Heatherdowns Rehab & Residential Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review and review of facility policy, the facility failed to ensure resident dignity was maintained. This affected two (#42 and #43) of two residents reviewed for dignity. The facility census was 71. Findings include: 1. Review of the medical record for Resident #42 revealed an admission date of 11/13/20 with diagnoses including dementia, traumatic brain injury, and encephalopathy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had mild cognitive impairment and was continent of bladder. Review of the current care plan revealed Resident #42 was independent with toileting, required one staff supervision with personal hygiene, and required staff set up assistance for eating and meals. Observation on 02/03/25 at 9:11 A.M. revealed Resident #42 was in bed. Sitting on the overbed table was a urinal full of dark colored urine. Continued observation revealed staff delivered Resident #42's breakfast tray and placed it 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.

Based on resident interview, staff interview, medical record review, and review of facility policy, the facility failed to ensure policies and procedures related to reporting and investigating allegations of misappropriation were implemented. This affected one (#16) of three residents reviewed for misappropriation. The facility census was 71. Findings include: Review of the medical record for Resident #16 revealed an admission date of 12/23/19. Diagnoses included: hypertension, hyperlipidemia, chronic kidney disease, gastroesophageal reflux disease (GERD), schizoaffective disorder, psychotic disorder with delusions to own physiological condition, dysphagia, protein calorie malnutrition, muscle wasting, and localized osteoporosis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/15/24, revealed Resident #16 was cognitively intact. Interview on 02/03/25 at 12:15 P.M. with Resident #16 revealed the resident reported $2.00 was stolen from her room within the past six months. Resident #16 stated she informed Certified Nursing Assistant (CNA) #614 about the stolen $2.00…

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

Based on observation, staff interview, medical record review and review of facility policy, the facility failed to provide adequate hygiene assistance for a dependent resident. This affected one (#31) of one resident reviewed for activities of daily living (ADLs) care. The facility census was 71. Findings include: Review of the medical record for Resident #31 revealed an admission date of 07/15/24. Diagnoses included paraplegia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/15/24, revealed Resident #31 was cognitively intact, was always incontinent of bowel and bladder, and was staff dependent for for toileting and personal hygiene. Review of the current care plan revealed Resident #31 had an ADL self-care deficit related to paraplegia. Interventions included staff assistance with cleaning following toilet use. Interview on 02/03/25 at 9:43 A.M. with Resident #31 revealed he had been incontinent of urine and soaked through his bedding. Resident #31 stated when staff brought in his breakfast, they changed his brief and his chux pad (incontinence pad), but left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview and review of facility policy, the facility failed to ensure podiatry needs were met. This affected one (#33) of one resident reviewed for podiatry services. The facility census was 71. Findings include: Review of the medical record revealed Resident #33 was admitted on [DATE]. Diagnoses included acute kidney failure, essential hypertension, bipolar disorder, anxiety disorder, bilateral primary osteoarthritis of hip, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/13/24, revealed Resident #33 was cognitively intact. Interview on 02/03/25 at 4:47 P.M. with Resident #33 revealed her toenails were long and thick with fungus, causing her pain. Resident #33 reported she was unable to trim them herself and staff were aware of the condition of her toenails. Concurrent observation revealed all ten of Resident #33's toenails were long, thick and yellowed. Interview on 02/04/25 at 12:24 P.M. with the Director 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.

Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure a medication error rate of less than five percent. Observation of 26 medication administration opportunities revealed two medication errors, resulting in a medication error rate of seven percent. This affected two residents (#1 and #51) of three observed for medication administration. The facility census was 71. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 06/24/22. Diagnoses included hypertension (high blood pressure). Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/08/24, revealed Resident #1 was cognitively intact. Review of the current physicians orders for February 2025 revealed Resident #1 was ordered lasix 40 milligrams (mg), give one tablet by mouth one time daily related to essential hypertension. Observation on 02/05/25 at 8:18 A.M. of medication administration for Resident #1 revealed Licensed Practical Nurse (LPN) #668 dispensed and administered lasix 20 mg to the resident.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview and review of facility policy the facility failed to ensure residents were repositioned in bed in a safe manner to prevent falls. This affected one resident (#11) of three residents reviewed for falls. The facility census was 77. Findings include: Review of Resident #11's medical record revealed an admission date of 07/15/24. Diagnoses included paraplegia, chronic osteomyelitis, stage four pressure ulcer of sacral region, stage four pressure ulcer of right buttock, depression, insomnia, and osteoarthritis. Review of Resident #11's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #11 was cognitively intact. Resident #11 required extensive assistance with bed mobility and was totally dependent on staff for transfers and toilet use. Resident #11 displayed no behaviors during the review period. Review of Resident #11's care plan revised 11/20/24 revealed supports and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and home health agency interview, the facility failed to ensure adequate preparation and coordination of services prior to Resident #1's discharge to home. This affected one resident (#1) of three residents reviewed for discharge. The facility census was 81. Findings include: Resident #1 admitted to the facility on [DATE] with diagnoses including cellulitis left lower limb, type II diabetes mellitus with diabetic neuropathy, embolism and thrombosis to arteries of lower extremities, non-pressure chronic ulcer of left heel and midfoot, non-pressure chronic ulcer left ankle, arteriosclerosis left leg with ulceration of left foot, unstageable pressure ulcer sacral region, major depressive disorder, right below knee amputation, phantom limb syndrome with pain, hemiplegia and hemiparesis following cerebrovascular disease, cerebral infarction, chronic obstructive pulmonary disease, hypertension, and heart failure. Review of the Minimum Data Set (MDS) assessment, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, review of the medical record, and review of facility policy, the facility failed to ensure pressure ulcer treatments were provided as ordered for Residents #60 and #64 and further failed to ensure preventive interventions were in place to prevent the development of a pressure ulcer for Resident #8 identified at risk for developing a pressure ulcer. This affected three (#8, #60 and #64) of three residents reviewed for pressure. The facility identified three residents (#8, #60 and #64) currently in the facility with pressure ulcers. The facility census was 75. Findings include: 1. Review of the medical record for Resident #60 revealed an admission date of 08/09/24, diagnoses included dementia, hallucinations, right sided heart failure, unstageable pressure ulcers to the right and left heels. Review of the comprehensive Minimum Data Set (MDS) assessment completed on 08/15/24 revealed Resident #60 had severe cognitive impairment, was dependent for all activities…

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

Based on review of the medical record, review of controlled substance administration records, review of medication administration records, staff interview, and policy review, the facility failed to ensure medications were administered per physician orders and failed to ensure an accurate system of dispensing and administering controlled substances. This affected three (#77, #26, #18) of three residents reviewed for medication administration. The facility census was 76. Finding include: 1. Review of the medical record for Resident #77 revealed an admission date on 06/21/23, a readmission date of 10/06/23, and a discharge date of 04/20/24. Diagnoses included acute on chronic respiratory failure with hypoxia, atrial fibrillation, congestive heart failure, chronic obstructive pulmonary disease, dysphagia, obstructive sleep apnea, hypertension, and chronic pain syndrome. Review of the physician's orders dated 04/13/24 revealed the resident had orders for lorazepam tablet 0.5 milligrams (mg) by mouth every four hours as needed. Review of a physician order dated 04/14/24, revealed orders…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, resident and staff interviews, and review of the facility policy, the facility failed evaluate, provide care and treatment, and conduct ongoing assessments to treat a resident's skin alteration. This affected one (Resident #4) of two residents reviewed for skin care and treatment. The facility census was 69. Findings include: Review of the medical record for Resident #4 revealed an admission date of 01/22/23. Diagnoses included congestive heart failure, chronic kidney disease, type II diabetes mellitus, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact, was independent with activities of daily living, was incontinent of urine, and had no skin breakdown with no skin alterations. However, Resident #4 was at risk for skin breakdown and received the application of nonsurgical dressing. Review of the care plan dated 03/31/24 revealed Resident #4 was at risk for skin alterations due to disease process,…

