Warren Nursing & Rehab

Based on record review, interview and review of facility policy, the facility failed to ensure resident consents or declinations were obtained for influenza and pneumococcal vaccines, and the facility failed to document site of administration, lot number, and expiration dates for administered vaccines. This affected five residents (Resident #5, #20, #25, #29, and #38) of seven residents reviewed for vaccinations. The facility census was 72.Findings include:1. Review of Resident #5's medical record revealed an admission date of 03/30/20. Diagnoses included Major Depressive Disorder (MDD), bipolar disorder, hypertension, congestive heart failure and chronic kidney disease stage III.Review of Resident #5's influenza and pneumococcal vaccination consent form dated 09/17/25 revealed the resident consented to both vaccinations.Review of Resident #5's Medication Administration Record (MAR) dated September 2025 revealed the resident received her influenza vaccination on 09/23/25 and she received her pneumococcal vaccination on 09/24/25; however, there was no required documentation such 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.

Based on record review, interview and review of facility policy, the facility failed to ensure resident consent or declinations were obtained for COVID-19 vaccinations. This affected five residents (Resident #5, #20, #25, #29, and #38) of seven residents reviewed for vaccinations. The facility census was 72.Findings include: 1. Review of Resident #5's medical record revealed an admission date of 03/30/20. Diagnoses included Major Depressive Disorder (MDD), bipolar disorder, hypertension, congestive heart failure and chronic kidney disease stage III.Review of Resident #5's COVID-19 vaccination consent form dated 09/17/25 revealed the resident consented to the vaccination.Review of Resident #5's Medication Administration Record (MAR) dated September 2025 revealed the resident was not administered the COVID-19 vaccination.2. Review of Resident #20's medical record revealed an admission date of 08/27/25. Diagnoses included acute on chronic respiratory failure, end stage renal disease, acute on chronic congestive heart failure, history or sepsis, and COVID-19.Further 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 observation, record review, interview, and review of facility policy, the facility failed to have call lights within reach for Resident #41, #50 and #56. This affected three residents ( #41, #50 and #56) of 72 residents observed for call lights. The facility census was 72. Findings include: 1. Review of the medical record for Resident #41 revealed an admission date of 09/22/23 with diagnoses including chronic respiratory failure and nontraumatic intercerebral hemorrhage. There were no physician orders regarding call lights.Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #41 had severe cognitive impairment and impairment bilaterally to the upper and lower extremities. Resident #41 was dependent for all activities of daily living (ADL).Review of the care plan dated 12/17/25 revealed Resident #41 had a potential for falls related to limited mobility and post cerebral vascular accident. Interventions included ensure call light was available to resident's unaffected…

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 facility policy review the facility failed to ensure resident advanced directives (code status) were accurate. This affected one resident (#6) of 53 residents reviewed for the annual survey. The facility census was 72.Findings include: Review of Resident #6's medical record revealed the resident was admitted on [DATE] with diagnosis that included: major depressive disorder, dementia, intracranial injury, essential hypertension, anxiety disorder, occlusion and stenosis of unspecified cerebral artery, alcohol dependence and unspecified psychosis. Record review revealed Resident #6 had an advanced directive order dated 05/07/20 for Full Code status (all life sustaining measures in the event of a cardiac or respiratory arrest).Review of a care plan dated 03/19/25 revealed the resident was a full code. Review of Resident #6's Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate cognitive impairment. Review of Resident #6 Care Conference Note dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review the facility failed to ensure they notified the emergency contact of a resident's change in condition. This affected one resident (Resident #38) of one resident reviewed for notification of change. The facility census was 72.Findings include: Review of Resident #38's medical record revealed an admission date of 10/06/25 and a discharge date to the hospital on [DATE]. Diagnosis included acute on chronic respiratory failure, ventilator dependent, neurogenic bladder, urinary tract infection, hypertension, and tracheostomy status.Review of Resident #38's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition, required substantial to maximal assistance with eating, and was dependent on staff for all other Activities of Daily Living (ADLs) including oral hygiene, toileting hygiene, showers, incontinence care, dressing, and bed mobility.Review of progress notes dated 12/19/25 at 2:58 P.M. revealed Resident #38 was experiencing 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to develop and implement comprehensive care plans for residents. This affected three residents (#13, #14, and #19) of three residents reviewed for comprehensive care plan implementation. The facility census was 72.Findings include:1. Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus with hyperglycemia, adult failure to thrive, homelessness, mood disorder, glaucoma, Guillain-Barre syndrome, obstructive sleep apnea, and panic disorder. Review of Resident #19's Minimum Data Set (MDS) 3.0 dated 10/26/25 revealed a BIMS score 15, indicating intact cognition. The MDS also revealed Resident #19 required set-up/supervision with all Activities of Daily Living and Mobility. The MDS also indicated the resident showed little interest or pleasure in doing things almost daily. Further review of Resident #19's Medical Record revealed on 11/11/25, 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 observation, record review, interview and policy review the facility failed to ensure residents were assisted with activities of daily living including hair, nail and oral care. This affected three residents (Resident #30, #31 and #51) of 12 residents reviewed for activities of daily living. The census was 72.Findings include: 1. A review of the medical record for Resident #30 revealed a date of admission of 08/08/25. Significant diagnoses included urinary tract infection, need for assistance with personal care, and morbid obesity. Review of a care plan dated 08/08/25 revealed Resident #30 had a self-care deficit related to morbid obesity. Interventions included assisting with activities of daily living as needed.Review of a quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15, indicating intact cognition.Review of bathing documentation revealed no concerns. Staff were using bathing wipes during 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 record review and interview, the facility failed to ensure a Magnetic Resonance Imaging (MRI) study was completed as ordered for Resident #80. This affected one resident (#80) reviewed for MRI follow-up. Also based on observation, record review and interview, the facility failed to ensure wounds received dressing orders and documented care. This affected one resident (Resident #18) of one resident observed for wound care of a surgical wound. The facility failed to ensure dressings were changed as ordered for one resident (Resident #28). The total census was 72.Finding include:1.Review of the medical record revealed Resident #80 was admitted to the facility on [DATE] with diagnoses including cervical disc disorder with myelopathy, high cervical region, spinal stenosis, cervical region, anemia, hyperkalemia, obesity, benign neoplasm of right ovary, type 2 diabetes mellitus with diabetic polyneuropathy, essential (primary) hypertension, acute respiratory failure with hypoxia, altered mental status, acute…

