Majestic Care Of Point Place

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review the facility failed to accurately and timely document in the medical records. This affected one Resident (Resident #37) out of ten residents reviewed for documentation. Additionally, the facility failed to transcribe physician orders. This affected four residents (#04, #37, #05, and #63) out of six reviewed for physician orders. The facility census was 63. 1. Review of the medical record for Resident #04 revealed an admission date of 07/27/22, diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left side, gastrostomy status, and acquired absence of left leg above the knee. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/19/25 revealed Resident #04 had moderate cognitive impairment and required staff assistance for all activities of daily living (ADL's), was always incontinent for bowel and bladder. Review of the provider notes revealed Resident #04 had left shoulder pain related to a fall…

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 interviews, and review of facility policies, the facility failed to ensure infection prevention measures were correctly utilized when providing care to residents. This affected three (Residents #03, #22, and #71) of six resident reviewed for infection control. The facility census was 63. 1. Review of the medical record for Resident #22 revealed she was admitted on [DATE]. Diagnoses included hemiparesis to the right side following a stroke, type two diabetes mellitus, dysphagia, aphasia, hypertension, neurogenic bladder, colostomy, and stage three pressure ulcer. Review of the Minimum Data Set 3.0 assessment dated [DATE] for Resident #22 revealed the resident was unable to communicate and was severely cognitively impaired, displayed no behaviors at the time of the assessment and was dependent for all care. Resident #22 was at risk for pressure ulcers and three were present on admission to her right heel, scapula, and sacrum. Review of a physician order 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, staff interview, review of the facility Self-Reported Incident (SRI) and review of the facility policy, the facility failed to ensure comprehensive person center care plans were updated to include identified resident needs and appropriate interventions. This affected two (#48 and #60) of three residents reviewed for comprehensive care plans. The facility census was 64. Findings include: 1. Review of the medical record revealed Resident #48 was admitted on [DATE]. Diagnoses included unspecified dementia, major depressive disorder, atherosclerotic heart disease of native coronary artery without angina pectoris, cerebrovascular disease, essential hypertension, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 05/02/25, revealed the resident was severely cognitively impaired. Review of a facility SRI, completed on 06/05/25, revealed on 05/30/25 at 6:15 P.M. a Certified Nursing Assistant (CNA) was picking up dinner trays and entered Resident #60's room 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 policy, the facility failed to ensure staff practiced proper hand hygiene. This had the potential to affect all 62 residents in the facility. Findings include: 1. Observation on 08/05/24 at 9:09 A.M. revealed Registered Nurse (RN) #203 was taking Resident #14's blood pressure at the medication cart. RN #203 removed the cuff from Resident #14's arm, documented the data, and handed Resident #14 a medicine cup with pills. After Resident #14 consumed the pills, he handed the cup to RN #203 to throw away. RN #203 then proceeded to chart and document at her medication cart. RN #203 was not observed to perform hand hygiene after providing care to Resident #14. Continued observation revealed RN #203 pushed the medication cart to the outside of Resident #15's room. RN #203 opened her medication cart and pulled out a medication push-card and pushed a pill into a medicine cup. RN #203 then opened a bottle and extracted one pill and put it into the medicine cup. Concurrent interview with RN #203 confirmed she did not perform hand…