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, physician office visit notes, staff interview, and review of the facility policy, the facility failed to ensure a sufficient supply of medical supplies and equipment were provided at the time of resident discharge from the facility. This affected one (Resident #01) of three residents reviewed for discharge. The facility census was 76 residents. Findings include: Review of the medical record for Resident #01 revealed an admission date of 12/04/23 with diagnoses including osteomyelitis left ankle and foot, amputation left great toe, protein calorie malnutrition, necrotizing fasciitis, polyneuropathy, sepsis, type two diabetes mellitus, hypertension, and pulmonary embolism. Review of physician orders for Resident #01 revealed an order dated 12/04/23 for insulin glargine inject 18 units subcutaneous every morning and at bedtime for diabetes mellitus type two. Review of the physician orders for Resident #01 revealed an order dated 12/06/23 for insulin aspart inject per sliding scale: if 0 - 150 = 0 units, 151 - 200 = 2 units, 201 - 250 = 4 units, 251 - 300…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the facility shower schedule, the facility failed to provide residents with assistance to complete scheduled showers. This affected two (Residents #01 and #05) of three residents reviewed for the provision of activities of daily living (ADLs). The facility census was 76 residents. Findings include: 1. Review of the medical record for Resident #01 revealed an admission date of 12/04/23 with diagnoses including osteomyelitis left ankle and foot, amputation left great toe, protein calorie malnutrition, necrotizing fasciitis, polyneuropathy, sepsis, type two diabetes mellitus, hypertension, and pulmonary embolism and a discharge date of 01/15/24. Review of the care plan for Resident #01 dated 12/06/23 revealed the resident was at risk for decline in activities of daily living (ADLs.) Interventions included the following: staff to assist resident with ADLS, encourage resident to participate in ADLs, maintain non-weight bearing status to the resident's…

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

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure staff practiced proper infection control practices when entering and exiting rooms under transmission based precautions. This had the potential to affect all 75 residents residing in the facility. The facility census was 75. Findings include: Observation on 12/11/23 at 8:58 A.M. revealed State Tested Nurse Aide (STNA) #101 donned an isolation gown to enter Resident #71's room, who was positive for COVID-19. STNA #101 was wearing an N95 respirator and goggles. Signage on the door to the room indicated Resident #71 was under transmission-based precautions (TBP) and staff were required to wear personal protective equipment (PPE) including an N95 respirator, a face shield, a isolation gown, and gloves upon entering the room. Additional signage indicated the N95 respirator and eye protection should be discarded upon exit from the room. STNA #101 did not put on gloves. STNA #101 carried in a meal tray for Resident #71, then before exiting the room, removed and disposed of the isolation…

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

Based on medical record review, staff interview, review of facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure pneumococcal vaccines were offered to residents per CDC guidelines. This affected two (#15 and #40) of five residents reviewed for vaccinations. The facility census was 75. Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 11/01/23 with a diagnosis of end stage renal disease. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 11/08/23, revealed Resident #15 had intact cognition. Review of the faxed information provided by the hemodialysis clinic, faxed on 12/11/23 at 3:58 P.M., revealed Resident #15 received the Prevnar 13 pneumococcal vaccination on 09/30/20. Review of CDC recommendations for pneumococcal vaccine timing for adults, dated 02/16/22, revealed based on the Resident #15's age and risk factors, Resident #15 should have been offered one dose of the pneumococcal 20-valent conjugate vaccine immunization at least one year after…

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

Based on medical record review, resident interview, staff interview, review of the facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure residents were offered COVID-19 booster vaccinations. This affected one (#40) of five residents reviewed for COVID-19 vaccinations. The facility census was 75. Findings include: Review of the medical record for Resident #40 revealed an admission date of 11/01/22 with diagnoses of chronic kidney disease and sickle cell disease. Review of the 5-day Minimum Data Set (MDS) assessment completed 11/14/23, revealed Resident #40 had intact cognition. Review of the COVID-19 immunizations for Resident #40 revealed he most recently received a COVID-19 booster vaccination on 02/10/22. Interview on 12/11/23 at 4:10 P.M. with Resident #40 revealed he could not recall if he was offered the COVID-19 bivalent booster vaccine; however, he would have accepted it if the facility offered it. Review of the Centers for Disease Control (CDC) guidelines for COVID-19 booster, found at…

