Troy Rehabilitation And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and staff interviews, the facility failed to implement a pressure redistribution device or cushion to the resident's chair according to the care plan to treat a pressure ulcer. This affected one (#36) out of three residents reviewed for wound care. The facility census was 134. Findings include: Review of the medical record for Resident #36 revealed an admission date of 11/21/24 with diagnosis of peripheral vascular disease, type 2 diabetes mellitus with diabetic neuropathy, and unspecified combined systolic (congestive) and diastolic (congestive) heart failure. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident with severe cognitive impairment. Resident #36 required set-up assistance with eating, required supervision assistance with oral hygiene, required partial assistance with personal hygiene, required substantial assistance with bed mobility, transfers, ambulating, and wheelchair mobility, and was dependent on staff assistance with toileting…

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, review of hospital documentation, staff interview, local health department interview, review of Legionella water testing, review of electronic mail (email) correspondence, and policy review, the facility failed to implement their water management policy and respond to the local health department (LHD) recommendations to remediate their water system to reduce the presence of microorganisms including Legionella. This affected one (#129) of three residents reviewed for Legionella and had the potential to affect all 128 residents residing in the facility. The facility census was 128. Findings include: Review of medical record for Resident #129 revealed an admission date of 03/23/23 and discharge date of 12/09/24. Diagnoses included but not limited to acute kidney failure, gastrointestinal hemorrhage, hypovolemic shock, Legionnaire's disease, atrial fibrillation, cocaine abuse, dermatitis, dependence on renal dialysis, and other pericardial effusion (noninflammatory). Review of Minimum Data…

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

Based on observations and resident and staff interviews, the facility failed to ensure resident rooms were clean and in good repair. This affected four (#15, #36, #43, and #116) of seven resident rooms reviewed for environment. The census was 131. Findings include: 1. Observation of Resident #116's room on 12/09/24 at 11:36 A.M. revealed and adhesive fly paper strip hanging on the wall behind the head of the bed. The fly paper had dead flies and gnats on it. Interview with Resident #116 on 12/10/24 at 7:34 A.M. revealed the fly paper strip had was in the room when she moved into it. Observation revealed the fly paper strip remained on the wall. Interview with Maintenance Director (MD) #445 on 12/16/24 at 11:14 A.M. revealed a private company handles pest control for the facility. That company does not put any fly strips in resident rooms. MD #445 was unaware that a fly strip was in Resident #116's room. MD #445 confirmed fly strips should not be hung up in resident rooms and removed the fly strip. 2. Observation in Resident #36's room on 12/10/24 at 8:36 A.M. revealed a pillow lying…

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, staff interviews, and policy review, the facility failed to ensure a resident was provided privacy when toileting. This affected one (#54) out of one residents reviewed for privacy. The facility census was 131. Findings include: Review of the medical records for Resident #54 revealed an admission date of 04/05/21 with diagnoses of cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and chronic obstructive pulmonary disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had range of motion impairment on one side of bilateral upper and lower extremities, required toileting hygiene, dressing, and personal hygiene, and required substantial assistance for bathing. Observation on 12/09/24 at 2:07 P.M. Resident #54 went into the shower room to use the bathroom, due to the bathroom in his room does not work. Observation of the shower room door revealed it…