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, review of facility fall investigations and review of facility policy, the facility failed to ensure fall prevention interventions were implemented as ordered and care planned. This affected one (#1) of three residents reviewed for falls. The facility census was 61. Findings include: Review of the medical record revealed Resident #1 was admitted on [DATE]. Diagnoses included dementia, protein-calorie malnutrition, major depression, polyneuropathy, anxiety disorder, and benign prostatic hyperplasia. Review of the Minimum Data Set (MDS) assessment, dated 02/11/24, revealed Resident #1 was cognitively intact, was able to make needs known, required substantial or maximal assistance with activities of daily living (ADLs), required partial to moderate assistance with transfers and repositioning, was incontinent of bowel and bladder, had no weight loss, received a mechanically altered diet, and was at risk for pressure ulcer development with no 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure incontinence care was properly administered to prevent infection. This affected one (#1) of three residents reviewed for the provision of incontinence care. The facility census was 61. Findings include: Review of the medical record revealed Resident #1 was admitted on [DATE]. Diagnoses included dementia, protein-calorie malnutrition, major depression, polyneuropathy, anxiety disorder, and benign prostatic hyperplasia. Review of the Minimum Data Set (MDS) assessment, dated 02/11/24, revealed Resident #1 was cognitively intact, was able to make needs known, required substantial or maximal assist with activities of daily living (ADLs), required partial to moderate assistance with transfers and repositioning, was incontinent of bowel and bladder, had no weight loss, received a mechanically altered diet, and was at risk for pressure ulcer development with no skin breakdown. Review of the plan 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, staff interview, and review of facility policy, the facility failed to ensure residents who required assistance with eating were provided a dignified dining experience. This affected two residents (#44 and #35) of nine residents observed eating lunch in the main dining room. The facility census was 65. Findings Included: Observation on 03/04/24 at 11:18 A.M., of the main dining room, found nine residents seated at four tables. Two residents, Resident #44 and Resident #35, were seated at a square table. The Director of Nursing (DON) was observed standing over Resident #44 and spooning bites of his lunch into his mouth. Interview on 03/04/24 at 11:22 A.M. with the DON verified she was standing to feed Resident #44. The DON reported she was feeding him chicken and dumplings, green beans, a roll, and a cream dessert. Continued observation on 03/04/24 at 11:23 A.M. found the DON asked Resident #35 if he needed help eating. A response was not heard, but the DON was observed standing between Resident #44 and #35 and providing both residents bites of their meals while…

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 facility policy review, the facility failed to ensure the physician was notified when blood glucose levels were outside of established parameters as ordered. This affected one (#36) of three residents reviewed for insulin. The facility census was 65. Findings include: Review of the medical record revealed Resident #36 was admitted on [DATE]. Diagnoses included end stage renal disease, type two diabetes mellitus with diabetic nephropathy and polyneuropathy, chronic diastolic (congestive) heart failure, muscle weakness, difficulty walking, delirium due to known physiological condition, essential hypertension, alcohol abuse, and major depressive disorder recurrent severe with psychotic symptoms. Review of the Minimum Data Set (MDS) assessment, dated 02/21/24, revealed Resident #36 was cognitively intact. Review of Resident #36's physician orders, dated 02/03/24 through 02/08/24, revealed an order for Novolog insulin to inject as per sliding scale subcutaneously…

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 orders to discontinue psychotropic medications were followed according to the physician order. This affected one resident (#44) of five residents reviewed for unnecessary medications. The facility census was 65. Findings Include: Review of Resident #44's medical record revealed an admission date of 12/01/22. Diagnoses included neurocognitive disorder with lewy bodies (dementia), schizoaffective disorder, chronic kidney disease, cognitive communication deficit, muscle weakness, chronic pain, depressive episodes, and anxiety disorder. Review of Resident #44's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three indicating Resident #44 was severely cognitively impaired. Resident #44 was dependent on staff for activities of daily living including toilet use, bathing, dressing, transfer, and eating. Resident #44 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 medical record review, staff interview, and review of a facility policy, the facility failed to maintain a complete and accurate medical record. This affected one (#51) of 16 resident medical records reviewed. The facility census was 65. Findings include: Review of the medical record for Resident #51 revealed the resident was admitted on [DATE] and had diagnoses that included chronic kidney disease and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #51, dated 12/14/23, revealed the resident was assessed with moderately impaired cognition and renal disease. Review of a nursing progress note for Resident #51, dated 02/23/24, revealed the nurse practitioner ordered a transfer to the hospital for evaluation and treatment. Further review of the progress note revealed it did not include a reason for Resident #51's transfer, such as the signs or symptoms exhibited by Resident #51 to necessitate a hospital transfer, nor any indication of the events…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, resident interview, and staff interviews, the facility failed to ensure admission orders were obtained to provide care and treatment to a resident with a suprapubic urinary catheter. This affected one (#8) of one resident identified with a suprapubic catheter. The facility census was 67. Findings include: Review of Resident #8's medical record revealed an admission date of 01/01/24, with diagnoses including, gastroparesis, chronic obstructive pulmonary disease, infection, and inflammatory reaction due to indwelling urethral catheter, neuromuscular dysfunction of bladder, methicillin resistant staphylococcus aureus infection, colostomy, stage 4 pressure ulcer left buttock, sepsis, anemia, chronic respiratory failure, paraplegia, schizophrenia, bipolar disorder, major depressive disorder, and type 2 diabetes mellitus. Review of the minimum data set assessment dated [DATE], revealed Resident #8 was assessed with intact cognition, ability to make needs known, dependent…

