Walnut Hills Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff and resident interviews, the facility failed to ensure their pharmacy services provided resident intravenous medication in a timely manner. This affected one resident (#45) of two residents reviewed for intravenous medication administration. The census was 45. Findings include: 1. Medical record review revealed Resident #45 was admitted on [DATE] with diagnoses including cerebral infarction, bacteremia and sepsis. Review of the Physician Orders dated 05/27/24 revealed to administer Ceftriaxone (antibiotic) 2 grams (g) intravenous (IV) every 12 hours for infection through 06/28/24. Review of the Medication Administration Record (MAR) dated June 2024 revealed the following IV antibiotics were not administered as ordered: Ceftriaxone 2 g IV was not administered upon rising on 06/08/24, 06/10/24, 06/19/24, 06/23/24 and 06/24/24. Ampicillin 2 g IV for bacteremia was not administered at 12 noon on 06/19/24 and 06/20/24. Ceftriaxone 2 g IV was not administered in the evening 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, observation, and interview, the facility failed to maintain an accurate medical record. This affected three residents (#45, #87 and #99) of six sampled residents. The census was 45. Findings include: 1. Medical record review revealed Resident #99 was admitted on [DATE] with diagnoses including chronic atrial fibrillation, congestive heart failure and edema. Review of the hospital Discharge Instructions dated 10/18/23 revealed Resident #99 was prescribed Torsemide (diuretic) 40 mg once a day. Review of the electronic Physician's Orders dated 10/17/23 revealed to administer two tablets of Torsemide 20 mg daily. Review of the electronic Medication Administration Record (MAR) dated October 2023 revealed two different doses to administer for Torsemide. The order was transcribed on the electronic MAR as follows: 'Torsemide 20 mg by mouth once daily. Give two tablets to equal 40 mg for Essential Hypertension. 20 mg po (orally) QD (everyday)'. On 07/03/24 at 12:40 P.M., interview with 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, policy review, and interview, the facility failed to maintain adequate infection control practices. This affected one resident (#87) of three residents observed for pressure ulcer treatments and one resident (#25) resident observed for incontinence care. The census was 45. Findings include: 1. Medical record review revealed Resident #87 was admitted on [DATE] with diagnoses including post-polio syndrome, hip fracture, hypertension and depression. Review of the Wound Progress Report dated 06/25/24 revealed Resident #87 had developed two facility acquired pressure ulcers including an unstageable pressure ulcer to the left midline buttock measuring 5.22 centimeters (cm) in length by 2.8 (cm) in width. The wound bed was covered with slough. On 06/27/24 at 12:18 P.M., observation of Resident #87's left midline buttock pressure ulcer treatment revealed Licensed Practical Nurse (LPN) #60 gathered her supplies, washed her hands at the sink and Hospice Aide #204 rolled…

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, job description review, and interview the facility failed to ensure a medication assistant did not perform duties outside her scope of practice. This affected four residents (#25, #32, #35 and #38 ) of nine residents reviewed for care and service. The facility census was 50. Findings included: 1. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE]. Diagnoses included low back pain, diabetes, hypertension, chronic kidney disease, osteoarthritis, osteoporosis, anxiety disorder, depression, thyroid nodule, seasonal allergies, gout, malignant neoplasm of large intestines, cataracts, cerebral infarction, and traumatic brain injury. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #25 had intact cognition. Review of the April physician's orders revealed Resident #25 had an order for tramadol (a narcotic pain medication) 50 milligrams (mg) once daily. Review of the February 2024 medication administration…