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 and staff interviews and policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded. This affected three (#67, #289 and #125) out of 26 residents reviewed during the survey. The facility census was 131. Findings include: 1. Review of the medical record for Resident #289 revealed an admission date of 11/19/24. Diagnoses included chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. Review of the admission MDS assessment dated [DATE] revealed Resident #289 was cognitively intact. The MDS assessment coded Resident #289 does not use oxygen. Observation on 12/09/24 at 10:52 A.M. revealed Resident #289 reclining in bed with an auto-adjusting positive airway pressure (APAP) device delivering oxygen via a nose piece. Resident #289 stated the device is constantly on as he his doctors have told him he needs a lung transplant. Interview on 12/16/24 at 2:18 P.M. with Unit Manager #482 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 medical record review, observations, staff interviews and policy review, the facility failed to ensure the care plan was revised to accurately reflect resident care. This affected two (#16 and #125) out of 26 residents reviewed for care plans. The facility census was 131. Findings include: 1. Review of the medical records for Resident #16 revealed an admission date of 09/17/23 with diagnoses of quadriplegia, unspecified open wound of left buttock, subsequent encounter, contracture of muscle, left hand, and contracture of muscle, right hand. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively intact, had impairment on bilateral upper and lower extremities. Resident #16 required set-up assistance with eating, oral hygiene, and wheelchair mobility, and required substantial assistance with toileting hygiene, bathing, dressing, personal hygiene, bed mobility, and transfers. Review of the physician orders revealed an order for showers scheduled on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations and resident and staff interviews, the facility failed to assist residents with needed activities of daily living (ADL) care. This affected two (#16 and #31) out of six residents reviewed for ADL care. The facility census was 131. Findings include: 1. Review of the medical records for Resident #16 revealed an admission date of 09/17/23 with diagnoses of quadriplegia, unspecified open wound of left buttock, subsequent encounter, contracture of muscle, left hand, and contracture of muscle, right hand. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively intact, had impairment on bilateral upper and lower extremities. Resident #16 required set-up assistance with eating, oral hygiene, and wheelchair mobility, and required substantial assistance with toileting hygiene, bathing, dressing, personal hygiene, bed mobility, and transfers. Review of the physician orders revealed an order for showers scheduled on Tuesday,…

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 pressure sore treatments were complete as ordered. This affected one (#125) out of five resident reviewed for pressure ulcer care. The facility census was 131. Findings include: Review of the medical records for Resident #125 revealed an admission date of 09/10/24, a discharge date of 09/12/24 to the hospital, and a re-admission date of 09/17/24. Diagnoses of post laminectomy syndrome, pressure ulcer of sacral region, stage 2, pressure ulcer of left buttock, stage 2, and pressure ulcer of right buttock, stage 2. Review if the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #125 was cognitively intact, required supervision with oral hygiene, required partial assistance with eating and personal hygiene, required substantial assistance with bathing and wheelchair mobility, and was dependent on staff assistance with toileting hygiene, dressing, bed mobility, and transfers. Further 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, observation, staff interviews, and review of facility policy, the facility failed to ensure interventions were in place for a resident at risk for falls. This affected one (#53) of two residents reviewed for accidents. The census was 131. Findings include: Review of Resident #53's medical record revealed an admission date of 10/02/15. Diagnoses included dementia with behavioral disturbance, low back pain, major depression disorder, hypertension, and Alzheimer's disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 was cognitively intact. Review of a care plan initiated 01/07/22 revealed Resident #53 was at risk for falls related to peripheral vascular disease, dementia with impaired cognition, and decreased mobility. Interventions listed included, keep bed in lowest position initiated on 09/14/24 and low bed initiated on 09/16/24. Review of progress notes revealed Resident #53 fell from the bed onto the floor on 09/14/24. Hospice added…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff and Nurse Practitioner (NP) #447 interviews and policy review, the facility failed to ensure indwelling catheter care was completed in accordance with the physician order and care plan. Additionally, the facility failed to ensure an adequate indication of use for an indwelling urinary catheter. This affected two (#234 and #291) out of two residents reviewed for catheter care. The facility census was 131. Findings include: 1. Review of the medical records for Resident #291 revealed an admission date of 11/12/24 with diagnoses of encephalopathy, hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease, and neuromuscular dysfunction of bladder (diagnosis added on 12/10/24). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #291 was cognitively intact, had no impairment to bilateral upper and lower extremities, required set-up assistance with eating and oral hygiene, required partial…