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 wound treatments were applied as ordered by the physician. This affected one (#9) of three residents reviewed for the application of wound treatments. The facility census was 67. Findings include: Review of Resident #9's medical record revealed an admission date of 10/19/23, with the diagnoses including: acute respiratory failure, chronic coronary microvascular dysfunction, type 2 diabetes mellitus, dysphagia, hypertensive heart and chronic kidney disease, dementia, autoimmune hepatitis, and stage 3 pressure ulcer to right and left buttock. Review of the minimum data set assessment dated [DATE] assessed Resident #9 with intact cognition, required substantial or maximal assistance with activities of daily living, dependent on staff for bed mobility and transfer, frequently incontinent of bowel and bladder, and at risk for pressure ulcer development. Review of a nursing plan of care, revealed it was revised 12/11/23 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, staff and resident interview, and policy review, the facility failed to provide consistent care and treatment to a resident identified with a suprapubic catheter. This affected one (#8) of one resident identified with a suprapubic catheter. The facility census was 67. Findings include: Review of Resident #8's medical record revealed an admission date of 01/01/24 with diagnoses including, gastroparesis, chronic obstructive pulmonary disease, infection, and inflammatory reaction due to indwelling urethral catheter, neuromuscular dysfunction of bladder, methicillin resistant staphylococcus aureus infection, colostomy, stage 4 pressure ulcer left buttock, sepsis, anemia, chronic respiratory failure, paraplegia, schizophrenia, bipolar disorder, major depressive disorder, and type 2 diabetes mellitus. Review of the minimum data set assessment dated [DATE], revealed Resident #8 was assessed with intact cognition, ability to make needs known, dependent on staff for 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 laboratory contract review and policy review, the facility failed to obtain laboratory blood testing within physician ordered timeframes. This affected one (#6) of three sampled residents reviewed for laboratory blood testing. The facility census was 67. Findings include: Review of Resident #6's medical record revealed an admission date of 11/14/23, with the diagnoses including: acute kidney failure, chronic kidney disease stage 3, epilepsy, lupus, paraplegia, severe protein calorie malnutrition, hyperkalemia, metabolic acidosis, neuromuscular dysfunction of bladder, colostomy, pulmonary hypertension, anemia, and hypertension. Review of the minimum data set assessment dated [DATE] assessed Resident #6 with intact cognition, dependent on staff for the completion of activities of daily living, utilized an indwelling catheter and ostomy. Review of a physician order dated 01/01/24 at 5:15 P.M., revealed an order was initiated for STAT (immediately) laboratory…

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 notify physician timely of critical laboratory blood testing results. This affected one (#6) of three sampled residents reviewed for laboratory blood testing. The facility census was 67. Findings include: Review of Resident #6's medical record revealed an admission date of 11/14/23, with the diagnoses including: acute kidney failure, chronic kidney disease stage 3, epilepsy, lupus, paraplegia, severe protein calorie malnutrition, hyperkalemia, metabolic acidosis, neuromuscular dysfunction of bladder, colostomy, pulmonary hypertension, anemia, and hypertension. Review of the minimum data set assessment dated [DATE] assessed Resident #6 with intact cognition, dependent on staff for the completion of activities of daily living, utilized an indwelling catheter and ostomy. Review of a physician order dated 01/01/24 at 5:15 P.M., revealed an order was initiated for STAT (immediately) laboratory (labs) to include a complete blood…

