Vancrest Of Urbana, INC

Based on medical record review and staff interview, the facility failed to have physician visits or progress notes available in resident medical records. This effected three (#15, #18, and #22) of four resident's medical records reviewed for reviewed for discharge. The census was 71. Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 04/08/23. Diagnoses included atrial fibrillation, hypertensive heart disease with heart failure, chronic systolic (congestive heart failure), chronic obstructive pulmonary disease, cerebral vascular disease, and depression. Further review of the medical record did not have physician progress notes or visit noted available for review. 2. Review of Resident #18's medical record revealed an admission date of 06/20/23. Diagnoses included chronic gout, hypertension, hyperlipidemia, and chronic kidney disease. Further review of the medical record did not have physician progress notes or visit notes available for review. 3. Review of Resident #22's medical record revealed an admission date of 07/28/23. Diagnoses…

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 reviews, the facility failed to store food and maintain food in a safe fashion and and failed to serve food in a hygienic manner. This had the potential to affect 67 of 67 residents who receive food from the kitchen. The total facility census was 67. Findings include: Observation of the reach in refrigerator with Dietary Manager (DM) #113 in the central kitchen on 02/27/23 at 9:40 A.M., revealed turkey lunch meat was in a zipper plastic bag dated 02/20/23 and ham lunch meat was in a zipper plastic bad was dated 02/20/23. At the time of the observation, DM #113 stated the two lunch meats should only be stored in the refrigerator for three days and DM #113 removed the lunch meat zipper bags from the refrigerator so they could not be used. There were two bowls in the reach in refrigerator that had a red liquid in them and the bowls were not dated or labeled. DM #113 verified the bowls should be dated and labeled and removed the bowls. DM #113 stated they were tomato soup. Observation of the lunch meal tray line on 03/01/23 from 12:00…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews and policy review, the facility failed to ensure residents who received psychotropic drugs were provided routine behavior monitoring. This affected four (#2, #3, #8 and # 58) of five residents reviewed for unnecessary medications. The total facility census was 67. Findings include: 1. Review of the Resident #2's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses including weakness, hypothyroidism, left knee replacement, depression, anxiety, dementia and cerebral infarction. Review of most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident is cognitively impaired, wanders daily but had no other behaviors. Resident #2 required limited assist with personal hygiene, supervision for toileting, and dressing and was independent with bed mobility, transfers, and eating. Resident #2 received seven days of antipsychotic and antidepressant medication and six days of antianxiety medication. Review of 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 record review, staff and resident interview, the facility failed to invite and involve a resident and/or their representative in their care planning and conduct care plan meetings. This affected one (#26) of 24 residents reviewed for care planning. The facility census was 67. Findings include: Review of the medical record for Resident #26 revealed admission date of 04/01/22. The resident was admitted with diagnoses including stroke and hemiplegia of the left dominant side. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required extensive two person assistance for bed mobility, one total dependence for transfers, toileting, and supervision for eating. Resident #26's MDS documentation revealed a quarterly MDS assessment was completed on 10/14/22. Review of the progress notes for Resident #26 revealed no documentation of care conferences being held. Upon request the facility provided paperwork for a care conference dated 10/26/23. There…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and policy review, the facility failed to notify a physician of a fall with a head injury. This affected one (#63) of two reviewed for accidents. The facility census was 67. Findings include: Review of medical record for Resident #63 revealed admission date of 02/02/23. The resident was admitted with diagnoses including pneumonia, bacteremia, hypertension, atrial fibrillation, depression, and anxiety. The resident remains in the facility. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident has intact cognition and required extensive one person assistance for bed mobility, transfers, dressing, toileting, personal hygiene, and supervision for eating. Record review revealed Resident #63 had an unwitnessed fall in the bathroom on 02/28/23. The fall resulted in contusion to the left forehead. Neurological assessments were initiated and were negative. Notification of the fall was written in the provider communication book. Interview 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 record review and staff interview, the facility failed to inform a resident/ representative of cost for care and services that they would be responsible for when a payor source would change. This affected two (#7 and #36) of three residents reviewed for beneficiary notification the cost of the skilled service after by Medicare Part A. The total facility census was 67. Findings include: 1. Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE], with Medicare Part A as her payor source. The resident record revealed the resident payor source changed on 02/16/23 to Medicaid and the resident remained in the facility. Resident #7's diagnoses included diabetes, chronic kidney disease, hypertensive heart disease, Parkinson's disease, hyperlipidemia, and depression. Review of Resident #7's quarterly minimum data set (MDS) assessment dated [DATE], revealed the resident was cognitively intact, had no behaviors, and required extensive assist for bed mobility, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, resident and staff interviews, the facility failed to maintain a environment in good repair. This affected one (#30) of 67 residents reviewed for homelike environment. The facility census was 67. Findings include: Review of medical record for Resident #30 revealed admission date of 04/29/22. The resident was admitted with diagnoses including stroke, hemiplegia affecting right dominant side. The resident remains in the facility. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had intact cognition and required supervision for eating and extensive assistance for all other activities of daily living. Interview and observation on 02/27/23 at 1:02 P.M., with Resident #30 revealed she was bothered by the chipped paint and dry wall damage beside her bed, which was caused by her recliner hitting the wall. Resident #30 shared the facility moved her bed against the damaged wall after a fall and she would like the wall fixed. Observation of the wall, 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 record review, staff interview and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to complete a discharge assessment in a timely manner. This affected one (#64) of 24 residents reviewed for assessments. The facility census was 67. Findings include: Review of the closed medical record for Resident #64 revealed admission date of 08/31/22. The resident was admitted with diagnoses including stroke, diabetes mellitus type two, hypertension and atrial fibrillation. The resident was discharged on 10/20/22. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident had impaired cognition and required extensive assistance or was totally dependent for her activities of daily living. Review of the MDS assessments in the medical record revealed a discharge assessment was not completed as of 02/28/23. Interview on 03/01/23 at 8:09 A.M., with MDS Nurse #124 verified a discharge MDS was not completed as required for Resident #64.…

