the floor with a laceration to the head. This affected one (#2) of three residents reviewed for timely notification in a facility census of 89. Findings include:Review of the medical record revealed Resident #2 admitted to the facility on [DATE]. Diagnoses included dementia, chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic neuropathy, malignant neoplasm of bladder wall, coronary artery disease, major depression with severe psychotic symptoms, anxiety disorder, osteoarthritis, history of transient ischemic attack, and hypertension. Review of the Minimum Data Set assessment dated [DATE] assessed Resident #2 with severe cognitive impairment, no range of motion impairment, independent with ambulation and transfer, and no falls since admission.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of facility incident report, review of hospital documentation, and review of facility policy, the facility failed to provide appropriate treatment and neurological assessments following the discovery of a resident on the floor unresponsive with a laceration to the head. This affected one (#2) of three residents reviewed for timely care and treatment. The facility census was 89. Findings include: Review of the medical record revealed Resident #2 admitted to the facility on [DATE]. Diagnoses included dementia, chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic neuropathy, malignant neoplasm of bladder wall, coronary artery disease, major depression with severe psychotic symptoms, anxiety disorder, osteoarthritis, history of transient ischemic attack, and hypertension. Review of the Minimum Data Set assessment dated [DATE] assessed Resident #2 with severe cognitive impairment, no range of motion impairment, independent 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, review of an incident report, review of witness statements, staff interview, and review of facility policies, the facility failed to ensure notifications were made to resident representatives and hospice providers following an incident of a resident being lowered to the ground. This affected one (#12) of five residents reviewed for notifications. The facility census was 89.Findings include: Review of Resident #12's medical record revealed an admission date of 12/31/24. Diagnoses included dementia, type II diabetes, displaced fracture of the shaft of the right femur (10/22/25), generalized anxiety disorder, major depressive disorder, anemia, and terminal diagnosis of rectal cancer. Review of Resident #12's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero (0) indicating Resident #12 was severely cognitively impaired. Resident #12 was dependent on staff for all activities of daily living including bed mobility 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, review of an incident report, review of written statements, staff interview, and review of a facility policy, the facility failed to thoroughly assess residents following an incident where the resident was lowered to the ground. This affected one (#12) of three residents reviewed for transfers. The facility census was 89.Findings include:Review of Resident #12's medical record revealed an admission date of 12/31/24. Diagnoses included dementia, type II diabetes, displaced fracture of the shaft of the right femur (10/22/25), generalized anxiety disorder, major depressive disorder, anemia, and terminal diagnosis of rectal cancer. Review of Resident #12's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero (0) indicating Resident #12 was severely cognitively impaired. Resident #12 was dependent on staff for all activities of daily living including bed mobility and transfer. Resident #12 displayed no behaviors at the time 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 open and closed medical record review, staff interview, review of a facility incident report, review of the Enhanced Information Dissemination and Collection (EIDC) system (system for reporting information) and review of the facility policy, the facility failed to report incidents of potential abuse and/or neglect to the State Survey Agency (SSA). This affected two (#100 and #68) of five residents reviewed for abuse. The facility census was 86. Findings include:1. Review of the closed medical record for Resident #100 revealed an admission date of [DATE] and a discharge date of [DATE]. Diagnoses included dementia with behaviors, diabetes mellitus (DM), peripheral vascular disease (PVD), chronic heart failure, chronic kidney disease (CKD) stage four, atrial fibrillation (A-fib) (abnormal heart rhythm), and atherosclerotic heart disease. Review of the plan of care, initiated on [DATE], revealed Resident #100 was care planned for advanced directives of Full Code (full life-saving measures to be taken 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 open and closed medical record review, staff interview, review of a facility investigation and review of facility policy, the facility failed to initiate and thoroughly investigate potential neglect and physical abuse. This affected two (#100 and #68) of five residents reviewed for abuse. The facility census was 86.Findings include: 1. Review of the closed medical record for Resident #100 revealed an admission date of [DATE] and a discharge date of [DATE]. Diagnoses included dementia with behaviors, diabetes mellitus (DM), peripheral vascular disease (PVD), chronic heart failure, chronic kidney disease (CKD) stage four, atrial fibrillation (A-fib) (abnormal heart rhythm), and atherosclerotic heart disease. Review of the plan of care, initiated on [DATE], revealed Resident #100 was care planned for advanced directives of Full Code (full life-saving measures to be taken in the event of cardiac/respiratory arrest) status. Interventions included: if resident was found unresponsive, staff were to call a stat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, staff interview, review of facility job descriptions, review of staff cardiopulmonary resuscitation (CPR) certifications and review of facility policy, the facility failed to ensure staff were competent and compliant with with implementing CPR per the physician orders and further failed to ensure nurse supervisors were qualified per the facility job description qualifications. This affected one (#100) of three residents reviewed for Advanced Directives. The facility census was 86.Findings include:Review of the closed medical record for Resident #100 revealed an admission date of [DATE] and a discharge date of [DATE]. Diagnoses included dementia with behaviors, diabetes mellitus (DM), peripheral vascular disease (PVD), chronic heart failure, chronic kidney disease (CKD) stage four, atrial fibrillation (A-fib) (abnormal heart rhythm), and atherosclerotic heart disease. Review of the plan of care plan, initiated on [DATE], revealed Resident #100 was care planned for advanced…