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, interview and facility policy review, the facility failed to have interventions in place to maintain a peripherally inserted central catheter (PICC) line for Resident #31. This affected one resident (#31) of one resident reviewed for intravenous (IV) access and had the potential to affect three additional residents (#1, #2, and #25) identified by the facility with IV access. The facility census was 72.Findings include:A review of the medical record revealed Resident #31 was admitted to the facility on [DATE] and discharged on 12/12/25. Significant diagnoses included diabetes type two with a foot ulcer, local infection of the skin and subcutaneous tissue, and methicillin resistant staphylococcus aureus (MRSA) of unspecified site. Significant orders included de-clotting by thrombolytic agent of vascular access device or catheter dated 09/11/25, flush PICC line with 10 milliliters (ml) of 0.9 percent sodium chloride every day shift (09/06/25), replace PICC line (09/25/25), cathflo activase…

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, interview, facility policy review and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to provide tracheostomy care according to professional standards for Resident #22 and failed to date and/or change oxygen tubing weekly for Residents #29 and #67. This affected three residents (#22, #29 and #67) of eight residents reviewed for respiratory care. The facility census was 72.Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 07/25/24 and diagnoses including tracheostomy status, ventilator associated pneumonia, and chronic respiratory failure. The resident had a physician order dated 11/17/25 to receive tracheostomy care every shift and as needed. Observation on 12/22/25 at 10:47 A.M. of tracheostomy care for Resident #22 by Licensed Practical Nurse (LPN) #341 revealed she used saline-moistened gauze to wipe at and around the tracheostomy tube and plate, then used another piece of gauze 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 record review, staff interview, and facility policy review, the facility failed to ensure residents were seen by a physician as required. This affected one resident (#69) of 15 residents reviewed for physician visits. The facility census was 72.Findings include: Review of the medical record for Resident #69 revealed an admission date of 09/24/24 with diagnosis that include cerebral infarction due to embolism of the left cerebellar artery, idiopathic aseptic necrosis of right humerus, severe protein-calorie malnutrition, aphasia, adult failure to thrive, gastrostomy, hyperosmolality and hypernatremia, hypothyroidism, acute kidney failure, hyperkalemia, and dehydration. Review of Resident #69's record revealed the resident was seen on 05/08/25 by Infectious Disease Doctor #809 for a urinary tract infections and on 09/07/25 by Medical Director #812 after resident had a fall. There were no other listed visits from a physician. Review of the Minimum Data Set (MDS) 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 observation, interviews, medical record review, and review of manufacturer instructions and facility policy, the facility failed to timely administer a physician ordered antibiotic for Resident #41 and correctly administer pen injected insulin for Resident #34 utilizing manufacturer instructions. This affected two residents (#34 and #41) out of two residents reviewed for medication administration. The facility identified 19 residents ( #1, #3, #5, #6, #17, #19, #21, #33, #34, #36, #44, #48, #50, #53, #57, #62, #63, #65 and #68) who received pen injected insulin. The facility census was 72.Findings include:1. Review of the medical record for Resident #34 revealed an admission date of 05/22/24 and diagnosis of diabetes mellitus type two. Physician orders effective December 2025 included an order for Toujeo solo star insulin 330 units (U) per milliliter (ml) solution pen injector, to inject 10 U subcutaneously every morning for diabetes mellitus. Review of the annual minimum data set (MDS) assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to obtain physician ordered laboratory testing. This affected three residents (#19, #27 and #57) out of three residents reviewed for laboratory testing. The facility census was 72.Findings include:1. Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus with hyperglycemia, adult failure to thrive, homelessness, mood disorder, glaucoma, Guillain-Barre syndrome, obstructive sleep apnea and panic disorder. Review of Resident #19's physician orders revealed an order dated 10/31/24 to obtain a Hemoglobin A1C (a blood test that measures the average blood sugar levels over the past two to three months that indicates the percentage of hemoglobin in the blood that is coated with sugar), a thyroid-stimulating hormone (TSH) level (a blood test that is used to check for thyroid gland problems), and Depakote level (measures the concentration of valproic acid in the blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff and family interviews, and facility policy review, the facility failed to provide timely dental services for Resident #6. This affected one resident (#6) of three residents reviewed for dental care. The facility census was 72.Findings include: Review of Resident #6's medical record revealed an admission date of 05/13/19 with diagnosis that include major depressive disorder, dementia, intracranial injury, essential hypertension, anxiety disorder, occlusion and stenosis of unspecified cerebral artery, alcohol dependence, and unspecified psychosis. Review of Resident #6's annual dental exam note dated 10/22/24 revealed the resident had an initial examination and was noted to have dentures. The initial exam noted Resident #6 was doing well with current dentures and the resident had no dental concerns. Review of the progress notes for Resident #6 revealed a note dated 12/17/24 authored by Social Service Designee (SSD) #351 which noted at the last care conference (date 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and review of facility policy, the facility failed to accomodate Resident #27's food preference as requested by the resident. This affected one resident (#27) of two residents reviewed for food choices. The facility census was 72. Findings include:Review of medical records for Resident #27 revealed an admission date of 01/14/25 with significant diagnoses including peripheral vascular disease, chronic obstructive pulmonary disease and dysphagia (difficulty swallowing). Significant orders included Regular diet with mechanical soft texture, magic cup two times daily with lunch and dinner, and health supplement two times daily.A review of a quarterly minimum data set assessment dated [DATE] revealed Resident #27 had no cognitive impairment.A review of a care plan dated 10/14/25 revealed Resident #27 had potential for alteration in nutrition and hydration related to peripheral vascular disease and dysphasia. Interventions included food in separate bowls per 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, interview, and review of facility policy, the facility failed to ensure a complete and accurate medical record for Resident #80. This affected one resident (#80) of 53 residents reviewed for the annual survey. The facility census was 72.Findings include:Review of the medical record revealed Resident #80 was admitted to the facility on [DATE] with diagnoses including cervical disc disorder with myelopathy, high cervical region, spinal stenosis, cervical region, anemia, hyperkalemia, obesity, benign neoplasm of right ovary, type 2 diabetes mellitus with diabetic polyneuropathy, essential (primary) hypertension, acute respiratory failure with hypoxia, altered mental status, acute kidney failure, obstructive sleep apnea, metabolic encephalopathy, quadriplegia, iron deficiency anemia, pain in right knee, vitamin D deficiency, muscle weakness, history of methicillin resistant staphylococcus aureus infection.Review of the Minimum Data Set (MDS) 3.0 assessment for Resident #80 dated 06/25/25…

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 medical record, interview, and review of the facility policy the facility failed to ensure Resident #80 received an indwelling urinary catheter upon physician recommendation, failed to ensure appropriate care and services related to indwelling urinary catheters were in place when Resident #80 returned to the facility, failed to ensure Resident #80 was free from complications related to the indwelling urinary catheter, and failed to ensure complications were followed-up on timely and appropriately. This affected one resident (Resident #80) of three residents who were reviewed for appropriate care and services related to urinary catheters and urinary tract infections. The facility census was 77. Findings include: Review of the medical record for Resident #80 revealed an admission date of 06/23/20 and a discharge date of 06/30/24. Diagnoses included stage four chronic kidney disease, liver disease, heart failure, neutropenia, pancytopenia, atrial fibrillation, chronic obstructive pulmonary…