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, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interviews, the facility failed to accurately assess a resident and reflect the accurate assessment on the the Minimum Data Set (MDS) 3.0 assessment. This affected two (#48 and #57) of 24 resident assessments reviewed for accuracy. The total facility census was 67. Findings include: 1. Review of Resident #48's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease, rheumatoid arthritis, idiopathic peripheral neuropathy, and palliative care. Review of Resident #48's physician orders revealed the resident started hospice care on 09/27/22 with a terminal diagnosis of Alzheimer's Disease. Resident #48 additionally had a physician order for bilateral palm protectors for four hours daily as tolerated dated 06/27/22. Review Resident #48's care plans revealed the resident had a care plan for activities of daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to develop a baseline care plan timely. This affected one (#172) of 24 residents reviewed fro care planning. The facility census was 67. Findings include: Review of medical record for Resident #172 revealed an admission date of 02/06/23. The resident was admitted with diagnoses including stoke, hemiplegia of left non dominant side and dysarthria (slurred or slow speech that can be difficult to understand). The resident remains in the facility. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed the resident had intact cognition and required extensive one person assistance for bed mobility, transfers, dressing, eating and toileting. Review of a care plan, initiated on 02/13/23, revealed a communication focus related to dysarthria due to a stroke; activities of daily living self-care performance due to hemiplegia and nutritional/dehydration…