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 facility policy review the facility failed to implement the facility policy regarding the requirement to report a resident to resident altercation to the state agency. This affected one resident (#15) reviewed for abuse. The facility census was 92. Findings include: Review of Resident #15's medical record revealed an admission date of 01/08/19. Diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease and atrial fibrillation. Review of Resident #15's quarterly Minimum Data Set (MDS) dated [DATE] revealed she had an impaired cognition and behaviors included wandering and rejection of care. Review of Resident #15's nurses note dated 02/20/25 revealed the resident was in the dining room sitting at the table eating lunch. An altercation between two other residents happened and in the process Resident #15 was hit in the face with a plate receiving a cut to her forehead. The nurse separated residents. Resident #15 was assessed by staff and received wound…

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 facility policy review the facility failed to report a resident to resident altercation. This affected one resident (#15) reviewed for abuse. The facility census was 92. Findings include: Review of Resident #15's medical record revealed an admission date of 01/08/19. Diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease and atrial fibrillation. Review of Resident #15's quarterly Minimum Data Set (MDS) dated [DATE] revealed she had an impaired cognition and behaviors included wandering and rejection of care. Review of Resident #15's nurses note dated 02/20/25 revealed the resident was in the dining room sitting at the table eating lunch. An altercation between two other residents happened and in the process Resident #15 was hit in the face with a plate receiving a cut to her forehead. The nurse separated residents. Resident #15 was assessed by staff and received wound care. Neurological checks were begun. Review of Resident #15's health status…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the facility policy, the facility failed to ensure treatments were provided with a physician's order. This affected one (#14) of four residents reviewed for physician orders. The facility census was 88. Findings include: Review of the medical record for Resident #14 revealed an admission date of 05/18/23 with a readmission date of 04/1/24 with diagnoses of Alzheimer's disease and dementia. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #14 had impaired cognition. Review of the physician orders dated 07/01/24 through current revealed no orders for Nystatin powder (a powder used to treat fungal or yeast infections on the skin). Review of the Medication Administration Record and Treatment Administration Record dated August 2024 revealed no documentation Resident #14 received Nystatin powder. Review of the Shower/Skin Assessment completed 08/01/24 revealed Resident #14 had dry/flaky skin and redness with excoriation 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, staff interview and review of the facility's recipes, the facility failed to ensure portion sizes were followed when serving all diet textures. This affected 83 residents identified by the facility as receiving food from the kitchen. Additionally, the facility failed to ensure recipes were followed during preparation of pureed foods. This affected five (#18, #20, #21, #38, and #287) of five residents identified by the facility as having a physician ordered pureed diet. The facility census was 83. Findings include: Interview on 05/14/24 at 10:57 A.M. with [NAME] #506 revealed the facility had 14 residents who received mechanical soft diets and five residents who received a pureed diet. Observations on 05/14/24, beginning at 10:57 A.M., revealed [NAME] #506 used a utensil to portion 15 scoops of baked turkey crunch to process for residents on a mechanical soft diet. Continued observation revealed [NAME] #506 used a utensil to portion six scoops of baked turkey crunch to process for residents on a pureed diet. While processing the pureed turkey, [NAME] #506 added…