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, review of the medical record, and review of the facility policy the facility failed to ensure the medication error rate was below five percent (%) when two medication errors occurred during 26 medication administration opportunities, resulting in a medication error rate of 7.69%. This affected one resident (Resident #32) of ten residents who were reviewed for medication administration. The facility census was 77. Findings include: Review of the medical record for Resident #32 revealed an admission date of 03/29/24 with diagnoses including chronic obstructive pulmonary disease (COPD), chronic embolism and thrombosis, morbid obesity, hyperlipidemia, congestive heart failure, major depressive disorder, stage three chronic kidney disease, acute respiratory failure, and chronic gout. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 09/20/24 revealed Resident #32 was cognitively intact with a primary medical condition categorized as debility and cardiorespiratory conditions. Resident #32 was on a scheduled pain regimen and…

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

Based on observation, interview, medical record review, and review of the facility policy the facility failed to ensure enhanced barrier precautions (EBP) were maintained while tracheostomy, ventilator, and feeding tube related care were performed by multiple staff members. This affected one resident (Resident #73) of three residents who had tracheostomies and who were observed during the administration of medications or procedures. The facility census was 77. Findings include: Review of the medical record for Resident #73 revealed an original admission date of 06/17/24 and a re-entry date of 07/17/24. Diagnoses included epilepsy, acute and chronic respiratory failure, congestive heart failure, muscular dystrophy, chronic obstructive pulmonary disease (COPD), neuromuscular dysfunction of bladder, anxiety disorder, sepsis, ileus, tracheostomy status, and attention to gastrotomy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 09/09/24 revealed Resident #73 had intact cognition and was dependent on staff for activities of daily living. Resident #73 had an…

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, interview, and review of facility policy the facility failed to ensure Resident #27's representative was notified of changes in condition related to an active infection which required a change in treatment and of positive cultures for multi drug-resistant organisms which required care plan updates. This affected one resident (Resident #27) of three residents (Residents #27, #39, and #79) reviewed. The facility census was 81. Findings include: Review of the medical record for Resident #27 revealed an admission date of 01/15/24 and a re-entry date of 03/14/24. Diagnoses included intractable epilepsy, temporal sclerosis, essential (primary) hypertension, bipolar disorder, hypothyroidism, gastrostomy status, depression, candidiasis, enterocolitis due to clostridium difficile, altered mental status, and presence of a neurostimulator. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 04/23/24 revealed Resident #27 had severely impaired cognition. Further review of the MDS revealed Resident #27 received enteral feedings and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and review of facility policy, the facility failed to implement a person-centered comprehensive care plan that addressed the physical, mental, and psychosocial needs of Resident #27. This affected one resident of five residents (Residents #27, #14, #39, #67, and #79) whose care plans were reviewed for appropriate person-centered interventions. Findings include: Review of the medical record for Resident #27 revealed an admission date of 01/15/24 and a re-entry date of 03/14/24. Diagnoses included intractable epilepsy, temporal sclerosis, essential (primary) hypertension, bipolar disorder, hypothyroidism, gastrostomy status, candidiasis, enterocolitis due to clostridium difficile, altered mental status, and depression. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 04/23/24 revealed Resident #27 had severely impaired cognition and a primary medical condition listed as epilepsy. Further review of the MDS revealed Resident #27 had bipolar…

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, interview, and package insert for Venlafaxine Extended Release (ER) the facility failed to ensure drug irregularities noted by the pharmacist were reported to the attending physician and acted upon timely. This affected one resident (Resident #27) of three residents (Residents #27, #39, and #79) who were reviewed for appropriate medications. The facility census was 81. Findings include: Review of the medical record for Resident #27 revealed an admission date of 01/15/24 and a re-entry date of 03/14/24. Diagnoses included intractable epilepsy, temporal sclerosis, essential (primary) hypertension, bipolar disorder, hypothyroidism, gastrostomy status, depression, candidiasis, enterocolitis due to clostridium difficile, altered mental status, and presence of a neurostimulator. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 04/23/24 revealed Resident #27 had severely impaired cognition and a primary medical condition listed as epilepsy. Further review of the MDS revealed Resident #27 had bipolar disorder, had been taking an…