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, and interview, the facility failed to maintain a medication error rate of less than five percent. Three errors occurred within 27 opportunities for error resulting in a medication error rate of 11.0 %. This affected two residents (Resident #45 and #49) of four reviewed for medication administration. The facility census was 50. Findings included: 1. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, hemiplegia to the right side, dysphagia, atherosclerotic heart disease, rheumatoid arthritis, hypertension, congestive heart failure, Sjogren's syndrome nontraumatic intracranial hemorrhage, pacemaker, and depression. Review of the quarterly [NAME] Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #45 had moderately impaired cognition. Review of the [DATE] physician's orders revealed Resident #45 had an order for Refresh tears 0.5 percent one drops in both eyes three times daily and lactulose…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medial record and interview with staff, the facility failed to ensure the physician was notified Resident #31 had not received her antidepressant medication as ordered by the physician. This affected one resident (Resident #31) of three residents reviewed for medication administration. The facility census was 53. Findings include: Review of the medical record revealed Resident #31 was admitted to the facility on [DATE]. Diagnoses included respiratory failure, dementia, insomnia, schizophrenia, hypertension, hemiplegia, polyneuropathy, restless leg syndrome, neuromuscular dysfunction of the bladder, breast cancer with breast removal, anxiety disorder and Parkinson's disease. Review of the physician orders revealed Resident #31 had an order for Zoloft 25 milligrams once daily dated 06/26/23. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had intact cognition. Review of the December 2023 medication administration record revealed Zoloft 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, review of the medical record and interview with the staff, the facility failed to ensure fall interventions were in place for Resident #13. This affected one resident ( Resident #13) of six residents reviewed for plan of care. The facility census was 53. Findings included: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE]. Diagnoses included heart failure, dementia, hypertension, osteoarthritis, insomnia, history of falling and hearing loss. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident # 13 had severely impaired cognition, was frequently incontinent of bladder and bowel and did not have any pressure areas. Review of the plan of care dated 09/01/22 with a revision date of 01/26/24 revealed Resident #13 was at risk for fall related injuries related to history of falls, impaired cognition, dementia, impaired mobility, impaired hearing, impaired vision, and insomnia. Intervention included a fall mat to the open side…

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 Resident #31, who had diagnoses of dementia and schizophrenia received adequate treatment, including the administration of the anti-depressant medication, Zoloft as ordered to assist the resident to maintain her highest practicable level of well-being. This affected one resident (#31) of three residents reviewed for medication administration. The facility census was 53. Findings included: Review of the medical record revealed Resident #31 was admitted to the facility on [DATE]. Diagnoses included respiratory failure, dementia, insomnia, schizophrenia, hypertension, hemiplegia, polyneuropathy, restless leg syndrome, neuromuscular dysfunction of the bladder, breast cancer with breast removal, anxiety disorder, Parkinson's disease. Review of the physician's orders revealed Resident #31 had an order for Zoloft 25 milligrams (mg) once daily dated 06/26/23. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview the facility failed to ensure the anti-anxiety medication, Ativan was only administered to Resident #13 with a valid physician order. This affected one resident (#13) of three residents reviewed for medication administration. The facility census was 53. Findings Included: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including heart failure, dementia, hypertension, osteoarthritis, insomnia, history of falling and hearing loss. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident # 13 had severely impaired cognition, was frequently incontinent of bladder and bowel and did not have any pressure areas. Review of the medication incident report dated 01/31/24 revealed on 01/10/24 Agency Nurse# 200 gave an Ativan 0.5 milligrams (mg) to Resident #13 without an order. It was not reported until 01/31/24. The notable detail of the report indicated the as needed anxiety medication had a…

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

Based on record review, interview and policy review the facility failed to ensure all potential new hires were checked against the state Nurse Aide Registry (NAR), reference checks were completed and background checks were completed in timely manner to ensure no employee had findings concerning abuse, neglect, exploitation or misappropriation of residents' property prior to working with residents. This was identified for seven employees, State Tested Nursing Assistant (STNA) #107, STNA #108, STNA #109, STNA #110, [NAME] Specialist #112, [NAME] #114 and Maintenance Staff (MS) #115, out of ten employees reviewed and had the potential to affect all 44 residents residing in the facility. Findings include: On 09/22/22 at 11:45 A.M., review of personnel files with Human Resources (HR) #106 revealed the following concerns: 1. Review of the personnel file for STNA #107 revealed a hire date of 06/27/22. There was no evidence STNA #107 was checked against the NAR on or prior to 06/27/22. No reference checks were available for review. 2. Review of the personnel file for STNA #108 revealed a…