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, review of the medical record and review of the facility policy, the facility failed to ensure floors were adequately maintained. This had the potential to affect all 83 residents of the facility. Additionally, the facility failed to ensure resident rooms were free from odors. This affected one (#43) one one resident reviewed for room odors. The facility census was 83. Findings include: 1. Observation on 05/13/24 at approximately 7:30 A.M. of the Bayview Dining Room revealed a sticky substance covering the floor throughout the dining room, which caused shoes to stick to the floor, become tacky, and make a squeaking noise while walking. Shoes remained tacky after leaving the dining room. Interview on 05/13/24 at approximately 7:30 A.M. with State Tested Nursing Assistant (STNA) #569 verified the floors were sticky in Bayview Dining Room and this occurred yearly when the air conditioning was turned off in the facility. 2. Observation on 05/13/24 from 8:57 A.M. to 9:07 A.M. 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 interview, medical record review and review of facility policy, the facility failed to ensure medications were secure at all times and further failed to ensure medications were stored in approved and labeled containers. This affected thirteen (#5, #8, #12, #13, #23, #24, #36, #38, #52, #58, #61, #69 and #71) residents of thirteen residents observed for the storage of medication. The facility census was 83. Findings include: 1. Review of the medical record for Resident #69 revealed an admission date of 05/30/23. Diagnoses included neurocognitive disorder with Lewy bodies, emphysema, lymphedema, depression, epilepsy and insomnia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/17/24, revealed Resident #69 was cognitively intact, with no behavioral symptoms, was independent with activities of daily living (ADLs) and mobility and used antidepressant medication. Review of the care plan dated 06/01/23 revealed Resident #69 had dementia with behavioral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and review of facility policy, the facility failed to ensure a copy of the advanced directives were in the resident's medical record. This affected two (#59 and #236) of three residents reviewed for advanced directives. The facility census was 83. Findings include: 1. Review of the medical record revealed Resident #59 revealed an admission date of [DATE]. Diagnoses included type II diabetes mellitus, dementia, iron deficiency anemia, long term use of insulin, hypomagnesemia, atrial fibrillation, personal history of other diseases of the musculoskeletal system and connective tissue, stage III chronic kidney disease, heart disease, and cellulitis of face. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #59 was severely cognitively impaired. Review of a physician order, dated [DATE], revealed Resident #59's advanced directives were Do Not Resuscitate Comfort Care - Arrest (DNRCC-Arrest). Review of the care plan, dated [DATE], 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 observation, staff interview, review of a hospital referral and medical record review, the facility failed to ensure accurate skin assessments were completed upon admission. This affected one (#236) of two residents reviewed for skin conditions. The facility census was 83. Findings include: Review of the medical record revealed Resident #236 was admitted on [DATE] with a diagnosis of dementia. Review of the Minimum Data Set (MDS) assessment for Resident #236, dated 05/09/24, revealed it was in progress at the time of review. Review of the hospital Community Referral Form, scanned to the facility on [DATE], revealed a traumatic face superior wound was first assessed on 04/27/24. A wound assessment dated [DATE] indicated the area had edema, ecchymosis (bruising), was red, dry, and intact. Review of the Nursing admission Screening, dated 05/09/24, revealed Resident #236 was alert and oriented to herself. Further review revealed Resident #236 had no identified skin concerns. Review of a Shower/Skin…