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

Based on observation and staff and resident interview, the facility failed to maintain resident dignity by utilizing disposable eating utensils and cups for meal service. This affected two (#25 and #26) of 12 residents observed eating on the 100 Hall. The census was 72. Findings included: Observation of meal service on 11/14/23 at 8:24 A.M. revealed staff were delivering meal trays to resident rooms on the 100 Hall. Observation of Resident #25 and Resident #26's meal tray revealed the residents received white plastic eating utensils and their beverages were in a Styrofoam cup. Interview with Dietary Manager #1 on 11/14/23 at 8:29 A.M. stated the disposable cups and eating utensils were provided to residents at times because residents were throwing away or hoarding the silverware. Dietary Manager #1 stated periodic sweeps of resident rooms were completed, and most of the silverware would be found and then used again. Dietary Manager #1 verified Resident #25 and Resident #26 received plastic eating utensils and disposable cups for the breakfast meal on 11/14/23. Interview 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 observation, staff interview, medical record review, and facility policy review, the facility failed to ensure medication was administered per physician orders. This affected one (#17) of three residents reviewed for medications. The census was 72. Findings included: Review of Resident #17's medical record revealed an admission date of 10/24/23. Diagnoses included diabetes mellitus type two, chronic kidney disease, and malnutrition. Review of Resident #17's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had an intact cognitive function. Review of Resident #17's admission orders dated 10/24/23 revealed and order for Levemir insulin 10 units to be administered subcutaneously (SQ) in the morning for diabetes. Review of Resident #17's October 2023 medication administration record (MAR) revealed Levemir 25 units SQ was to be administered daily. Further review revealed Resident #17 was administered Levemir 25 units SQ on 10/25/23. The order entered for Levemir 25 units was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interviews, resident interviews, and review of facility policy the facility failed to provide preventative skin care treatments as ordered. This affected three residents (#28, #71 and #75) of the four residents reviewed for skin care and treatment. The facility census was 75. Findings include: 1 Review of the medical record for Resident #28 revealed an admission date of 11/01/22. Diagnoses included encephalopathy, chronic viral hepatitis C, anemia, acute respiratory failure, morbid obesity, sickle cell disease, major depressive disorder, hypertensive heart and chronic kidney disease, and heart failure. Review of the quarterly Minimum Data Set (MDS) assessment 3.0 dated 08/04/23 revealed Resident #28 was cognitively intact. The assessment revealed the resident had no skin breakdown; however, the resident was identified as being at risk for skin breakdown with interventions of barrier creams, ointments and pressure reducing devices for bed and wheelchair. 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.

Based on review of the nursing staff information and staff schedules and staff interview, the facility failed to ensure the services of a registered nurse for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 66 residents currently residing in the facility. Findings include: Review of the nursing staff information and staff schedule for 09/17/22 revealed no registered nurse (RN) was present working in the facility. Further review of the schedule for 09/18/22 revealed there was only a RN for four hours. During an interview on 09/22/22 at 9:35 A.M., with the Scheduler #505 verified the facility had no RN on duty in the facility on 09/17/22 and only had an RN for four hours on 09/18/22.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews, the facility failed to notify the resident and the resident's representative in writing the reason for transfer. This affect five residents (#03, #14, #37, #44 and #48) out of five residents reviewed for hospitalization. In addition, the facility failed to send notification of transfer to the State Ombudsman for three residents (#37, #44, and #48) out of five residents reviewed for hospitalization. The facility census was 66. Findings include: 1. Review of Resident #03's medical record identified an admission date of 06/13/22 and a readmission date of 09/19/22. Diagnoses included osteomyelitis, stage IV pressure ulcer to the right heel, iron deficiency anemia, chronic obstructive pulmonary disease, hypertension, peripheral vascular disease, dementia. Review of the medical record revealed Resident #03 was discharged to the hospital on [DATE]. Review of both the electronic and hard charts revealed no evidence Resident #03 or the representative for Resident #03…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure residents received bed hold notifications upon hospitalization. This affected two residents (#14 and #44) out of five residents reviewed for hospitalization. The facility census was 66. Findings include: 1. Review of Resident #44's medical record was admitted to the facility on [DATE], diagnoses included fracture right ischium, gastrointestinal hemorrhage, chronic kidney disease, anemia, type II diabetes mellitus, atrial fibrillation, and malnutrition. Further review of the medical record revealed Resident #44 was discharged to a local hospital on [DATE]. Review of both the electronic and hard charts revealed no evidence Resident #44 was given a bed hold notice by the facility as required. 2. Review of Resident #14's medical records revealed an original admission date of 11/23/18 and a re-admission date of 09/30/22. Diagnoses included diabetes mellitus type II, unspecified protein-calorie malnutrition, essential…