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 staff interviews, the facility failed to ensure a physician ordered consult with specialized physician appointment was made timely. This affected one (#63) of 24 residents records reviewed for quality of care. The facility census was 67. Findings include: Review of medical record for Resident #63 revealed admission date of 02/02/28. The resident was admitted with diagnoses including pneumonia, bacteremia, hypertension, depression and anxiety. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had intact cognition and required extensive one person assistance for bed mobility, transfers, dressing, toileting, personal hygiene, and supervision for eating. Review of the physician orders for Resident #63 revealed a 02/23/23 order for a gastrointestinal (GI) consult. Observation on 03/01/23 at 9:47 A.M., revealed Medical Records #134 was on the phone making an appointment for Resident #63. Interview with Medical Records #134,…

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, resident and staff interview, the facility failed to ensure a follow up appointment with an ophthalmologist was scheduled and a physician ordered medication was started for maintaining This affected one (#10) of four residents reviewed for vision and hearing services. The facility census was 67. Findings include: Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE], with the diagnoses included osteomyelitis, peripheral vascular disease, type two diabetes, atrial fibrillation, dementia, and hypertension. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively impaired and had adequate vision without corrective lenses. Review of Resident #10's care plan indicated he had impaired visual function related to a bind spot of the unspecified eye. Interventions include to arrange consultation with eye care practitioner as required, monitor for any changes in ability to complete…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the policy, the facility failed to ensure new fall interventions were timely implemented after a resident sustained a major injury requiring a hospital visit. This affected one (#22) of two residents reviewed for accidents. The facility census was 67. Findings include: Medical record review for Resident #22 revealed an admission date on 12/22/21. Diagnoses included chronic kidney disease and chronic obstructive pulmonary disease. Resident #22 was sent to the hospital on [DATE] and readmitted to the facility on [DATE] with a new diagnosis of non-traumatic subdural hemorrhage. Review of the Minimum Data Set (MDS) assessment dated on 01/05/23 revealed Resident #22 was severely cognitively impaired. Resident #22 utilized a wheelchair to ambulate at the facility. Review of the progress note dated 02/05/23 revealed an activity staff member observed Resident #22 on the floor, face first. Resident #22 was bleeding from above the right eyebrow and under right eye.…

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, policy review, and staff interviews, the facility failed to obtain weights in a timely manner. This affected two (#172 and #63) of three residents reviewed for nutrition. The facility census was 67. Findings include: 1. Review of medical record for Resident #172 revealed an admission date of 02/06/23. The resident was admitted with diagnoses including stroke, hemiplegia of left non dominant side and dysarthria (slurred or slow speech that can be difficult to understand). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident has intact cognition and required extensive one person assistance for bed mobility, transfers, dressing, eating and toileting. Review of the care plan initiated on 02/16/23, revealed a nutritional/dehydration risk related to a stroke, dysphagia and vitamin deficiency. Interventions included to obtain a weight at a minimum of monthly and report any significant change to the physician, provide and serve nutritional supplements as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and policy review, the facility failed to act on pharmacy recommendations timely and the facility failed to provide a rationale for refusing a pharmacy recommendation. This affected three (#2, #8 and #3) of five residents reviewed for unnecessary medications. The facility census was 67. Findings include: 1. Review of the Resident #2's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses including weakness, hypothyroidism, left knee replacement, depression, anxiety, dementia and cerebral infarction. Review of most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident is cognitively impaired, wanders daily but had no other behaviors. Resident #2 required limited assist with personal hygiene, supervision for toileting, and dressing and was independent with bed mobility, transfers, and eating. Resident #2 received seven days of antipsychotic and antidepressant medication and six days of antianxiety…