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, observation, staff interview and review of the facility policy, the facility failed to maintain appropriate physician orders, failed to accurately assess a dialysis access sites and further failed to ensure a dialysis catheter site was covered. This affected one (#17) of one resident reviewed for dialysis. The facility identified one resident on dialysis. The facility census was 83. Findings include: Review of the medical record for Resident #17 revealed an admission date of 10/04/23. Diagnoses included dementia, end stage renal disease, and dependence on renal dialysis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/20/24, revealed Resident #17 was rarely/never understood and received dialysis. Review of the physician orders for Resident #17 revealed an order dated 02/15/23 to check thrill and bruit every shift, an order dated 02/15/23 to 05/15/24 to assess and document in progress notes the upper right chest central line catheter site for dressing condition, redness, pain, drainage and swelling. An order dated 09/29/23 stated 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 and staff interview, the facility failed to ensure non-pharmacological behavioral interventions were assessed or implemented to address resistance to care resulting in lack of timely care and/or treatment. This affected one (#46) of four residents reviewed for behavioral services. The facility census was 83. Findings include: Resident #46 admitted to the facility on [DATE] with diagnoses including dementia, type II diabetes mellitus, hypertension, dysphagia, depression, and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 04/17/24, Resident #46 was moderately cognitively impaired, sometimes understood/understands, rejected care daily, required partial to moderate assistance with activities of daily living (ADLs), was frequently incontinent of bowel and bladder, was at risk for pressure ulcer development with no skin breakdown and received antianxiety, antidepressant and antibiotic medications. Review of the plan of care (POC) revealed the following: on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to ensure an accurate Nutritional Assessment was completed. This affected one (#50) of four residents reviewed for nutrition. The facility census was 83. Findings include: Review of the medical record for Resident #50 revealed an admission date of 06/29/22 with diagnoses of dementia and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had intact cognition and was on a therapeutic diet. Review of a diet order dated 04/09/24 revealed Resident #50 should receive a no added salt (NAS) diet, with regular textures and thin liquid consistency. The order additionally noted low fat, 2000 milligram (mg) sodium and low cholesterol. Review of a diet order dated 04/09/24 through 05/01/24 revealed Resident #50 was on a 1500 milliliter (ml) fluid restriction and should receive 800 ml on first shift, 500 ml on second shift, and 200 ml on third shift. Review of a diet order dated 04/10/24 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 medical record review, family interview, and staff interview, the facility failed to ensure resident/family concerns were resolved timely. This affected one resident (#65) of three residents reviewed for grievances. The facility census was 84. Findings include: Review of the medical record for Resident #65 revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified dementia, delusional disorders, essential (primary) hypertension, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment 3.0 dated 09/06/23 revealed the resident was rarely understood. Review of a communication progress note for Resident #65 completed by Social Services #207, dated 09/21/23, revealed the family was in for a scheduled care conference. The note detailed the family's concern related to continued missing clothing including warm up pants black in color with light blue stripe down the side, a set black hoodie with black pants with gray camouflage stripe down the side. It 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, and review of facility policy the facility failed to ensure resident rooms and resident equipment were appropriately clean. This affected three residents (#10, #65 and #79) of four residents reviewed for a clean environment. The facility census was 84. Findings include: Observation on 10/02/23 at 9:42 A.M. of Resident #65's room revealed the air conditioning unit vents had a thick layer of dust, the floor of the corners of the room had dead bugs, debris, and cobwebs, and the base of the bedside table had a thick layer of dirt. Interview on 10/02/23 at 9:52 A.M. with Registered Nurse (RN) #200 verified Resident #65's room condition and stated housekeeping does not thoroughly clean the resident's rooms. Observation on 10/02/23 at 10:00 A.M. revealed resident's (#10 and #79) room had cobwebs with dirt and debris in the corners near the floor and the air conditioning vents had a thick layer of dust. Interview on 10/02/23 at 10:01 A.M. with State Tested Nursing Assistant (STNA) #201 verified the cobwebs in the corners of the room with dirt 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, staff interview, and sanitizer manufacturer instructions for use, the facility failed to maintain the facility food service kitchen environment, equipment and cleaning solution in a sanitary manner. This affected all 72 residents who received food from the facility. One resident (#34) was identified by the facility to receive nothing by mouth. The facility census was 73 Findings include: Observation on 12/12/22 at 8:00 A.M. a tour of the facility kitchen discovered the kitchen ceiling with peeling paint and ceiling overlayment material was breaking free above the food preparation table, steam table, tray line, and above the clean dishwasher discharge side. Located inside the microwave on the steam table was a heavy amount of food debris clinging to the walls inside. The food mixer was observed with food debris splatter on the surface. Inside the walk-in freezer was a case of mixed vegetables, case of pies and bag of rolls covered in frozen ice leading from refrigeration plumbing. Observation on 12/12/22 at 8:15 A.M. noted Dietary Helper (DH) #312 using a bucket…