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 interview, the facility failed to implement a person-centered care plan for a resident who was unable to speak English. This affected one resident (#47) out of one resident reviewed for communication. The facility identified two residents who do not speak the predominant language of the facility. The facility census was 66. Findings include: Review of Resident #47's medical record revealed an admission date of 12/10/19. Diagnoses included Parkinson's disease, COVID-19, protein-calorie malnutrition, type II diabetes, hyperlipidemia, anxiety, major depressive disorder, and hypertension. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #47 was cognitively impaired, and does not need or want an interpreter to communicate with a doctor or health care staff. The assessment revealed the resident had unclear speech, was usually understood, and usually understood instructions. Review of Resident #47's care plan revised 09/20/22 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 medical record review, staff interview, and policy review, the facility failed to ensure the resident care plans were revised to reflect current resident medical/behavioral conditions. This affected one resident (#48) out of three residents reviewed for activities of daily living. The facility census was 66. Findings Include: Review of the medical record revealed Resident #48 was admitted to the facility on [DATE], and re-admitted to the facility on [DATE]. Diagnoses included COVID on 08/23/22, and pneumonia on 08/26/22, muscle weakness, type II diabetes mellitus, unspecified protein-calorie malnutrition, cerebrovascular disease, dementia, hypertension and obesity. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #48 was cognitively impaired, was totally dependent for bed mobility, dressing, and toilet use and required extensive assistance with personal hygiene with one person assistance for bathing. Review of the revised care plan dated 08/25/22 revealed interventions for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview, the facility failed to ensure residents who spoke only a foreign language had an effective form of daily communications to express their wants and needs. This affected one resident (#47) out of one resident reviewed for communication. The facility identified two residents who do not speak the predominant language of the facility. In addition, the facility failed to ensure residents Activities of Daily Living (ADLs) planned care was implemented to prevent decline. This affected one resident (#48) out of four resident reviewed for ADLs. The facility census was 66. Findings include: 1. Review of Resident #47's medical record revealed an admission date of 12/10/19. Diagnoses included Parkinson's disease, COVID-19, protein-calorie malnutrition, type II diabetes, hyperlipidemia, anxiety, major depressive disorder, and hypertension. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #47 was cognitively impaired, and does not need or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident and staff interview, and policy review, the facility failed to ensure dependent residents were transferred out of bed as desired. This affected two residents (#26, and #23) of four reviewed for activities of daily living. The facility census was 66. Findings Include: 1. Review of Resident #26's medical record revealed an admission date of 05/21/21. Diagnoses included multiple sclerosis, hemiplegia and hemiparesis, paraplegia, and bipolar disorder. Review of Resident #26's Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was cognitively intact. Resident #26 was totally dependent on staff for bed mobility, transfer, and toilet use. The resident required extensive assistance with personal hygiene and dressing. Resident #26 displayed no behaviors during the review period. Review of Resident #26's care plan revised 09/13/22 revealed supports and interventions for self-care deficit, and mobility limitations. Interventions included staff to assist up to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure timely wound assessments were completed. This affected one resident (#03) out of four residents reviewed of pressure ulcers. The facility census was 66. Findings include: Review of Resident #03's medical record identified an admission date of 06/13/22 and a readmission date of 09/19/22. Diagnoses included osteomyelitis, stage IV pressure ulcer to the right heel, iron deficiency anemia, chronic obstructive pulmonary disease, hypertension, peripheral vascular disease, dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #03 was cognitively intact, had clear speech, usually understands and was usually understood, required supervision with bed mobility, transfers and toilet use and extensive assistance with dressing, and personal hygiene with one person physical assist for bathing. Resident #03 had two unhealed pressure ulcers, a stage III pressure ulcer to the left heel and a stage…