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 policy review, the facility failed to ensure staff wore proper personal protective equipment (PPE) in a COVID positive environment and changed PPE after exposure. This had the potential to affect 11 (#57, #58, #60, #62, #63, #64, #65, #66, #67, #68, and #69) non infected residents of the 12 residents on Resident #59's hall. The facility census was 69. Findings include Review of the medical record for the Resident #59 revealed an admission date of 08/28/23. Diagnoses included chronic obstructive pulmonary disease, hemiplegia and hemiparesis, osteomyelitis, respiratory failure, diabetes, heart disease and COVID-19. Review of physician orders for 12/23/23 for transmission based isolation due to COVID-19 positive diagnosis until 01/03/24. Observation and interview on 12/27/23 at 11:16 A.M., revealed Licensed Practical Nurse (LPN) #191 walked into a COVID-19 positive Resident #59's room wearing only a leopard print surgical mask. Upon her exit, LPN #191 confirmed Resident #59 had tested positive for COVID-19 and confirmed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, staff interview, and resident interviews, the facility failed to ensure timely response to call lights and providing care per personal preference. This affected two (#30 and #61) of three residents reviewed for call light responses. Facility census was 69. Findings include 1. Review of the medical record for Resident #30 revealed an admission date of 06/21/23. Diagnoses included chronic obstructive pulmonary disease, atrial fibrillation, muscle weakness, dysphasia, chronic pain, anxiety, and chronic pain. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 was cognitively intact and required substantial/maximum assist for toileting transfers and mobility. Review of the plan of care dated 10/18/23 revealed resident had an activity of daily living (ADL) self-care deficit related to memory loss, mobility, and cognitive loss with interventions resident requires one to two person assist for repositioning and turning in bed, encourage use of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, staff interview, and resident interview, the facility failed to provide timely incontinence care to a dependent resident. This affected one (#30) of three residents reviewed for assistance with care and treatment. The facility census was 69. Findings include Review of the medical record for Resident #30 revealed an admission date of 06/21/23. Diagnoses included chronic obstructive pulmonary disease, atrial fibrillation, muscle weakness, dysphasia, chronic pain, anxiety, and chronic pain. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 was cognitively intact and required substantial/maximum assist for toileting transfers and mobility. Review of the plan of care dated 10/18/23 revealed resident had an activity of daily living (ADL) self-care deficit related to memory loss, mobility, and cognitive loss with interventions resident requires one to two person assist for repositioning and turning in bed, encourage use of call light and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, medical record review, and policy review, the facility failed to ensure a resident who was self-administering medications was safely disposing of used syringes. This affected one (#27) of one resident who self-administers injectable medication. The facility identified nine residents (#4, #12, #20, #22, #26, #29, #33, and #35), who resided on the 200 hall, who were cognitively impaired and independently mobile. The facility census was 66. Findings include: Review of Resident #27's medical record revealed an admission date of 01/07/22, with diagnosis including multiple sclerosis (MS). Review of Resident #27's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #27's physician's orders for October 2023 revealed an order for interferon beta-1b subcutaneous kit 0.3 milligram (mg) (used for treatment of MS) to be given every other day in the evening. Review of Resident #27's assessment 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 observation, resident and staff interviews, medical record review, and policy review, the facility failed to ensure medications were secured and not left at the beds side unattended. This affected one (#27) of one resident who self-administers injectable medication. The facility identified nine residents (#4, #12, #20, #22, #26, #29, #33, and #35), who resided on the 200 hall, who were cognitively impaired and independently mobile. The facility census was 66. Finding include: Review of Resident #27's medical record revealed an admission date of 01/07/22, with diagnoses including multiple sclerosis (MS) and history of urinary tract infection (UTI). Review of Resident #27's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #27's physician's orders for October 2023 revealed an order for interferon beta-1b subcutaneous kit 0.3 milligram (mg) (used for multiple sclerosis) to be given daily every other day in the evening and cefepime…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure behavioral health needs were appropriately addressed or monitored. This affected one (Resident #1) of three residents reviewed for behavioral health services. The facility census was 66. Findings include: Review of the closed medical record revealed Resident #1 was admitted on [DATE] with a diagnosis of major depressive disorder, severe without psychotic features. The resident was discharged on 06/10/23. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact, showed minimal signs of depression and had no behaviors. The resident received antianxiety, antidepressant, hypnotic, antibiotic, and opioid medications. Review of the care plan initiated on 05/01/23, revealed Resident #1 was care planned for depression with appropriate interventions. The care plan did not identify if the resident had suicidal ideations or history of suicide attempts. Review of the social service progress note…