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 store tortillas, cheese, salami, and turkey in a manner to prevent food borne illness and contamination. This had the potential to affect all 69 residents residing in the facility who were receiving food from the kitchen. There were 15 residents (#7, #33, #44, #55, #67, #69, #70, #71, #72, #76, #77, #79, #81, #83, and #238) who were identified by the facility as receiving nothing by mouth. The facility census was 86. Findings include: On 03/25/24 at 9:30 A.M. a tour of the dry storage area of the kitchen revealed a 36-count package of tortillas with a use by date of 02/23/24. Interview with Dietary Manager (DM) #823 verified the use by date at the time of the observation. On 03/25/24 at 10:00 A.M. an inspection of the snack refrigerator located in the kitchen revealed a 160 count, open package of American cheese that was undated. There were also two packages of approximately 20 slices each of American cheese that was wrapped in plastic and undated. 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, resident representative interviews, and staff interviews, the facility failed to ensure residents and/or their responsible parties were included in and offered the opportunity to participate in quarterly care plan meetings. This affected five residents (#13, #18, #25, #42, and #56) of five residents reviewed for care planning. The facility census was 86. Findings include: 1. Review of Resident #13's medical record revealed an admission date of 05/01/20. Diagnoses included chronic obstructive pulmonary disease (COPD), muscle weakness, difficulty walking, paranoid schizophrenia, bipolar disorder, delusional disorder, generalized anxiety disorder, unspecified atrial fibrillation, and morbid obesity. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 11 of 15, moderate cognitive impairment, and suffered from inattention, disorganized thinking which fluctuated in severity, and impaired thought…

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 interview the facility failed to obtain written authorizations to manage resident funds. This affected three residents (#18, #34, and #291) of eight residents reviewed for facility fund management. The facility census was 86. Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of 05/20/23. Significant diagnoses included acute kidney failure, unspecified dementia, and adult failure to thrive. Resident #18 had a court appointed guardian. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had a BIMS score of three of 15, indicating severe cognitive deficit. A review of the resident fund management authorization form dated 08/22/23 revealed it was signed by Resident #18. There was no signature by the guardian. On 03/27/24 at 1:50P.M. an interview with Business Office Manager (BOM) #710 who manages resident funds verified there was no signature of the guardian. 2. Review of the medical records for 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, observation, interview, and review of the facility policy the facility failed to ensure a clean environment with walls in good repair for Resident #12. The facility did not ensure an environment free of broken window blinds for Residents #48 and #71. The facility did not ensure a room with comfortable temperatures for Residents #54 and #64. This affected five residents (#12, #48, #71, #54 and #64) of 34 residents observed for environment who resided on the Dogwood and Crab Apple units. The facility census was 86. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 9/17/10. Significant diagnoses included diabetes mellitus type II, morbid obesity, weakness, mood disorder, schizophrenia, anxiety, major depressive disorder, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating Resident #12 was cognitively intact. On 03/25/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure resident care plans were updated to reflect the physician's orders. This affected two residents (#42 and #66) of six residents reviewed for care plans. The facility census was 86. Findings include: 1. Review of the medical record for Resident #42 revealed an admission date of 07/13/19. Significant diagnoses included congestive heart failure, edema, diabetes mellitus type II and chronic kidney disease. Significant orders included monitor weight monthly, fluid restriction of 2000 milliliters a day broken down as 860 milliliters for day shift, 300 milliliters for night shift and 840 milliliters for dietary. Other orders included Lasix 40 milligrams (mg) (diuretic) two times daily and potassium 20 milliequivalents (mEq) (supplement) daily. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 of 15, indicating Resident #42 was cognitively intact. Review of the care plan dated…

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

Based on record review, interview, and review of the facility policy the facility did not ensure they had an effective antibiotic stewardship program that monitored antibiotic use including reducing the risk of adverse effects of the development of antibiotic resistant organisms from unnecessary or inappropriate antibiotic use. This affected 28 residents (#10, #16, #29, #30, #31, #38, #40, #44, #47, #51, #53, #55, #59, #63, #68, #73, #75, #77, #80, #83, #189, #190, #191, #238, #287, #288, #290 and #337) out of 34 residents identified as ordered antibiotics during the months of February 2024 and March 2024. The facility census was 86. Findings include: 1. Review of the form labeled, Date reported to QA/ RM Committee and dated 03/01/24 revealed the facility tracked residents that had received antibiotics for the month of February 2024. The form included the resident name, admission date, onset of infection date, site of infection, pathogen, antibiotic that was ordered, if isolation was ordered, if the infection was healthcare associated, the date the infection resolved, and if the…