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 maintain a clean and sanitary environment. This affected all residents residing in the facility. The facility census was 73. Findings include: Observation on 12/12/22 at 8:18 A.M. of Resident #33's room revealed deep scratches in the drywall above the bed and a round hole approximately one and half inches in diameter in the plaster in the corner above the baseboard behind the bed. There were two additional oblong holes in the plaster above the round hole in the wall behind the head of bed, both approximately one and half inches in length. Observation on 12/12/22 at 8:30 A.M. of Resident #10's room revealed a half moon shaped tear in the drywall above the baseboard in the hallway as you enter the room. The baseboard in the closet to the left as you enter the room was sitting face down on the floor. Observation on 12/12/22 at 8:33 A.M. of Resident #34 and Resident #69's room revealed splintering of the wood on the door around the lock with blond colored wood exposed on the dark brown door. Observation on 12/12/22 at 8:38…

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 local health inspection documentation, the facility failed to maintain the facility food service kitchen environment free of pests. This affected all 72 residents who received food from the kitchen. One resident (#34) identified by the facility to receive nothing by mouth. The facility census was 73. Findings include: Observation on 12/12/22 at 8:00 A.M. a tour of the kitchen discovered the juice dispensing machine identified with multiple flying gnats on the dispensing nozzle and holder. Interview on 12/13/22 9:20 A.M. with Maintenance Director #1 revealed being unaware of the gnats in the area of the kitchen juice dispensing machine. Review of facility pest control contractor treatments dated 11/23/22, 10/26/22, and 09/26/22 revealed the last treatment applied for small fruit flies in the kitchen was applied on 09/26/22. Review of the local health department inspection results, dated 11/15/22, revealed a lot of gnats were discovered flying in the area of the dish machine. Interview on 12/12/22 at 11:55 A.M. with Dietary Manager (DM) #323…

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 receiving psychoactive medications and psychiatric symptoms were consistently monitored for effective treatment and potential side effects of treatment medications, and the presence of adequate behaviors to warrant the use of psychotropic medications. This affected four (#17,#59, #62, #65) of five residents reviewed for the administration of unnecessary medications. The facility identified 38 residents who received psychotropic medications. The facility census was 73. Findings include: 1. Review of the medical record revealed Resident #65 admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, encephalopathy, chronic obstructive pulmonary disease, chronic kidney disease stage 3, hypothyroidism, hypertension, seizure disorder, mild intellectual disability, restlessness, and agitation. Review of the Minimum Data Set (MDS) assessment, dated 11/16/22, assessed 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.

Based on observation, staff interview, and menu review, the facility failed to ensure all items listed on the menu were provided to residents. This affected 15 residents (#23, #46, #124, #1, #4, #15, #19, #20, #25, #27, #37, #41, #47, #50, and #52 ) receiving altered texture diets. The facility census was 73 Findings include: Review of the menu for the noon meal on 12/13/22 revealed all diet types were to rereceive dinner roll and a pat of butter. Observation on 12/13/22 at 10:55 A.M. noted Dietary Helper (DH) #312 to obtain and prepare the lunch puree meal items. DH #312 placed canned pears to a blender and pureed the food item. Once the pears were pureed the pears were removed from the blender and placed to a serving pan. DH #312 cleansed the blender and proceeded to place slices of pork loin into the blender with ladles of gravy added to the puree. Once the pork loin was mixed to a puree it was placed to a serving pan and the blender was cleansed. DH#312 then obtained boiled/cooked sliced green beans and proceeded to puree followed by placing to a serving pan. At no time 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 medical record review, staff interview, review of Situation, Background, Assessment Recommendation (SBAR) documents and review of facility policy and procedure, the facility failed to ensure residents met criteria prior to the initiation of antibiotics. This affected four (#5, #34, #67 and #70) of four residents reviewed for antibiotic use. The facility identified seven residents ordered antibiotics. The facility census was 73. Findings include: 1. Review of Resident #5's medical record revealed an admission date of 03/21/22. Diagnoses included Alzheimer's disease, hypertension, atrial fibrillation, unspecified mood disorder, venous insufficiency, depression and cellulitis of left lower limb. Review of a plan of care focus area revised 12/09/22 revealed Resident #5 had a left shin wound and infection. Interventions included the antibiotic Bactrim DS oral tablet 800-160 milligram (mg) one tablet by mouth two times a day for cellulitis. Review of a physician order dated 12/08/22 revealed Resident #5 was ordered Bactrim DS oral tablet 800-160 mg one tablet by mouth two times…