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

Based on observation, staff interview, and review of facility policies, the facility failed to ensure foods stored in the refrigerator and freezer were stored in a safe and sanitary manner. This had the potential to affect all residents with the exception of three (#38, #102, and #156) residents identified by the facility as receiving no food from the kitchen. The facility census was 59. Findings include: Observation and concurrent interview on 09/11/23 beginning at 8:20 A.M., during a tour of the kitchen with interim Dietary Manager (DM) #341, revealed seven cucumbers in the walk-in refrigerator were uncovered on a metal pan, and the cucumbers had soft spots and a white substance on them. DM #341 touched the cucumbers and verified the white substance was mold, removed the pan, and stated the cucumbers would be thrown away. Additional observation of the walk-in refrigerator revealed an opened three pound container of apple pie filling, dated 08/02/23, and approximately half-full. Observation of the container with DM #341 revealed no indication of a use by date after opening. DM #341…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, and medical record review, the facility failed to honor a resident's preference to be transferred to bed. This affected one (#38) of one residents reviewed for choices. The facility census was 59. Findings include: Review of Resident #38's medical record revealed an admission date of 07/27/22. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, dysphagia, chronic obstructive pulmonary disease (COPD), human immunodeficiency virus (HIV), type II diabetes, chronic viral hepatitis C, atherosclerosis, and acquired absence of left leg above the knee. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was moderately cognitively impaired, required extensive assistance with bed mobility and total dependence for locomotion, toileting, dressing, eating, and personal hygiene. Review of the plan of care reviewed 07/12/23, revealed Resident #38 had an activities of daily living (ADLs) self-care performance deficit…

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 policy review, the facility failed to ensure a resident's advance directives for code status were consistent throughout the medical record. This affected one (#25) of nine residents reviewed for advance directives. The facility census was 59. Findings include: Review of Resident #25's medical record revealed and admission date of 09/06/19. Diagnoses included a contusion of the head, cerebral infarction, diabetes mellitus type two, dysphagia, chronic pain, and atrial fibrillation. Review of the annual Minimum Data Set (MDS) assessment revealed Resident #25 was cognitively impaired. Review of the plan of care last revised 08/04/23 revealed Resident #25 established a Do Not Resuscitate Comfort Care (DNRCC) advanced directive meaning no life-saving measures would be implemented in the event of cardiac or respiratory arrest. Review of a physician order dated 09/06/23 revealed Resident #25 had and order for a DNRCC code status. Review of a divider tab in Resident #25's paper chart revealed a hand written note which indicated 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, observation, resident and staff interview, and review of a facility policy, the facility failed to ensure a resident dependent for care received assistance with shaving and nail care. This affected one (#38) of four residents reviewed for activities of daily living. The facility census was 59. Findings include: Review of Resident #38's medical record revealed an admission date of 07/27/22. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, dysphagia, chronic obstructive pulmonary disease (COPD), human immunodeficiency virus (HIV), type II diabetes, chronic viral hepatitis C, atherosclerosis, and acquired absence of left leg above knee. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was moderately cognitively impaired, required extensive assistance with bed mobility, and total dependence for locomotion, toileting, dressing, eating, and personal hygiene. Review of the plan of care reviewed 07/12/23 revealed Resident #38 had…

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 resident and staff interview, and review of a facility policy, the facility failed to provide timely incontinence care for a resident. This affected one (#38) of three residents reviewed for incontinence care. The facility census was 59. Findings include: Review of Resident #38's medical record revealed an admission date of 07/27/22. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, dysphagia, chronic obstructive pulmonary disease (COPD), human immunodeficiency virus (HIV), type II diabetes, chronic viral hepatitis C, atherosclerosis, and acquired absence of left leg above the knee. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was moderately cognitively impaired, required extensive assistance with bed mobility and required total dependence for locomotion, toileting, dressing, eating, and personal hygiene. Additionally, Resident #38 was assessed as always incontinent of bowel and bladder. 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, observation, and staff interview, the facility failed to ensure a resident's tube feeding was administered per physician order. This affected one (#38) of one residents reviewed for tube feeding. The facility census was 59. Findings include: Review of Resident #38's medical record revealed an admission date of 07/27/22. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, dysphagia, chronic obstructive pulmonary disease (COPD), human immunodeficiency virus (HIV), type II diabetes, chronic viral hepatitis C, atherosclerosis, and acquired absence of left leg above the knee. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was moderately cognitively impaired, required extensive assistance with bed mobility, required and total dependence for locomotion, toileting, dressing, eating, and personal hygiene. Additionally, Resident #38 was assessed with a feeding tube and received 51 percent (%) or more of total calories through 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, resident and staff interview, and review of a facility policy, the facility failed to timely respond to a request for pain medication changes. This affected one (#11) of one residents reviewed for pain management. The facility census was 59. Findings include: Review of Resident #11's medical record revealed an admission date of 07/25/20 and a readmission date of 05/16/23. Diagnoses included chronic obstructive pulmonary disease (COPD), alcoholic cirrhosis, pulmonary hypertension, chronic cystitis without hematuria, spondylosis, osteoarthritis, anxiety disorder, gout, and congestive heart failure (CHF). Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had frequent pain and was on scheduled pain medication. Review of the plan of care, reviewed 09/12/23, revealed Resident #11 had pain related to osteoporosis, osteoarthritis, gout, spondylosis, and thoracic and lumbar hernia. Interventions included to administer analgesia per physician 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 medical record review and staff interview, the facility failed to ensure pharmacy recommendations were addressed by the physician in a timely manner. This affected one (#14) of five residents reviewed for unnecessary medication. The facility census was 59. Findings include: Review of the medical record for Resident #14 revealed the resident was admitted on [DATE]. Diagnoses included schizoaffective disorder, type two diabetes mellitus with foot ulcer, chronic kidney disease stage III, muscle weakness, essential (primary) hypertension, ventricular tachycardia, major depressive disorder peripheral vascular disease, acute diastolic (congestive) heart failure, and hyperlipidemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of the physician order dated 11/12/22 revealed Resident #14 was prescribed the antihistamine Allegra allergy tablet 180 milligram (mg) to give one tablet by mouth one time a day for itching. Review of the physician…