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

Based on interview, observation, record review, and review of the facility policy the facility did not ensure Resident #80 was treated in a dignified, respectful manner after he requested a blanket from staff because he was cold, and the blanket was not provided. This affected one resident (#80) out of two residents reviewed for dignity. The facility census was 86. Findings included: Review of the medical record for Resident #80 revealed an admission date of 01/26/24 with diagnoses including chronic respiratory failure with hypoxia, epilepsy, atrial fibrillation, presence of tracheostomy, chronic obstructive pulmonary disease (COPD), and pneumonia. He was assessed as cognitively intact. Review of the care plan dated 02/20/24 revealed Resident #80 had a self-care deficit related to diagnoses of COPD, chronic lung disease, cerebral infarction that affected activities of daily living (ADL) due to shortness of breath, decreased activity tolerance, and weakness. Interventions included assist with ADL as needed and monitor for increased shortness of breath and fatigue. Observation 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 notify two residents (#8 and #34) when their personal funds account balance was within two hundred dollars of the state allowed limit. This affected two residents (#8 and #34) of eight residents reviewed for personal funds. The facility census was 86. Findings include: 1. Review of the medical record for Resident #8 revealed an admission date of 06/01/14. Significant diagnoses included unspecified dementia, depression, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Resident #8 had a court appointed guardian. Resident #8 was on Medicaid as a payor source. A review of resident account balances as of 03/27/24 revealed Resident #8 had $2405.63 in a resident fund account. On 03/27/24 at 1:50P.M. an interview with BOM #710 who manages resident funds revealed she makes phone calls to notify residents,…

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 interview, observation, and record review the facility did not ensure staff were knowledgeable regarding how to locate baseline care plans and/ or had [NAME]'s (communication tool that identifies care and services residents require) in place to ensure staff were aware what care and services residents were to receive on admission. This affected two residents (#76 and #82) out of two residents reviewed for baseline care plan. The facility census was 86. Findings include: 1. Review of the medical record for Resident #82 revealed an admission date of 02/14/24 with diagnoses including myelodysplastic syndrome (disorder of the blood cell formation in the bone marrow), diabetes, hypertension, and osteoarthritis. Review of the Admission/ readmission Packet- V2 dated 02/14/24 and completed by Licensed Practical Nurse (LPN) #838 revealed Resident #82 was alert and oriented times three, communicated verbally with clear speech. The Braden Scale for Predicting Pressure Ulcer Risk was completed and noted Resident #82…

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 interview, observation, record review, and review of the facility policy the facility failed to ensure residents who were dependent on staff for assistance with activities of daily living (ADL) including hygiene, fingernail care, and oral care were provided with adequate care. This affected three residents (#51, #71, and #82) out of six residents reviewed for ADL care. This had the potential to affect 67 residents (#1, #3, #4, #6, #7, #8, #9, #11, #12, #14, #15, #19, #21, #22, #23, #25, #26, #27, #28, #29, #30, #32, #33, #34, #35, #36, #37, #39, #40, #42, #44, #45, #46, #47, #48, #49, #51, #50, #53, #54, #55, #57, #59, #60, #63, #64, #65, #66, #67, #70, #71, #72, #73, #74, #77, #79, #80, #81, #82, #83, #187, #237, #238, #287, #288, #289, and #290) who required assistance with ADL. The facility census was 86. Findings include: 1. Review of the medical record for Resident #82 revealed an admission date of [DATE] with diagnoses including myelodysplastic syndrome (disorder of the blood cell formation in 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 observation, interview, and record review the facility did not ensure Resident #53's concern regarding hearing and/or request for hearing aids were timely met. This affected one resident (#53) out of one resident reviewed for hearing and had the potential to affect six residents (#6, #15, #30, #51, #53, and #69) identified as hard of hearing. The facility census was 86. Findings include: Review of the medical record for Resident #53 revealed an admission date of 09/12/22 with diagnoses including diabetes, hypertension, congestive heart failure, and chronic obstructive pulmonary disease. Review of the care plan dated 09/26/23 revealed Resident #53 had a risk for communication problems related to hearing deficit. Interventions included anticipating and meeting needs, referring to audiology for hearing consult as ordered, allowing adequate time to respond, repeating (if necessary), do not rush, face when speaking, and using simple brief consistent words. Review of the Ear Nose Throat (ENT) Nurse…

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, record review, and review of the facility policy the facility failed to change nasal cannula oxygen tubing in a timely manner. This affected two residents (#6 and #289) of 34 residents utilizing oxygen. The facility census was 86. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 06/30/20. Significant diagnoses included chronic obstructive pulmonary disease, morbid obesity, diabetes mellitus, and heart failure. Significant orders included oxygen at three liters per minute via nasal cannula, nasal cannula ear cushions, and change oxygen tubing weekly. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was moderately impaired cognitively. Review of the care plan dated 12/13/23 revealed Resident #6 was at risk for altered respiratory status and oxygen should be delivered as ordered. A review of the Treatment Administration Record (TAR) revealed oxygen tubing was changed 03/06/24, 03/13/24, 03/20/24. 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 interview, observation, record review, and review of self-reported incident (SRI) the facility did not ensure Resident #6's behavior plan of care was followed by staff. This affected one resident (#6) out of one resident reviewed for behavioral health services. The facility census was 86. Findings include: Review of the medical record for Resident #6 revealed an admission date of 06/23/20 with diagnoses including atrial fibrillation, morbid obesity, chronic obstructive pulmonary disease, heart failure, chronic pain, and anxiety. Review of the care plan dated 09/11/23 revealed Resident #6 had the potential to be verbally aggressive, throw objects, make false allegations due to ineffective coping skills. Interventions included assess understanding of the situation, allow time to express self and feelings towards the situation, and give as many choices as possible about care. The care plan revealed when she becomes agitated intervene before agitation escalates, guide away from source of distress, engage…