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

Based on observation, interview, record review and policy review the facility failed to ensure a resident received recommended Restorative Range of Motion (ROM) services after being discharged from therapy. This affected one of one resident reviewed for restorative nursing services (Resident #27). The facility census was 44. Findings included: Review of Resident #27's medical record revealed an admission date of 02/10/06. Diagnoses included spastic quadriplegic cerebral palsy, pain in her left hand, and dependence of a wheelchair. Review of Resident #27's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/09/22, revealed the resident was cognitively intact. The assessment identified that Resident #27 used a wheelchair and required extensive physical assistant with the help of two people for bed mobility/transferring and extensive physical assistance with physical help of one person for personal hygiene. Review of Resident #27's Care Plan, dated 12/01/21, revealed the resident had an activity of daily living self-care deficit related to weakness, impaired mobility, spastic…

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, interview, and record review the facility failed to ensure a resident received adequate monitoring while receiving blood thinning medication. This affected one of six residents reviewed for unnecessary medication use (Resident #11). The facility census was 44. Findings include: Review of Resident #11's medical record revealed an admission date of 01/07/22. Diagnoses included unspecified dementia without behavioral disturbance, anemia, atherosclerosis heart disease of native coronary, edema, depression, and pain. Review of Resident #11's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/13/22, revealed the resident had a cognitive impairment. The assessment identified that Resident #11 required extensive physical assistant with the help of two people for bed mobility and transferring. Review of Resident #11's Care Plan, dated 06/24/22, revealed the resident has impaired cerebrovascular status related to hypertension and coronary artery disease. Interventions included aspirin and Plavix (blood thinning medications) therapy as ordered and to monitor 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.

Based on medical record review, staff interview and policy review, the facility failed to ensure residents receiving antibiotic medication had appropriate indication for antibiotic use. This affected two (Resident #25 and #29) of five residents reviewed for medication use. The facility census was 44. Findings include: 1. Review of Resident #25's medical record revealed an admission date of 04/28/20 with diagnoses that included cerebrovascular accident with hemiplegia and congestive heart failure. Further review of the medical record revealed antibiotic orders on 10/01/21 through 10/08/21 for the use of amoxicillin (antibiotic) 500 milligrams (mg) three times daily. Review of the facility Revised McGreer Criteria for Infection Surveillance Checklist (antibiotic assessment form) completed on 10/04/21 indicated the amoxicillin was initiated due to Resident #25 with a complaint of ear fullness. Further review of the antibiotic assessment form revealed no evidence of any other symptoms reported by the resident. The form indicated the use of antibiotics did not meet criteria 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, interview, and record review, the facility failed to ensure the width between bed rails were the proper dimensions to ensure safety for 10 residents (Resident #5, Resident #13, Resident #15, Resident #43, Resident #19, Resident #30, Resident #35, Resident #50, Resident #52, Resident #53) out of 69 residents observed for the use of bed rails. Findings include: 1. Record review revealed Resident #52 was admitted on [DATE] with diagnoses including but not limited to dementia, abnormal posture, muscle weakness, history of falling, and attention and concentration deficit. Resident #52's Bed Rails Use Assessment Form, dated 12/02/19, revealed the resident had bed rails due to the resident representative request and for safety. Observation on 12/03/19 at 3:36 P.M. revealed Resident #52 was lying in his bed with bilateral half bed rails up. Observation on 12/03/19 at 4:00 P.M. with Licensed Practical Nurse (LPN) #38, revealed the width between the rails within the bed rail on Resident #52's bed…