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, policy review and staff interviews, the facility failed to give a physician ordered medication for a weight gain for congestive heart failure as ordered. This affected one (#44) of five resident records reviewed for medications. The facility census was 67. Findings include: Review of medical record for Resident #44 revealed admission date of 02/06/23. The resident was admitted with diagnoses including kidney disease stage three (of four), atrial fibrillation, acute on chronic congestive heart failure. The resident remains in the facility. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident has impaired cognition and required one person assistance for toileting, limited assistance for personal hygiene, bed mobility, transfers and supervision for eating. Review of the care plan initiated 02/06/23 revealed an altered cardiovascular status related to acute on chronic congestive heart failure. Interventions included but were not limited to assess for shortness of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, family and facility staff interview, the facility failed to ensure laboratory test were completed timely. This affected two (#2 and #3) of five residents reviewed for unnecessary medications. The total facility census was 67. Findings include: 1. Review of the Resident #2's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses including weakness, hypothyroidism, left knee replacement, depression, anxiety, dementia and cerebral infarction. Review of most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident is cognitively impaired, wandered daily but had no other behaviors. Resident #2 received six days of anticoagulant and antianxiety medication and seven days of antipsychotic and antidepressant medications. Review of Resident #10's admission orders dated 10/27/22 (Thursday) revealed the following orders: Coumadin (anticoagulant) 8 milligram (mg) Monday, Wednesday, and Friday; Coumadin 7.5 mg on Tuesday, Thursday ,…

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 medical record and staff interviews, the facility failed to ensure physician ordered radiology test were completed timely. This affected one (#22) of 24 resident reviewed for radiology. The facility census was 67. Findings included: Review of Resident #22's medical record revealed an admission date on od 12/22/21 and re-admission date of 02/11/23. Diagnoses for Resident #22 included chronic kidney disease, chronic obstructive pulmonary disease, nontraumatic subdural hemorrhage on 02/05/23, and dysphagia. Review of the Minimum Data Set (MDS) assessment dated on 01/05/23 revealed Resident #22 was severely cognitively impaired and required for assistance extensive one-person physical assist for dressing, bed mobility, transfers, eating, bathing, and toilet use. Resident #22 used a wheelchair to ambulate at the facility. Review of hospital discharge document dated on 02/05/23 revealed to complete a CAT (Computed Axial Tomography) scan of the head without contrast by or approximate on 02/20/23.…

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, resident and facility staff interview, the facility failed to timely obtain dental services. This affected one (#10) of three residents reviewed for dental services. The total facility census was 67. Findings include: Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE], with the diagnoses including osteomyelitis, peripheral vascular disease, type two diabetes, atrial fibrillation, dementia, and hypertension. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed the resident had cognitive impairment, and did not have mouth pain, discomfort or difficulty with chewing. Resident #10's medical record was silent to the resident being provided dental services at the facility. Review of Resident #10's admission contract signed by the resident revealed the resident had signed to receive dental practitioner services at the facility. Review of the last year of dental visits revealed the dentist had been at the facility…

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

Based on record review, observation, staff interview, and policy review, the facility failed to provide a diet order to meet the needs of the resident. This affected one (#22) of three residents reviewed for dietary needs. The facility census was 67. Findings include: Review of record for Resident #22 revealed an admission date on of 12/22/21 and re-admission date of 02/11/23, with diagnosis including chronic kidney disease, chronic obstructive pulmonary disease, nontraumatic subdural hemorrhage on 02/05/23, and dysphagia. Review of Minimum Data Set (MDS) assessment dated on 01/05/23 revealed the resident was severely cognitively impaired. Resident required for assistance extensive one-person physical assist for dressing, bed mobility, transfers, eating, bathing, and toilet use. Review of the plan of care dated on 02/12/23 revealed Resident #22 was at risk for nutritional status due to fracture to right humerus. Resident was total dependence during meals at all times. Interventions included monitor for signs and symptoms of chewing or swallowing difficulties, honor food preferences,…

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 maintain the kitchen in a clean and sanitary manner. This had the potential to affect all 70 residents who receive meals from the kitchen. The census was 70. Findings include: 1. Observation of the kitchen on 01/21/20 at 9:05 A.M. revealed a grayish fuzzy like substance on the light fixture above the food preparation table. Interview with Dietary Aide #143 on 01/21/20 at 9:05 A.M. verified there was a grayish fuzzy like substance on the light fixture above the food preparation table. 2. Observation of the kitchen on 01/22/20 at 11:13 A.M. revealed a grayish fuzzy like substance on the light fixture above the food preparation table. Interview with Dietary Manager #152 on 01/22/20 at 11:13 A.M. verified there was a grayish fuzzy like substance on the light fixture above the food preparation table. 3. Observation of the kitchen on 01/22/20 at 12:10 P.M. revealed a grayish fuzzy like substance on the piping along the ceiling above the tray line area. Interview with Dietary Manager #152 on 01/22/20 at 12:10…