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 interview and record review the facility did not ensure Resident #13's lab work was obtained as ordered by the physician. This affected one resident (#13) out of five residents reviewed for unnecessary medications including lab work. The facility census was 86. Findings include: Review of medical record for Resident #13 revealed an admission date of 05/01/20 with diagnoses including schizophrenia, bipolar disorder, and morbid obesity. Review of annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had impaired cognition. She displayed hallucinations and delusions. Review of the March 2023 physician's order revealed Resident #13 had an order dated 05/05/20 to have a glycated hemoglobin test (hbA1c) (a lab to obtain an overall picture of what the average blood sugar level was over the past three months) every three months. She also had an order for Risperdal (antipsychotic medication which can increase the risk of impaired glucose metabolism). Review of the lab work revealed 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 interview and record review the facility failed to ensure residents had received and/or the facility had documented evidence that residents were offered the pneumococcal and influenza vaccines. This affected three residents (#39, #61, #80) of the five residents reviewed for immunizations. The facility census was 86. Findings include: 1. Review of the medical record for Resident #39 revealed an admission date of 08/01/23 with diagnoses including myotonic muscular dystrophy, chronic obstructive pulmonary disease (COPD), morbid obesity with alveolar hypoventilation, congestive heart failure (CHF), unspecified atrial fibrillation, dependence on respirator status, and tracheostomy status. Review of immunizations in the electronic medical record did not reflect the pneumococcal vaccine had been administered. Review of the consent form for Pneumococcal and Influenza Vaccines revealed Resident #39 signed the consent requesting the vaccine on 09/20/23. Review of the annual Minimum Data Set (MDS) assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure Resident #16 donned a safety apron during smoking per his intervention on his care plan and that the designated smoking area was maintained in a clean, safe, and sanitary manner. This affected one resident (Resident #16) out of two residents (Resident #16 and #33) reviewed for smoking and had the potential to affect six residents (Resident #8, #12, #16, #50, #316 and #367) who smoke in the designated smoking area off the 600 unit. Findings include: Review of the medical record for Resident #16 revealed an admission date of 03/09/17 and diagnoses included hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, chronic obstructive pulmonary disease, hypertension, and nicotine dependence. Review of quarterly smoking safety assessment dated [DATE] and completed by Licensed Practical Nurse (LPN) #811 revealed Resident #16 was a smoker and required supervision when he smoked. There was no…

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

Based on observation, interview and record review, the facility failed to properly store, label, and dispose of resident medications. This affected one resident (Resident #14) of three residents on the 700 unit who received latanoprost ophthalmic solution (eye drops), one resident (Resident #2) of two residents on the 700 unit who received Lantus (long acting insulin), one resident (Resident #10) of one resident on the 700 unit who received Novolog (short acting insulin), one resident (Resident #57) of one resident on the 700 unit who received trifluridine ophthalmic solution (eye drops), and one resident (Resident #30) of four residents on the 600 unit who received Novolin (short acting insulin). Findings include: 1. Observation on 04/19/22 at 1:56 P.M. on the 700 unit with Licensed Practical Nurse (LPN) #456 during medication storage review revealed Resident #14 had latanoprost ophthalmic solution with an opened date of 03/03/22 with manufacturer's directions to discard after six weeks of opening. Resident #14's latanoprost should have been discarded on 04/14/22. 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 interview, the facility failed to notify Resident #165's physician timely of a change in the resident's abdominal incision. This affected one (Resident #165) of two residents reviewed for general skin conditions. Findings include: Review of Resident #165's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including asthma and incisional hernia with obstruction without gangrene. Review of Resident #165's Admission/readmission Packet form dated 04/07/22 indicated the resident had a abdominal midline incision hernia repair. Review of Resident #165's progress note dated 04/14/22 at 2:36 A.M. authored by Licensed Practical Nurse (LPN) #805 indicated drainage was observed at the incision site in the right upper quadrant. Pus without odor was cleaned with normal saline and a dressing applied. Review of Resident #165's physician orders revealed an order dated 04/16/22 to cleanse the right upper quadrant laproscopic wound site with normal saline 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 and interview, the facility failed to ensure Residents #37 and #46's comprehensive assessments were completed accurately. This affected two (Residents #37 and #46) of twenty-five residents whose records were reviewed for accurate comprehensive assessments. Findings include: 1. Review of the medical record for Resident #46 revealed an admission date of 03/17/22 with diagnoses including chronic kidney disease, essential hypertension, and acute osteomyelitis. Review of Resident #46's Admission/readmission Packet form dated 03/17/22 revealed she was admitted with a stage four pressure ulcer (deep wound that reaches the muscles, ligaments, or even bone) to the coccyx. Review of the Resident #46's Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed she had intact cognition and did not have a pressure ulcer/injury, a scar over a bony prominence, or a non-removable dressing/device. Interview on 04/20/22 at 10:46 A.M. with Licensed Practical Nurse (LPN) #450 verified 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, interview and record review the facility failed to ensure Resident #33's care plan was revised as needed. This affected one resident (Resident #33) out of 25 residents whose comprehensive care plans were reviewed. The facility census was 67. Findings include: Review of medical record for Resident #33 revealed an admission date of 10/18/17 and diagnoses including hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, chronic respiratory failure with hypoxia, morbid obesity, schizoaffective disorder, and bipolar disorder. Review of the care plan dated 06/17/20 revealed Resident #33 had self-care deficits noted as she had a right sided hemiplegia. She required assistance with most activities of daily living except she was able to feed herself. She refused to get out of bed most of the time and refused to wear a palm guard. She wore a brace to her right lower leg. Interventions included ankle foot orthosis (AFO) to her right lower extremity,…