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, medical record review, and policy review, the facility failed to ensure fall interventions were in place as care planned and ordered. This affected one resident (#34) out of three residents reviewed for falls. The facility census was 66. Finding included: Review of Resident #34's medical record revealed an admission date of 07/15/21. Diagnoses included congestive heart failure, protein-calorie malnutrition, diabetes mellitus type II, major depression, and muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was assessed with severely impaired cognition and required extensive one person physical assistance for bed mobility and transfers. Review of the fall risk assessment completed on 10/14/21, 01/14/22, 04/12/22, 06/18/22, and 08/09/22 revealed Resident #34 was assessed at risk for falls. Review of a nursing progress note dated 06/18/22 revealed Resident #34 was found on the floor beside her bed not on the side 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 observation, medical record review, resident and staff interview, and policy review, the facility failed to implement nutritional interventions as recommended by the dietician. This affected one resident (#14) out of four residents reviewed for nutrition. The facility census was 66. Findings include: Review of Resident #14's medical records revealed an original admission date of 11/23/18 and a re-admission date of 09/30/22. Diagnoses included diabetes mellitus type II, unspecified protein-calorie malnutrition, essential hypertension, major depression, and vitamin D deficiency. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was assessed with moderately impaired cognition and required supervision and set up assistance only for eating. Review of a dietary progress note dated 09/07/22 revealed Resident #14 returned to the facility following a transfer to the hospital on [DATE]. Resident #14's meal intakes were between 50 percent (%) and 100% and Resident #14 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of a hospital document, and review of a pharmacy document, the facility failed to administer medications as ordered. This affected one resident (#14) out of five residents reviewed for unnecessary medications. The facility census was 66. Findings include: Review of Resident #14's medical records revealed an original admission date of 11/23/18 and a re-admission date of 09/30/22. Diagnoses included diabetes mellitus type II, unspecified protein-calorie malnutrition, essential hypertension, major depression, and vitamin D deficiency. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was assessed with moderately impaired cognition. Review of a hospital document dated 08/27/22 revealed Resident #14 was ordered the antibiotic Keflex 500 milligrams (mg) by mouth every 12 hours for five days. Review of a pharmacy document titled New Prescription Summary, dated 08/27/22 revealed Resident #14 was prescribed Keflex 500 mg by mouth…

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 monthly pharmacy reviews, medical record review, staff interview, and policy review, the facility failed to complete monthly reviews of resident's medication regimen and failed to report irregularities to the facility. This affected one resident (#14) out of five residents reviewed for unnecessary medications. The facility census was 66. Findings include: Review of Resident #14's medical records revealed an original admission date of 11/23/18 and a re-admission date of 09/30/22. Diagnoses included diabetes mellitus type II, unspecified protein-calorie malnutrition, essential hypertension, major depression, and vitamin D deficiency. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was assessed with moderately impaired cognition. Review of the monthly pharmacy reviews dated between September 2021 and August 2022 revealed no documentation Resident #14's medication regimen was reviewed by the pharmacy in February 2022. Additionally, Resident #14's medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of monthly pharmacy reviews, medical record review, staff interview, and policy review, the facility failed to recommend gradual dose reductions of a psychotropic medication. This affected one resident (#14) out of five residents reviewed for unnecessary medications. The facility identified 29 residents in the facility who received antidepressant medications. The facility census was 66. Findings include: Review of Resident #14's medical records revealed an original admission date of 11/23/18 and a re-admission date of 09/30/22. Diagnoses included diabetes mellitus type II, unspecified protein-calorie malnutrition, essential hypertension, major depression, and vitamin D deficiency. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was assessed with moderately impaired cognition. Review of a physician order dated 07/19/21 revealed Resident #14 was ordered the antidepressant medication mirtazapine (Remeron) 7.5 milligrams (mg) one tablet by mouth at bedtime related…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure residents who tested positive for COVID-19 were quarantined separately from their roommates who were not COVID-19 positive. This affected one resident (#49) out of seven residents reviewed for infection control. The facility census was 66. Findings Include: 1. Review of Resident #47's medical record revealed an admission date of 12/10/19. Diagnoses included Parkinson's disease and COVID-19 added 08/23/22. Review of Resident #47's census information revealed Resident #47 resided the same room since 03/04/22. No room changes were found. Review of Resident #47's COVID-19 testing and notifications revealed on 08/21/22 Resident #47 tested positive for COVID-19. On 08/28/22 Resident #47 was retested and was still positive. On 08/31/22, 09/06/22, 09/13/22, and 09/19/22 Resident #47 tested negative for COVID-19. Review of Resident #47's progress notes revealed on 08/23/22 a dietary noted indicated Resident #47 should be…