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 interview, the facility failed to maintain resident dignity. This affected two residents (Resident #11 and #32) observed in one of three dining rooms and one resident (Resident #8) observed with an indwelling urinary catheter. The facility identified two residents with an indwelling or external catheter. Findings include: 1. Medical record review revealed Resident #32 was admitted on [DATE] with diagnoses including Alzheimer's disease and dementia. Review of the care plan: activities of daily living (ADL) Functional/Rehab Potential dated 10/18/19 revealed to provide privacy and dignity. On 12/02/19 at 11:59 A.M., observation revealed Resident #32 was sitting in a specialized wheelchair in the dining room. The lunch meal included breaded fish, tartar sauce, mashed potatoes with garlic and a piece of banana cake. On 12/02/19 between 12:03 P.M. and 12:17 P.M., observation of the lunch meal revealed the following: Resident #32 picked up the banana cake with her left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review the facility failed to ensure advance directive information was consistently documented between medical record/data sources. This affected two residents (Resident's #13 and #47) of 24 residents records reviewed. Findings included: 1. Record review revealed Resident #47 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including low back pain, history of falling, malignant neoplasm of the bladder, dysphagia, prediabetes, diverticulitis, gastro-esophageal reflux, dementia, acute kidney failure, Parkinson disease, malignant neoplasm of the skin, hypertension, cognitive communication, anemia, and hypercholesterolemia. Review of Resident #47's paper record revealed a signed code status indicating the resident requested not to be resuscitated and comfort care-Arrest (DNRCC-A) only, however, on the outside of the chart (on the stem of the chart) indicated the resident was a full code. Review of Resident #47's current…

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, beneficiary notification review, policy review and interview, the facility failed to provide residents with required information regarding options of continuation of skilled services. This affected two (Resident #34 and #71) of three residents reviewed for beneficiary notices. Findings include: 1. Record review revealed Resident #34 was admitted on [DATE] with diagnoses including hypertension and muscle weakness. Review of the SNF (skilled nursing facility) Beneficiary Protection Notification Review dated 08/08/19 revealed current skilled services were to end on 08/07/19; however, there was no evidence of what skilled services were ending. Review of the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) dated 08/08/19 revealed the resident wanted the care listed above and could not appeal because MCR would not be billed. The services listed were for long term care services with a daily room rate of $271.00. There was no evidence the facility provided the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview, the facility failed to ensure eye glasses were clean for residents requiring assistance. This affected one (Resident #61) of three residents reviewed for communication/sensory. Findings include: Medical record review revealed Resident #61 was admitted on [DATE] with diagnoses including diabetes mellitus and cerebral vascular accident (CVA) with left hemiplegia (paralysis on one side of the body). Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #61 was cognitively intact for daily decision-making, had adequate vision with the use of glasses and he required extensive assist with personal hygiene. Review of the undated Resident Care Guide revealed Resident #61 wore glasses. Review of the care plan: ADL Self-Care Deficit due to CVA with left hemiplegia dated 10/14/19 revealed Resident #61 required extensive assistance with personal hygiene. Review of the record revealed no care plan addressing the resident's need to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview, the facility failed to assist and ensure supports were in place as recommended to maintain positioning. This affected one resident (Resident #32) observed in one of three dining rooms. Findings include: Medical record review revealed Resident #32 was admitted on [DATE] with diagnoses including Alzheimer's disease and open reduction internal fixation of the left hip. Review of the OT (occupational therapy) Discharge summary dated [DATE] revealed recommendations including the use of a specialized wheelchair with a right lateral support, a right padded arm rest, and right padded leg box. Review of the OT Long-Term Goals dated 07/15/19 included Resident #32 was to demonstrate midline sitting after set-up in a reclining wheelchair with the addition of a right lateral support and potentially a left lateral support to facilitate the ability to perform functional tasks at wheelchair level. Review of the care plan: Musculoskeletal System revised 10/18/19 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview, the facility failed to ensure resident hearing aides were used. This affected one (Resident #8) of three residents reviewed for communication-sensory. Findings include: Medical record review revealed Resident #8 was admitted on [DATE] with diagnoses including depression and diabetes mellitus. Review of the Resident Care Guide dated 11/16/18 revealed Resident #8 wore hearing aids. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #8 had adequate hearing with hearing aids. Review of the significant change MDS assessment dated [DATE] revealed the resident had moderate difficulty hearing and did not have hearing aids or other hearing appliance. Review of the Focused and Comprehensive assessment dated [DATE] revealed the resident had hearing difficulty. No evidence the resident wore hearing aids. Review of the care plans: Alteration in communication related to moderate difficulty hearing dated 09/06/19 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy review the facility failed to ensure pressure ulcers were assessed accurately. This affected three (Residents #5, #47, and #52) of three residents reviewed for pressure ulcers. Finding include: 1. Record review revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including anemia, Parkinson's disease, bladder cancer, prediabetes, and lumbar fracture. Review of Resident #47's Braden scale for predicting pressure sore risk dated 11/13/19 indicated the resident had a potential problem with friction and shearing and had inadequate nutritional intakes. Review of Resident #47's skin assessments dated 11/21/19 and 11/28/19 revealed on 11/21/19 a new area on the right inner buttocks was identified. The skin area was classified as other. The description indicated the area measure one centimeter (cm) long by 1/2 cm wide superficial open skin area. There was no evidence of a description of the wound. The treatment was to cleanse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview the facility failed to ensure Resident #41 bilateral hand splints were applied per orders. This affect one (Resident #41) of one resident reviewed for range of motion. Findings include: Record review revealed Resident #41 was admitted on [DATE] with diagnoses which included Alzheimer disease, primary generalized osteoarthritis, contracture of left elbow, contracture left hand, and abnormal posture. Minimum Data Assessment (MDS) completed on 10/23/19 revealed Resident #41 is rarely or never understood and has no behaviors. The MDS also revealed Resident #41 required extensive assistance of two staff members for dressing and personal hygiene. Resident #41 also had functional limitations and was impaired on both sides in upper extremities and one side of her lower extremity. Record review for Resident #41's care plan created 10/29/19 included Resident #41 was at risk for impaired functional range of motion (ROM) related to her contracture's and degenerative…