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, staff interview, and review of the facility COVID-19 testing line list, the facility failed to ensure resident's COVID-19 testing was documented in the medical record. This affected two (#29 and #62) of two residents reviewed for COVID-19, with the potential to affect all residents of the facility. The facility census was 73. Findings include: 1. Review of Resident #29's medical record revealed an admission date of 10/09/20. Diagnoses included hypertension, malignant neoplasm of unspecified right female breast, hypertensive chronic kidney disease, type II diabetes, rheumatoid arthritis, chronic obstructive pulmonary disease (COPD) and Alzheimer's disease. Review of a plan of care focus area initiated 12/12/22 revealed Resident #29 had COVID-19 infection. Interventions included assess per orders, document and notify the physician of changes, good hand hygiene for all direct care staff and isolate in a single occupancy room. Review of a nursing progress note dated 12/12/2022 revealed Resident #29's COVID-19 outbreak testing results came back positive.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure residents were notified when their personal funds account balance was within $200.00 of the Medicaid resource limit. This affected three (#8, #15 and #23) of five residents reviewed for personal funds. The facility census was 73. Findings include: Record review revealed Resident #8 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, major depressive disorder, cerebrovascular disease, hypothyroidism, and vitamin D deficiency. Review of the current account statement for Resident #8 revealed a balance of $5,429.01. Review of both the medical and financial record for Resident #8 revealed no evidence Resident #8 or the representative were notified the personal account balance was above the $2,000.00 state Medicaid resource limit as required. Interview on 12/14/22 at 2:20 P.M. with Business Office Manager (BOM) #401 verified the resource limit notification had not been provided. 2. Record review revealed Resident #15…

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, staff interview, and review of facility policy, the facility failed to notify the physician of a significant medication error. This affected one (#59) of five residents reviewed for unnecessary medications. The facility census was 73. Findings include: Review of Resident #59's medical record revealed an admission date of 04/19/22. Diagnoses included dementia, hypertension, benign prostatic hyperplasia, post-traumatic stress disorder (PTSD), anxiety disorder, osteoarthritis, major depressive disorder, type II diabetes, restlessness, and unspecified mood disorder. Review of the annual Minimum Data Set (MDS) assessment, dated 12/07/22, revealed Resident #59 was severely cognitively impaired, had no mood symptoms, no behaviors, and no hallucinations or delusions. Additionally, active diagnoses included unspecified dementia, anxiety, depression and PTSD. Lastly, Resident #59 received anti-psychotic and anti-depressant medications on a routine basis. Review of a psychiatric progress note dated 09/12/22 revealed a gradual dose reduction for Risperdal was 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.

Based on observation, medical record review and staff interview, the facility failed to ensure privacy for residents dependent for care. This affected two (#1 and #13) of two residents reviewed for privacy. The facility census was 73. Findings include: 1. Review of Resident #1's medical record revealed an admission date of 04/20/10. Diagnoses included Alzheimer's disease, chronic kidney disease, anxiety disorder, chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/07/22, revealed Resident #1 was severely impaired for decision making and required total dependence bed mobility, transfers, dressing, toilet use and personal hygiene. Additionally, Resident #1 was always incontinent of bowel and bladder. 2. Review of Resident #13's medical record revealed an admission date of 04/26/17. Diagnoses included unspecified dementia, type II diabetes, chronic kidney disease, major depressive disorder, heart failure, hypertension and atherosclerotic heart disease. Review of the quarterly…

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, manufacturer instructions for use, and facility policy, the facility failed to transport residents in the hallway utilizing the appropriate device in a safe manner. This affected one (#44) of four residents reviewed for accidents in a facility census of 73. Findings include: Review of the medical record revealed Resident #44 admitted to the facility on [DATE]. Diagnoses included dementia, hypertension, major depression, obsessive compulsive disorder, anxiety disorder, and osteoarthritis of right knee. Review of the Minimum Data Set (MDS) assessment, dated 11/08/22, revealed Resident #44 with severe cognitive impairment, dependent on the extensive assistance of one staff for the completion of activities of daily living including transfer, and dependent on staff for mobility utilizing a wheelchair. Review of the plan of care developed on 10/26/22 addressed the residents activity of daily living (ADL) self-care performance deficit related to cognitive…

