Cedarvale Commons Rehabilitation and Healthcare Ce

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, staff interview, and review of facility policy and procedures, the facility failed to ensure the personalized air conditioner (PTAC) in Resident #55's room was maintained in a clean manner and the facility also failed to maintain plumbing in Resident #48's bathroom to prevent leaking. This affected two residents (#48 and #55) of 30 residents in the sample. The facility census was 64. Findings include 1. Review of the medical record for Resident #55 revealed an admission date of 07/30/24. Diagnoses included epilepsy, anxiety, dementia, diabetes, psychotic disorder and heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was cognitively impaired with a Brief Interview of Mental Status (BIMS) of 05. Interview and observation on 06/16/25 at 10:33 A.M. with Resident #55 confirmed PTAC machine was visibly dirty and had a thick layer of dust on the vent. Resident turned on the PTAC air conditioner and a foul (trash like) smell came…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of facility policy and procedures, the facility failed to ensure as needed (PRN) psychotropic medication and antianxiety medication were not ordered for longer than 14 days without a stop date or reassessment for appropriateness. This affected one resident (#21) of five reviewed for unnecessary medication. The facility census was 64. Findings include: 1. Review of the medical record for Resident #21 revealed an admission date of 05/24/23. Diagnoses included Parkinson's dysphasia, muscle wasting, diabetes, and malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had cognitive impairment with a Brief Interview of Mental Status (BIMS) of 09 out of 15. Review of Resident #21's physician order dated 04/02/25 to 06/24/25 revealed an order for Haloperidol (antipsychotic medication) injection solution 5 milligrams per milliliter (mg/ml) with instructions to give 10 mg once every 24 hours as needed (PRN) for severe agitation.…

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 ensure Minimum Data Set (MDS) assessments were completed accurately for two Residents (#21 and #25) of 30 residents reviewed in the sample. The facility census was 64. Findings include: 1. Review of the medical record for Resident #21 revealed an admission date of 05/24/23. Diagnoses included Parkinson's dysphagia, muscle wasting, diabetes and malnutrition. a. Review of the incident accident log dated 12/01/25 to 06/16/25 revealed Resident #21 had falls on 12/15/24, 02/28/25, 03/05/25, 03/06/25, 03/13/25, and 03/17/25. Review of Resident #21's progress note dated 02/28/25 revealed the resident had a fall by her room door when trying to leave during a fire drill. The resident's wrist was visibly swollen and an X-ray was ordered. Review of the fall investigation dated 02/28/25 revealed Resident #21 had a fall with injury and a swollen wrist. The X-ray returned with no findings of a fracture. Review of the progress notes dated 03/05/25 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 record review and staff interview, the facility failed to ensure a pre-admission screening and resident review (PASARR) was updated after a change in the mental health diagnosis for one resident. This affected one resident (#21) out of four reviewed for PASARR. The facility census was 64. Findings include Review of the medical record for Resident #21 revealed an admission date of 05/24/23. Diagnoses included Parkinson's dysphasia, muscle wasting, diabetes and malnutrition. A diagnosis of unspecified psychosis was added to the medical record on 07/02/22 and schizophrenia was added to the medical record as a diagnosis on 07/19/24. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had cognitive impairment with a Brief Interview of Mental Status (BIMS) of 09 out of 15. Review of Resident #21's most recent PASARR dated 10/24/23 revealed panic/anxiety disorder and another mental disorder were documented (delusional disorder and post-traumatic stress disorder). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy and procedure, the facility failed to ensure care plans were developed as appropriate. This affected one resident (#21) of 22 residents reviewed for care planning. The facility census was 64. Findings include: Review of the medical record for Resident #21 revealed an admission date of 05/24/23. Diagnoses included Parkinson's disease, dysphagia, muscle wasting, diabetes, and malnutrition. Review of the social services documentation revealed Resident #21 was approved for Medicaid on 07/17/24. Review of Resident #21's dental consent dated 07/31/24 revealed the resident signed a consent to receive dental services. Review of the dental visit notes dated 04/16/25 revealed Resident #21 had multiple teeth that needed removed. It listed 19 teeth affected for removal. It stated the resident had broken teeth and that the resident reported pain in her mouth. The note further stated Medicaid resident-resources were sent to the facility and 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 record review, resident interview, staff interview, and review of policy and procedure, the facility failed to ensure a resident received showers/bed baths as scheduled. This affected one (Resident #24) out of two residents reviewed for activities of daily living (ADLs). The facility census was 64. Findings include: Review of the medical record for Resident #24 revealed an admission date of 09/26/23 and diagnoses including cerebral palsy (unspecified), generalized muscle weakness, unsteadiness on feet, and major depressive disorder (recurrent, mild). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #24 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Additionally, the resident required maximum assistance with bathing. Review of the care plan for Resident #24 revealed a self-care deficit related to factors including chronic fatigue, generalized weakness, impaired mobility, poor balance, poor coordination, and shortness of breath, which necessitated staff assistance with personal hygiene, including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, staff interview, family interviews, review of hospital records, and review of the facility policy, the facility failed to ensure a resident, who was identified at risk of nutritional problems and malnutrition, maintained acceptable parameters of nutritional status, and failed to follow nutritional interventions, complete weekly weights as ordered, provide appropriate assistance with meals, and provide appropriate oversight and monitoring to address significant and severe weight loss for Resident #10. This affected one (#10) of five residents (#10, #21, #26, #34, and #35) reviewed for nutrition. The facility identified a total of eight residents (#10, #11, #21, #27, #33, #35, #46 and #58) as being at nutritional risk. The facility census was 64. Findings include: Review of the medical record for Resident #10 revealed an admission date of 03/01/24. Diagnoses included respiratory failure, dysphagia, atrial fibrillation, diabetes, muscle weakness, metabolic…