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

Based on medical record review, observation, resident and staff interviews, and review of policy, the facility failed to ensure physician orders were in place for respiratory device and oxygen administration. This affected one (#289) out of one resident reviewed for respiratory care. The facility census was 131. Findings include: Review of the medical record for Resident #289 revealed an admission date of 11/19/24. Diagnoses included chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. Review of the physician orders revealed no order for the use of an Automatically Adjusting Positive Airway (APAP) device. An order placed on 12/09/24 at 10:46 A.M. revealed oxygen to be administered at five liters per minute via nasal cannula. Observation on 12/09/24 at 10:52 A.M. revealed Resident #289 reclining in bed with an APAP device delivering oxygen via a nose piece. Resident #289 stated the APAP device is constantly on as he his doctors have told him he needs a lung transplant. Interview on 12/16/24 at 2:18 P.M. with Unit Manager #482 provided verification 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, observations, staff interview and policy review, the facility failed to ensure medications were administered as ordered resulting in four medication errors out of 40 opportunities or a 10 percent (%) medication error rate. This affected two (#105 and #125) out of three reviewed for medication administration. The facility census was 131. Findings include: 1. Review of the medical records for Resident #105 revealed an admission date of 08/22/23 with diagnoses of Parkinson's disease without dyskinesia, moderate protein-calorie malnutrition and hypertensive chronic kidney disease with stage 5 chronic kidney. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #105 with severe cognitive impairment, had no impairment to bilateral upper and lower extremities. Resident #105 required partial assistance with eating and oral hygiene. Resident required substantial assistance with personal hygiene. Review of physician orders revealed an order dated 12/01/24…

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 arbitration agreements and staff and resident interviews, the facility failed to ensure facility staff knew a residents' cognitive status and ability to understand before having the resident sign an arbitration agreement. This affected one (#283) of four residents reviewed for arbitration agreements. The census was 131. Findings include: Review of Resident #283's medical record revealed an admission date of 11/20/24. Diagnose listed included type two diabetes mellitus, hypertensive heart disease, muscle weakness, prostate cancer, and vascular dementia. Review of a quarterly Minimum data Set (MDS) assessment dated [DATE] revealed Resident #283 had severe cognitive impairment. Resident #283's brief interview for mental status (BIMS) score was four out of a possible 15. Review of social service assessment notes dated 11/21/24 at 9:10 A.M. revealed Resident #283 was alert and oriented times one (new his name). Resident #283 had a history of dementia. Review of general…

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

Based on medical record review, observation, staff interview and review of the facility policy, the facility failed to maintain infection control protocols for an indwelling urinary catheter bag and tubing. This affected one (#234) out of two residents reviewed for urinary catheter care. The census was 131. Findings included: Review of medical record for Resident #234 revealed admission date of 12/03/24. The resident was admitted with diagnoses including urinary tract infection, neuromuscular dysfunction of bladder, retention of urine. and dementia. Review of the physician's orders for Resident #234 dated 12/04/24 for Foley catheter care every shift. A care plan for Resident #234 dated 12/04/24 related to indwelling catheter revealed individualized interventions which included maintaining drainage bag below the bladder level. Observation on 12/12/24 at 8:30 A.M. of Resident #234 was in bed with eyes closed and his indwelling urinary catheter bag and tubing was lying on the floor under the bed rail. Interview with Licensed Practical Nurse #439 on 12/12/24 at 8:32 A.M. verified…

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 medications were stored in a safe manner. This directly affected one (#137) of one random resident observed. The facility census was 138. Findings include: Observation on 07/30/24 at 11:05 A.M., revealed two medications in a small, plastic medication cup, sitting on the overbed table of Resident #137. Resident #137's roommate was observed in the room but was not independently mobile. No other residents were observed in the area. Interview at the time of the observation, with Licensed Practical Nurse (LPN) #241, verified the findings and identified the two pills as a Flomax 0.4 milligram (mg) capsule, and a gemfibrozil 600 mg tablet. LPN #137 removed the pills from the room and discarded them. Review of the medical record of Resident #137 revealed an admission date of 06/04/24. Diagnoses include hyperlipidemia and benign prostatic hyperplasia without lower urinary tract symptoms. Review of the physician orders dated 06/04/24 revealed Flomax 0.4 milligrams (mg) to 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 policy review, the facility failed to ensure resident's rooms were maintained in a clean and sanitary manner. This affected two (#39 and #68) of 138 resident's rooms that were observed. The facility census was 138. Findings include: Observation on 07/30/24 at 11:05 A.M., of the oxygen concentrator beside the bed of Resident #39, with oxygen tubing attached to the machine and the oxygen in the nares of Resident #39, had a large amount of a dried white substance on the top and the front of the concentrator. Interview on 07/30/24 at 11:20 A.M., with Registered Nurse #319 provided verification the concentrator had the large amount of a dried white substance on the top and front. Observation on 07/30/24 at 11:10 A.M., of Resident #68's room revealed a large number of debris on the floor near where a room mate's bed had been. The debris included: sunflower seeds, empty water bottle, an empty can of chewing tobacco, a plastic grocery items with various items, a grabber tool, and various food particles. On the floor under the windows 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 observations, staff interviews and policy reviews, the facility failed to provide assistance with activities of daily care for a resident dependent on staff for assistance. This affected two (#20 and #49) of three residents reviewed for assistance with care needs. The facility census was 137. Findings include: 1. Review of medical record for Resident #20 revealed admission date of 12/04/17. The resident was admitted with diagnoses including congestive heart failure, stroke and Crohn's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed he was rarely understood and had a long-term memory problem with modified independence cognition. He required maximum assistance for eating, and was dependent with bed mobility, transfers and toileting. He was always incontinent of bowel and bladder. Observation on 03/13/24 at 2:27 P.M., of Resident #20 revealed a layer of thick plaque to his top teeth and his nails were noted to extend approximately 0.6 centimeters beyond his…