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 interviews, the facility failed to ensure minimum data set (MDS) assessments were accurate. This affected four (#68, #73, #21, and #22) of 16 residents reviewed for accuracy of the assessment. The census was 70. Findings include: 1. Review of the medical record for Resident #68 revealed the resident was admitted to the facility on [DATE]. Diagnoses include diabetes mellitus type two, hyperlipidemia, congestive heart failure, chronic obstructive pulmonary disease, muscle weakness, insomnia, chronic pain, osteoporosis, cognitive communication deficit, hypertension, chronic respiratory failure, and hyponatremia. Review of an admission minimum data set (MDS) assessment dated [DATE], revealed Resident #68 had no natural teeth or tooth fragments (edentulous). Review of a quarterly MDS assessment dated [DATE], revealed the resident had intact cognition. Review of Resident #68's plan of care dated 06/19, revealed the resident was at risk for oral…

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 notify the resident/resident representative in writing of the reason transfer/discharge to the hospital. Additionally, the facility failed to send a copy of the notice to the Ombudsman. This affected two (#63 and #21) of five resident's reviewed for hospitalization. The census was 70. Findings include: 1. Review of the medical record for Resident #63 revealed the resident was admitted to the facility on [DATE]. Diagnoses include congestive heart failure, diabetes mellitus type two, major depressive disorder, cellulitis, morbid obesity, chronic kidney disease, cellulitis of left lower limb, hypertension, and osteoporosis. Review of a progress note dated 11/20/19 at 12:16 P.M. revealed Resident #63 had an unwitnessed fall at the facility on 11/20/19. Documentation revealed the physician was at the facility and gave orders to send the resident to the hospital for evaluation and treatment. The resident was admitted to the hospital. Review 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 and staff interview, the facility failed to notify the resident/resident representative of the bed hold and reserve bed payment policy upon transfer to the hospital. This affected one (#63) of five resident's reviewed for hospitalization. The census was 70. Findings include: Review of the medical record for Resident #63 revealed the resident was admitted to the facility on [DATE]. Diagnoses include congestive heart failure, diabetes mellitus type two, major depressive disorder, cellulitis, morbid obesity, chronic kidney disease, cellulitis of left lower limb, hypertension, and osteoporosis. Review of a progress note dated 11/20/19 at 12:16 P.M. revealed Resident #63 had an unwitnessed fall at the facility on 11/20/19. Documentation revealed the physician was at the facility and gave orders to sent the resident to the hospital for evaluation and treatment. The resident was admitted to the hospital. Review of a progress note dated 11/26/19 at 9:43 P.M. revealed Resident #63 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 2. Review of the medical record for Resident #21 revealed an admission date of 10/27/09 with diagnoses including dementia with behavioral disturbance, Alzheimer's disease, and generalized muscle weakness. Review of the comprehensive care plan revealed a care plan focus of Resident #21 had potential for injuries/falls related to cognitive deficits, does not wait for assistance, wandering, incontinence, and per x-ray has osteopenia which increases risk of injury with falls. The care plan had a goals of safety will be maintained through next review, and will have minimal risk of injury from falls through next review. The care plan had fall interventions which included call light within reach while in the room, encourage non-skid footwear at all times, encourage to rest throughout the day, ensure blanket corner is tucked on left side of the bed, frequent orientation to room, bathroom, call light and facility, keep needed items within reach, left side of bed against the wall, maintain uncluttered environment,…

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.