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

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 the care and management and continued need for an indwelling urinary catheter for Resident #63. This affected one resident (Resident #63) of one resident reviewed for having an indwelling urinary catheter. The facility census was 73. Findings include: Record review revealed Resident #63 was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, diabetes mellitus type II, benign prostatic hyperplasia with lower urinary tract symptoms, hypertension, acute and chronic respiratory failure, atrial fibrillation, chronic obstructive pulmonary disease, cardiomyopathy, dementia, and chronic kidney disease, stage 3. Review of the medical record reviewed Resident #63 had a scheduled Cardiologist appointment on 10/26/22. At the appointment Resident #63 was admitted to the hospital for a diagnosis of right sided heart failure. Resident #63 returned to the facility on [DATE]. Further…

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, staff interview, and review of facility pharmacy policies, the facility failed to ensure intravenous (IV) administration tubing was changed every 24 hours and failed to change dressings at IV cites per the policy. This had the potential to affect two (#224 and #12) out of two residents reviewed for IV medications. The facility census was 73. Findings include: Review of Resident #224's record revealed an admission date of 12/07/22. Diagnoses included acute cystitis, sepsis without acute organ dysfunction, Escherichia coli (e-coli), bacteremia and neoplasm of the bladder. Review of a physician order dated 12/07/22 revealed Resident #224 was ordered the antibiotic ceftriaxone sodium 2000 milligrams in 50 milliliters of 0.9% normal saline intravenously once daily for cystitis for ten days. Review of the medical record for Resident #224 revealed a midline single lumen catheter in the left basilic vein. Observation on 12/13/22 at 8:19 A.M. revealed a bag of ceftriaxone 2 grams in 100 milliliters labeled for Resident #224…

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 implement interventions for the treatment of depressed mood. This affected one (#65) of one resident reviewed for mood and behavioral interventions. The facility census was 73. Findings include: Review of the medical record revealed Resident #65 admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, encephalopathy, chronic obstructive pulmonary disease, chronic kidney disease stage 3, hypothyroidism, hypertension, seizure disorder, mild intellectual disability, restlessness, and agitation. Review of the Minimum Data Se (MDS) assessment, dated 11/16/22, assessed the resident with the ability to make needs known, cognitively intact, resistive to care daily, requires supervision assistance with activities of daily living, continent of bowel and bladder, and receives an antianxiety medication daily. Review of a nursing plan of care developed on 11/07/22 address the resident having a…

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

Based on medical record review, staff interview and review of facility policy, the facility failed to ensure medications were administered per physician order. This affected one (#62) of five residents reviewed for unnecessary medications. The facility census was 73. Findings include: Review of Resident #62's medical record revealed an admission date of 06/20/22. Diagnoses included anxiety disorder, post-traumatic stress disorder (PTSD), spinal stenosis, major depressive disorder, unspecified dementia, benign prostatic hyperplasia, unspecified mood disorder and unspecified psychosis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/01/22, revealed Resident #62 was severely cognitively impaired, required extensive assist with activities of daily living (ADLs), and had active diagnoses including Alzheimer's disease, anxiety disorder, depression, psychotic disorder, and unspecified mood disorder. In addition, Resident #62 received antipsychotic, anti-anxiety and anti-depressant medications daily. Review of a plan of care focus area initiated 06/20/22 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 observation, staff interview, and medical record review, the facility failed to ensure residents were free from significant medication errors. This affected one (#224) resident observed during medication administration and two (#224 and #59) residents reviewed for medication administration. The facility census was 73. Findings include: 1. Review of Resident #224's record revealed an admission date of 12/07/22. Diagnoses included acute cystitis, sepsis without acute organ dysfunction, Escherichia coli (e-coli), bacteremia and neoplasm of the bladder. Review of a physician order dated 12/07/22 revealed Resident #224 was ordered the antibiotic ceftriaxone sodium 2000 milligrams in 50 milliliters of 0.9% normal saline intravenously once daily for cystitis for ten days. Review of the medical record for Resident #224 revealed a midline single lumen catheter in the left basilic vein. Observation on 12/13/22 at 8:19 A.M. revealed a bag of the antibiotic ceftriaxone 2 grams in 100 milliliters labeled 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.