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 ensure Resident #13 was properly assessed post falling and failed to investigate the falls thoroughly, and failed to ensure Resident #16 and Resident #55 were fed by qualified professionals. This affected one (Resident #13) of two residents reviewed for accidents, and two (Resident #16 and Resident #55) of four residents reviewed for nutrition. Findings include: 1. Record review revealed Resident #13 was admitted on [DATE] with diagnoses including but not limited to Alzheimer's, arthritis, spinal stenosis, muscle weakness, difficulty walking, attention and concentration deficit. Resident #13's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed her cognition was moderately impaired, she required two person extensive assistance with bed mobility, transfers, and toilet use, and was frequently incontinent of urine. Review of Resident #13's fall history provided by the facility revealed she had a fall on 07/13/19, 07/27/19, 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 observation, medical record review, policy review and interview, the facility failed to maintain infection control practices during a pressure ulcer dressing change. This affected one (Resident #5) of three residents reviewed for pressure ulcers. Findings include: Medical record review revealed Resident #5 was admitted on [DATE]. Diagnoses included a facility-acquired Stage III pressure ulcer (full thickness tissue loss with no bone, tendon or muscle exposed) to the right buttock. On 12/04/19 between 10:21 A.M. and 10:45 A.M. observation of Resident #5's pressure ulcer dressing change included the following: Licensed Practical Nurse (LPN) #109 gathered supplies from the treatment cart including a new package of mesalt and a pair of treatment scissors from the top drawer of the treatment cart. The scissors were laying in the drawer and were not in a sealed package. LPN #109 was observed opening the package of mesalt, used the treatment scissors to cut an approximate quarter inch strip of the mesalt,…

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.