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 facility policy review, the facility failed to provide oxygen to one resident (#58) out of two reviewed for respiratory care. The facility census was 64. Findings Include: Review of the medical record for Resident #58 revealed an admission date 04/28/25. Diagnoses included chronic systolic heart failure, paroxysmal atrial fibrillation, and chronic pain syndrome. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #58 had a Brief Interview of Mental Status (BIMS) of 15 that indicated he was cognitively intact. Resident #58 was dependent on turning, personal hygiene, toileting, dressing upper and lower body. Review of the plan of care dated 06/10/25 revealed that Resident #58 had impaired respiratory status related to anxiety, congestive heart failure, history of smoking, obesity, pulmonary edema, and respiratory failure. Interventions included activity level as tolerated, administer medication as ordered, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of facility policy, the facility failed to ensure pharmacy reviews were followed up on in a timely manner and documentation of the pharmacy recommendations were maintained for one resident (#21) out of five reviewed for pharmacy recommendations. The facility census was 64. Findings include Review of the medical record for Resident #21 revealed an admission date of 05/24/23. Diagnoses included Parkinson's dysphagia, muscle wasting, diabetes and malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had cognitive impairment with a Brief Interview of Mental Status (BIMS) of 09. a. Review of monthly pharmacy reviews dated 08/2024 revealed Resident #21 had pharmacy recommendations, but it did not state what the recommendation was. Review of monthly pharmacy reviews dated 09/2024 revealed Resident #21 had pharmacy recommendations, but it did not state what the recommendation was. Review of monthly pharmacy reviews 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, observation, interview, and facility policy review, the facility failed to ensure a medication error rate less than five percent (%). Two errors were observed out of twenty-six opportunities, equaling an error rate of 7.69%. This affected two residents (#59 and #217) out of three residents reviewed for medication administration. The facility census was 64. Findings Include: 1. Review of the medical record for Resident #59 revealed an admission date of 10/05/23. Diagnoses included type two diabetes and developmental disorder of scholastic skills. Review of the physicians order dated 12/09/24 revealed that Resident #59 had an order for Calcium Carbonate 500 milligrams (mg) with instructions to take one tablet by mouth every six hours as needed for indigestion. Review of the physician order dated 01/07/25 revealed that Resident #59 had an order for Calcium Carbonate 500 mg with instructions to take two at bedtime for indigestion. Review of the plan of care dated 04/03/25 revealed that…