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 interview and record review the facility failed to ensure Resident #16 received restorative nursing range of motion and restorative ambulation program per his plan of care. This affected one resident (Resident #16) out of one resident reviewed for restorative nursing programs. The facility identified eight residents (Resident #2, #14, #16, #21, #30, #42, #49, #56) who had a restorative nursing program. Findings include: Review of the medical record for Resident #16 revealed an admission date of 03/09/17 and diagnoses including hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, chronic obstructive pulmonary disease, hypertension, and nicotine dependence. Review of Physical Therapy Discharge Summary dated 11/02/21 and completed by Physical Therapist #900 revealed Resident #16 received physical therapy from 08/10/21 to 11/01/21 due to hemiplegia and hemiparesis following cerebrovascular disease affecting his left non-dominant side. Discharge recommendations…

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 interview, the facility failed to ensure physician orders were obtained timely for Resident #165's wound care to the laproscopic wound on her right upper quadrant. This affected one (Resident #165) of two residents reviewed for general skin conditions. Findings include: Review of Resident #165's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including asthma and incisional hernia with obstruction without gangrene. Review of Resident #165's Admission/readmission Packet form dated 04/07/22 indicated the resident had a abdominal midline incision hernia repair. Review of Resident #165's progress note dated 04/14/22 at 2:36 A.M. authored by Licensed Practical Nurse (LPN) #805 indicated drainage was observed at the incision site in the right upper quadrant. Pus without odor was cleaned with normal saline and a dressing applied. Further review of the medical record revealed Resident #165 did not have a physician order for wound care to her right…

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 and interview, the facility failed to ensure a multi-use glucometer was appropriately disinfected and sanitized between resident use to prevent cross contamination. This affected one resident (Resident #13) of nine residents (Resident #11, #13, #14, #18, #25, #37, #40, #46, #167) who received blood glucose testing (BGT) on the 500 unit. Findings include: Review of Resident #13's medical record revealed an admission date of 12/15/21 with diagnoses including type two diabetes without complications, acute kidney failure and essential hypertension. Review of Resident #13's Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed Resident #13 was cognitively impaired. Review of Resident #13's physician order dated 03/01/22 indicated to complete a BGT twice daily for glucose monitoring. Observation on 04/18/22 at 9:10 P.M. with Registered Nurse (RN) #452 revealed she obtained Resident #43's BGT by using a multi-use glucometer. RN #452 returned to the medication cart…

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 interview and record review the facility failed to ensure Resident #30 and Resident #64 had or that facility had documented evidence that they were offered the pneumococcal vaccine. This affected two residents (Resident #30 and #64) out of five residents (Resident #8, #20, #28, #30, #64) reviewed for immunizations. The facility census was 67. Findings include: 1. Review of medical record for Resident #30 revealed an admission date of 07/31/19 and diagnoses including diabetes, morbid obesity, congestive heart failure, dementia, and history of COVID-19. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had impaired cognition. The MDS assessment also revealed Resident #30 was not up to date regarding his pneumococcal vaccination as the MDS revealed he was not offered the vaccine. Review of undated facility form labeled, Immunization Audit Report for Resident #30 revealed no documentation Resident #30 received or that he was offered the pneumococcal vaccine. Interview…

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.