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, resident guardian interview, and review of a facility policy, the facility failed to ensure timely dental care. This affected one (#26) of one residents reviewed for dental care. The facility census was 59. Findings include: Review of Resident #26's medical record revealed an admission date of 01/24/23. Diagnoses included other intervertebral disc degeneration lumbosacral region, chronic obstructive pulmonary disease (COPD), spinal stenosis, adult failure to thrive, osteoarthritis, hypertension depression, benign prostatic hyperplasia, and alcohol abuse. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was moderately cognitively impaired, required extensive assistance with personal care, and had no mouth or facial pain, no discomfort, or difficulty with chewing. Review of a plan of care intervention revised 06/23/23 revealed Resident #26 had oral and dental health problems related to the natural…

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 resident and staff interview, the facility failed to ensure substitutions of similar nutritional value were offered timely to residents. This affected one (#18) of one residents reviewed for food preferences. The facility census was 59. Findings include: Observation on 09/12/23 at 11:05 A.M., of lunch service revealed a meal of fried chicken, mashed potatoes and gravy, and green beans was being served. Each resident had a meal ticket which indicated allergies and preferences. Dietary [NAME] (DC) #260 reviewed each meal ticket as the meal was plated. DC #260 plated one serving of fried chicken and one serving of mashed potatoes and gravy for Resident #18. Interview at this time with DC #260 stated Resident #18 did not like green beans. Continued observation revealed the meal was placed on a tray, covered, and placed on the cart to be delivered to Resident #18's room. Interview with DC #260 at the time of the observation confirmed there was no vegetable substitution available for Resident #18. DC #260 stated she had no idea of a resident's likes or dislikes…

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, facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidance the facility failed to ensure pneumococcal vaccinations were offered and administered per recommendations. This affected two (#33 and #34) of five residents reviewed for immunizations. The facility census was 59. Findings include: 1. Review of the medical record for Resident #33 revealed the resident was admitted on [DATE]. Diagnoses included acquired absence of left great toe and right leg above knee, type two diabetes mellitus with foot ulcer, chronic obstructive pulmonary disease, muscle weakness, dysphagia, major depressive disorder, and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment completed 07/17/23 revealed the resident was moderately cognitively impaired. According to the assessment, Resident #33 was up to date with the pneumococcal vaccine. Review of the vaccine record dated 09/14/23 revealed Resident #33 last had the Pneumococcal…

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 accurate tube feeding orders were implemented. This affected one (Resident #1) of three residents reviewed for tube feedings. The facility identified four residents who received tube feedings. The facility census was 52. Findings included: Review of Resident #1's medical record revealed an admission date of 12/16/22, a readmission date of 12/30/22, and a discharge date of 07/31/23. Diagnoses included pneumonia, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), type II diabetes, dysphagia, dementia, severe protein-calorie malnutrition, metabolic encephalopathy, epilepsy, and encounter for attention to gastrostomy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was moderately cognitively impaired, required extensive assistance with Activities of Daily Living (ADLs) and received 51% or more of total calories through tube…

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.