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

Based on observations, staff interviews and policy review, the facility staff failed to provide proper hand hygiene after providing incontinence care to a resident. This affected two (#17, and #18) residents of three residents observed. The facility census was 137. Findings include: 1. Review of medical record for Resident #18 revealed admission date of 01/13/24 with a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. The resident was admitted with diagnoses including malignant neoplasm to the palate, Parkinson's disease and sensorineural hearing loss bilateral. Observation on 03/13/24 at 9:57 A.M., of incontinence care provided by State Tested Nurse Assistant (STNA) #103 revealed Resident #18 was incontinent of bowel. After thoroughly cleaning the stool from Resident #18, STNA #103 placed a clean incontinence product and clothes on Resident #18. STNA #103 then removed her gloves and left the room without any hand hygiene. Interview on 03/13/24 at 10:03 A.M., STNA #103 verified she did not remove her gloves directly after providing incontinence care, 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 record review, observations, staff interview, review of information from Center for Disease Control and Prevention (CDC) and policy review, the facility failed to ensure proper personal protective equipment (PPE) was worn in residents room who was positive for Coronavirus Disease 2109 (COVID-19). This affected one (#129) out of three residents sampled for infection control practices and had the potential to affect nine (#121, #122, #123, #124, #125, #126, #127, #128, and #130) additional residents who reside on the transitional care unit three. The facility census was 140. Findings include: Review of medical record for Resident #129 revealed the resident was admitted to the facility on [DATE]. Diagnoses include epilepsy, COVID-19, chronic obstructive pulmonary disease, type two diabetes, need for assistance with personal care, chronic kidney disease stage three, anxiety, major depressive disorder, polymyalgia, intellectual disabilities, and constipation. Review of Resident #129's minimum data set (MDS)…

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

Based on observations and interviews, the facility failed to provide and maintain a clean resident smoking area. This affected 23 of 23 facility identified residents who smoke (Residents #39, #86, #45, #93, #89, #71, #370, #90, #68, #19, #55, #04, #15, #40, #92 ,#25, #82, #377, #07, #365, #02, #76, and #21). The facility census was 120. Findings include: Observation on 06/07/22 at 02:50 P.M. revealed two residents, Resident #76 and #71 in wheelchairs on the patio of the resident smoke area. Leading up to the patio area, an adjacent landscaped area of appropriately 10 feet by 20 feet was filled with stones, small sticks and dried peanut shells. There were greater than 50 extinguished cigarette butts in the landscaped area. Interview on 06/08/22 at 1:40 P.M. with Housekeeper #433 revealed on 06/08/22, she had cleaned the patio and cigarette butt filled area in the A.M. She verified the area is covered with sticks and peanut shells and had cigarette butts in the area daily. Interview on 06/08/22 at 1:50 P.M. with the Environmental Director #613 verified the resident smoke area 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 reviews, staff interviews and review of the facility policy, the facility failed to ensure a person-centered comprehensive care plan was developed and implemented to address the dietary needs/recommendations of two residents. This affected two residents (#13 and #110) of five sampled residents reviewed for nutrition during the annual survey. The facility census was 120. Findings include: 1. Review of the medical record for Resident #110 revealed the resident was admitted to the facility on [DATE] with diagnoses including end stage renal disease, fluid volume overload and lung cancer. Review of the Comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment and required supervision with eating. The MDS assessment did not indicate Resident #110 was receiving a therapeutic diet while in the facility. Review of the resident's hospital coordination of care report received by the facility's Director of Marketing and Admissions #603 on 04/29/22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide meal assistance for one resident, (Resident #13) of three residents reviewed who required mealtime assistance. The facility census was 120. Findings include: Review of the medical record revealed Resident #13 was admitted on [DATE] with diagnoses of Parkinson disease, upper respiratory infection, dysphagia, malnutrition, and depression. The physician ordered a mechanical altered diet, a supplement three times a day for risk of malnutrition and tube feeding of Jevity 1.5 at 65 milliliters per hour from 7:00 P.M. to 7:00 A.M. Review of the Minimum Data Set, (MDS) dated [DATE] revealed the resident had intact cognition and required extensive assistance of one staff person for meal assistance. The nutrition plan of care dated 05/23/22 revealed the resident was at risk for aspiration, swallowing problems, and chronic weakness. Interventions included provide feeding assistance as needed, provide nutrition supplement as ordered and adaptive curved…