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 facility policy review, the facility failed to appropriately and safely store medications and biologicals. This affected two residents (#2 and #217) out of 30 residents in the survey sample. The facility census was 64. Findings Include: 1. Review of the medical record for Resident #217 revealed an admission date 05/08/25. Diagnoses included chronic obstructive pulmonary disease, type two diabetes, gastroesophageal reflux disease, and major depressive disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #217 had a Brief Interview of Mental Status (BIMS) of 15 that indicated she was cognitively intact. Review of Resident #217's physician orders revealed the resident did not have an order for Calcium Carbonate (TUMS) or an order to have medications unattended at bedside. Observation on 06/16/25 at 10:15 A.M. revealed Resident #217 had a medication cup that contained three round tablets, resembling TUMS, in the med cup…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure dental services were arranged in a timely manner. This affected three residents (#10, #21, and #50) of four residents reviewed for dental services. The facility census was 64. Findings include: 1. Review of the medical record of Resident #50 revealed an admission date of 08/04/22. Diagnoses included chronic obstructive pulmonary disease, anxiety, depression, type two diabetes mellitus with diabetic neuropathy, malingerer, and antisocial personality disorder. Review of Resident #50's plan of care dated 03/11/25 revealed the resident had the potential for pain due to dental pain. Interventions included to refer to ancillary services as needed. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had intact cognition. The resident was assessed as having no dental issues. Review of a progress note dated 05/19/25, authored by Nurse Practitioner (NP) #400,…

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 resident interview, staff interview, and record review, the facility failed to place Resident #26 on the appropriate diet. This affected one resident (#26) out of 30 residents reviewed for the sample. The facility had a census of 64. Findings include: Review of the medical record for Resident #26 revealed an original admission date of 01/30/25 and the most recent re-entry on 05/28/25. Diagnoses included acute osteomyelitis of the left tibia and fibula, extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli infection, metabolic encephalopathy, and acute kidney failure with tubular necrosis. Review of the 5-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #26 revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Additionally, Section K of the MDS stated Resident #26 had no swallowing disorders, was on a therapeutic diet, but it did not state that the resident was receiving a mechanically altered diet. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews, the facility failed to ensure an effective antibiotic stewardship program was being followed/implemented regarding McGeers criteria for one resident (#10) out of four residents reviewed for infections. The facility census was 64. Findings include: Review of the medical record for Resident #10 revealed an admission date of 03/01/24 with diagnoses including urinary tract infection site not specified, acute pyelonephritis, chronic respiratory failure with hypercapnia, and carcinoma in situ of unspecified bronchus and lung. Review of Resident #10's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 04, indicating severely impaired cognition. Review of the nurses' notes revealed Resident #10 exhibited signs and symptoms consistent with a urinary tract infection on two occasions during June 2025. On 05/29/25 at 09:35 A.M., the resident was documented as having increased confusion and urinary discomfort. 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, staff interview, and review of facility policy and procedure, the facility failed to ensure education was provided prior to offering the coronavirus (COVID) vaccine for two residents (#26 and #162) out of five residents reviewed for vaccines. The facility had a census of 64. Findings include: 1. Review of the medical record for Resident #162 revealed an admission date of 11/14/24. Diagnoses included chronic obstructive pulmonary disease, type one diabetes mellitus without complications, atherosclerotic heart disease, and generalized muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #162 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 13. Review of the immunization records revealed Resident #162 received the COVID vaccine (Comirnaty) intramuscular suspension prefilled syringe, 30 micrograms (mcg)/0.3 milliliter (mL) messenger Ribonucleic Acid (mRNA) vaccine, administered one time on 06/24/25 for COVID…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, the facility failed to provide appropriately sized incontinence briefs for residents who have bariatric needs. This affected three (Residents #48, #66, and #77) of three bariatric residents reviewed. The facility census was 78. Findings include: 1. Record review for Resident #48 revealed this resident was admitted to the facility on [DATE] and had diagnoses including chronic respiratory failure, atrial fibrillation, incontinence, urinary tract infections, anxiety, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had minimally impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 13. This resident was assessed to be frequently incontinent of both bowel and bladder. Interviews with Registered Nurse (RN) #30 and Licensed Practical Nurse (LPN) #60 on 08/07/24 at 9:15 A.M. revealed the facility is always out of 3XL incontinence briefs for Resident #48. Both stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record reviews, and review of facility policies, the facility failed to ensure oxygen tubing was changed monthly due to inadequate supply. This affected one resident (#41) of the four residents reviewed for respiratory care. The facility census was 78. Findings include: Record review for Resident #41 revealed this resident was admitted to the facility on [DATE] and had diagnoses including acute respiratory failure with hypoxia, sleep apnea, mood disorder, and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had minimally impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 11. This resident was assessed to have received oxygen continuously while residing in the facility. Review of the care plan dated 05/06/24 revealed this resident received oxygen therapy. Interventions included to change the humidifier bottle and tubing every month and as needed per facility…