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 a facility policy, the facility failed to store foods in a safe and sanitary manner. This had potential to affect 77 out of 78 residents in the facility. This did not affect Resident #41 who did not eat food from the kitchen. The facility census was 78. Findings include: Observation on 09/09/19 at 9:03 A.M. of facility's walk-in refrigerator revealed a cardboard box labeled two ten pound packages of ground beef which was stored on a shelf above a cardboard box with oranges. Interview on on 09/09/19 at 9:04 A.M. with Dietary Manager #291 verified in the walk-in refrigerator raw meat was stored on a shelf above oranges. Review of the facility policy titled Storage of Perishable Foods, dated November 2005, revealed meats shall be stored on the bottom shelf.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility policy and staff interview, the facility failed to provide a notice of transfer to residents and responsible parties upon transfer/discharge from the facility. This affected four residents (#3, #7, #8 and #75) of four residents reviewed for hospitalization. The facility identified 23 residents that had been transferred from the facility in the last 90 days. The facility census was 78. Findings include: 1. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE]. Diagnoses included heart failure, acute respiratory failure with hypoxia, muscle weakness, difficulty walking, signs and symptoms involving cognitive functions and awareness, chronic atrial fibrillation, anemia, nontoxic single thyroid nodule, type two diabetes mellitus with diabetic chronic kidney disease, major depressive disorder, sleep apnea, disorder of the brain unspecified, essential hypertension, chronic obstructive pulmonary disease, chronic kidney disease, end…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews and policy review, the facility failed to ensure the resident's advance directives were accurate in the medical record. This affected three (Resident #8, #14 and #41) of 24 residents reviewed for advance directives. The facility census was 78. Findings include: 1. Review of Resident #8's medical record revealed an admission date of [DATE]. Diagnoses included stage five chronic kidney disease, muscle weakness, altered mental status, anxiety, diabetes mellitus type II, and cerebral palsy. Review of the paper medical record revealed a document that indicated Resident #8 wished to have a Do Not Resuscitate Comfort Care (DNRCC) code status, indicating the DNR Comfort Care protocol would be activated immediately. This documented was signed on [DATE]. Review of monthly physician orders for [DATE] revealed an ordered dated [DATE] under the advanced directives section indicating Resident #8 was a full code status (the use of all life-saving measures if a person's heart or…

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 facility policy and staff interview, the facility failed to offer and document resident and responsible party choices of bed hold options upon transfer to the hospital. This affected three residents (#3, #7 and #8) of four residents reviewed for hospitalization. The facility identified 23 residents that had been transferred from the facility in the last 90 days. The facility census was 78. Findings include: 1. Review of the medical record revealed Resident #3 was with an initial admission date of 08/24/18. Diagnoses included heart failure, acute respiratory failure with hypoxia, muscle weakness, difficulty walking, signs and symptoms involving cognitive functions and awareness, chronic atrial fibrillation, anemia, nontoxic single thyroid nodule, type two diabetes mellitus with diabetic chronic kidney disease, major depressive disorder, sleep apnea, disorder of the brain unspecified, essential hypertension, chronic obstructive pulmonary disease, chronic kidney disease,…