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 interviews the facility failed to ensure a resident had physician orders for a therapeutic diet. This affected one of (#110) of five residents sampled for nutrition. The facility census was 120. Findings include: Review of the medical record for Resident #110 revealed the resident was admitted to the facility on [DATE] with diagnoses including end stage renal disease, fluid volume overload and lung cancer. Review of the Comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment and required supervision with eating. The MDS assessment did not indicate Resident #110 was receiving a therapeutic diet while in the facility. Review of the resident's hospital coordination of care report received by the facility's Director of Marketing and Admissions #603 on 04/29/22 at 11:51 A.M., revealed orders for a therapeutic diet of no added salt and low K+ (potassium). Review of Resident #110's hospital discharge instructions/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 interview the facility failed to provide medication as ordered. This affected one Resident #365 of five residents reviewed for medication administration. The facility census was 120. Findings include: Medical record review for Resident #365 revealed admission date 05/20/22 and discharge date [DATE]. Diagnoses included osteomyelitis of vertebra, lumbar region, inflammatory spondylopathies, low back pain, and chronic pain. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident had impaired cognition. The resident required extensive one-person assistance for bed mobility and extensive two-person assistance for transfers. The resident received scheduled and as needed pain medications. The assessment revealed occasional pain over the last five days. Pain was rated at eight on a one to ten scale. Review of the Plan of Care dated 05/23/22 revealed the resident had potential for pain related to chronic pain. Interventions included to administer medications…

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, interview and record review, the facility failed to provide adaptive feeding utensils for two residents (Residents #13 and # 363) of three residents reviewed for assistance devices. The facility census was 120. Findings include: 1. Review of medical record revealed Resident #13 was admitted on [DATE] with diagnoses of Parkinson disease, upper respiratory infection, dysphagia, malnutrition, and depression. The physician ordered a mechanical altered diet, a supplement three times a day for risk of malnutrition and tube feeding of Jevity 1.5 at 65 milliliters per hour from 7:00 P.M. to 7:00 A.M. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition and required extensive assistance of one staff person for meal assistance. The nutrition plan of care dated 05/23/22 revealed the resident was at risk for aspiration, swallowing problems, and chronic weakness. The Dietetic Technician # 605 entered an intervention on 03/18/22 to provide adaptive equipment curved…

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 interview, the facility failed to label, date and discard resident refrigerated foods on three nursing units, (Nursing Unit 100, Memory Care Unit and C-1/CD-1/D-2 Unit) of three units reviewed. This had the potential to affect 72 of 120 residents identified by the facility to receive foods on these units. The facility census was 120. Findings include: Observation on 06/09/22 at 8:19 AM resident food storage refrigerator on 100 unit revealed no temperature log was completed for dates of 06/03/22, 06/04/22, 06/05/22 and 06/08/22. One container of supplement, Med Pass, was not dated, and one was dated of 04/18/22. There were four containers of various foods including a soup container, meat container, fruit container and an unknown food container with no labels and dates. There was a sign on the outside door of the refrigerator, No Employee Food- all food must be labeled and dated. Interview on 06/08/22 at 8:20 A.M. with Licensed Practical Nurse (LPN) # 509 verified the supplement was expired, the supplement container not dated, and foods in containers were not…

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