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 a facility policy, the facility failed to timely and accurately revise comprehensive care plans. This affected two (#31 and #36) of 23 residents reviewed for care plans. The facility census was 78. Findings include: 1. Review of Resident #36's medical record revealed an admission date of 11/20/18. Diagnoses included chronic obstructive pulmonary disease, muscle weakness, osteoarthritis, major depression, anxiety, insomnia, chronic pain, and chronic kidney disease. Review of Resident #36's most recent comprehensive Minimum Data Set (MDS) revealed an admission MDS was completed on 11/25/18. Review of Resident #36's Care Area Assessment (CAA) Summary Worksheet revealed Resident #36 triggered for activities of daily living (ADL)/rehabilitation potential indicating Resident #36 required assistance with ADLs related to decreased mobility and weakness. Resident #36 triggered for urinary incontinence and indwelling catheter indicating Resident #36 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review and staff interview, the facility failed to complete a discharge summary for a resident that was a planned discharge from the facility. This affected one (resident #77) of two residents reviewed for discharge. The facility census was 78. Finding include: Review of medical record reveal Resident #77 was admitted on [DATE] and discharged on 06/19/19. Diagnosis included essential hypertension and edema. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 was cognitively intact. Record review for Resident #77 revealed there was no discharge summary or post-discharge plan of care with discharge instructions. Interview on 09/12/19 at 10:55 A.M. with Regional Nurse #100 verified the facility did not develop a discharge summary or post-discharge plan of care with discharge instructions. Regional Nurse #100 reported Resident #77 was admitted to the facility's assisted living unit and communication was verbal. Review of the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility policy, staff interview, resident interview and observation, the facility failed to follow up on range of motion recommendation from therapy services. This affected one (Resident #14) of two residents reviewed for restorative services. The facility identified 11 residents who currently received restorative services. The facility census was 78. Findings include: Review of the medical record for Resident #14 revealed the resident was admitted to the facility on [DATE] and had a readmission date of 06/05/18. Diagnoses include intermittent atrial fibrillation, hypertension, difficulty waking, muscle weakness, obesity, depression, heart failure, asthma, gastro-esophageal reflux disease, osteoarthritis, trigger thumb and carpal tunnel syndrome repair. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/03/19, revealed the resident had no cognitive deficits and was totally dependent on staff for all activities of daily living except for eating. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility policy, staff and resident interview and observation, the facility failed to implement a physician ordered and therapy recommended splinting program/functional program for a resident upon discharge from skilled therapy services. This affected one (#31) of three residents revealed for range of motion services. The facility identified four residents with splints. The facility census was 78. Findings include: Review of the medical record for Resident #31 revealed the resident was admitted to the facility on [DATE]. Diagnoses included intestinal adhesions, lack of coordination, dysphagia, abnormal posture, hypertension, rheumatoid arthritis, dementia, cerebral palsy, hallucinations, gastro-esophageal reflux disease, muscle spasm, urine retention, Parkinson's disease, intervertebral disc degeneration thoracic region, muscle weakness and unsteadiness on feet. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/12/19, revealed Resident #31 had no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review and staff interview, the facility failed to apply supplemental oxygen as ordered. This affected one (Resident #33) of 26 residents identified by the facility with a physician order for supplemental oxygen. The facility census was 78. Findings include: Review of the medical record for Resident #33 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstruction pulmonary disease, essential hypertension, unspecific dementia without behavioral disturbance, congestive heart failure and pneumonia. Review of the Minimum Data Set (MDS) assessment, dated 07/03/19, revealed Resident #33 was cognitively impaired. Review of physician's orders for Resident #33 revealed supplemental oxygen was to be applied continuously. Observation on 09/11/19 at 2:06 P.M. and 09/11/19 at 3:41 P.M. revealed Resident #33 was sitting in a wheelchair in the resident's room without supplemental oxygen applied. The oxygen tubing and nasal cannula were observed…

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

Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to follow a physician's order for a mechanical soft diet. This affected one (#28) of three residents reviewed for nutrition. The facility identified 12 residents with mechanically altered diets. The facility census was 78. Findings include: Review of Resident #28's medical record revealed an admission date of 09/07/16. Diagnoses included essential hypertension, oral phase dysphagia and muscle weakness. Review of a physician order, dated 02/25/19, revealed Resident #28 was ordered a regular diet with mechanical soft consistency. Review of the Minimum Data Set (MDS) assessment, dated 07/10/19, revealed Resident #28 was severely cognitively impaired, was on a mechanically altered diet, and was independent for eating with set up only help needed. Review of the nutritional assessment, completed on 07/12/19, revealed Resident #28 was on a mechanical soft diet. Observation on 09/12/19 at approximately 7:40 A.M. revealed Resident #28 was sitting by the South Hall nurses'…

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.