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

Based on observations, staff and resident interviews, review of the Resident Council food food committee minutes, and policy review, the facility failed to ensure the food was served at the appropriate and safe temperatures to the residents. This had the potential to affect all residents except for one resident (#44) who received all his nutrition via a tube feeding. The facility census was 67. Findings include: Interview with Resident #2 on 12/22/23 at 9:18 A.M. revealed the food was served cold nine out of 10 meals. Observations of the lunch meal service on 12/22/23 starting at 11:25 A.M. revealed the meal service was in progress and meals for the 100 hall were already served from the kitchen. Using the surveyor's calibrated thermometer, the steam table hot holding food temperature for the puree cheese rice was 120 degrees Fahrenheit (F) and macaroni and cheese was 128 degrees F. [NAME] #75 verified the food temperatures and heated the pans of pureed cheese rice and macaroni and cheese in the oven. [NAME] #75 revealed she did not check or record any food temperatures prior to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to complete a baseline care plan for one (Resident #262) out of the two residents reviewed for baseline care plans. The facility census was 62. Findings include: Review of the medical record for Resident #262 revealed an admission date of 09/30/22. Diagnoses included nondisplaced fracture of right femur, urinary tract infection, encephalopathy, wedge compression fracture of unspecified lumbar vertebra, diabetes mellitus, chronic atrial fibrillation, and chronic kidney disease. Review of the Nurse Designee Functional assessment dated [DATE] revealed Resident #262 required substantial/maximal staff assistance for eating, oral hygiene, and toilet hygiene. Resident #262 did not walk or transfer at the time of the assessment. Further review of the medical record revealed a Brief Interview for Mental Status dated 10/03/22 which revealed the resident had moderate cognitive impairment. Further review of the medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to update care plans to ensure plans met the resident's current level of needs. This affected two (Residents #50 and #33) of three reviewed for care planning. The facility census was 62. Findings include: 1. Medical record review for Resident #50 revealed an admission date of 07/10/22. Diagnoses included paraplegia, pain in thoracic spine, muscle wasting and atrophy, muscle spasm, and limitation of activities due to disability. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had intact cognition. Resident #50 required extensive assistance of two plus persons for bed mobility, transfers, toilet use, and personal hygiene. Review of Resident #50's care plan dated 07/20/22 revealed no goals or interventions in place for Activities of Daily Living (ADLs). Interview on 10/05/22 at 11:16 P.M. with Licensed Practical Nurse (LPN) #140 verified Resident #50's care plan did 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.

Based on medical record review, dialysis contract review, and staff interviews, the facility failed to conduct ongoing assessment of a resident related complications prior to and/or post dialysis. The facility also failed to communicate the resident's vital signs and medical status with the dialysis center. This affected the one (Resident #263) resident who received dialysis. The facility census was 62. Findings include: Review of the medical record for Resident #263 revealed an admission date of 09/27/22. The medical record for Resident #263 revealed medical diagnoses of congestive heart failure (CHF), diabetes mellitus (DM), unspecified protein-calorie malnutrition, chronic kidney disease, and dependence on renal dialysis. Review of the admission Observation dated 09/28/22 revealed Resident #263 was alert and oriented to person, place, time, and situation. The assessment revealed Resident #263 required supervision or assistance with mobility, transfers, and ambulation. Review of Resident #263's current physician orders revealed the resident had an order for hemodialysis at 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 medical record review and staff interview, the facility failed to complete laboratory (lab) orders as directed. This affected one (Resident #22) of three residents reviewed for physician orders. The facility census was 62. Findings include: Medical record review for Resident #22 revealed an admission date of 11/10/20. Diagnoses included chronic obstructive pulmonary disease (COPD), muscle wasting and atrophy, type II diabetes, major depressive disorder, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had intact cognition. The resident required supervision for bed mobility, transfers, walk in room, walk in corridor, toilet use, and personal hygiene. The resident received antianxiety, antidepressant, and opioid medications. Review of physician orders dated 07/23/22, start date 07/25/22, revealed a one time order for the following labs: basic metabolic panel (BMP), complete blood count (CBC) with differential, Hemoglobin A1C, and thyroid…

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 properly practice proper infection control procedures when providing wound care. This affected one (Resident #46) out of four residents reviewed for infection control procedures during wound care. The facility census was 62. Findings include: Review of the medical record for Resident #46 revealed she was admitted to the facility on [DATE] with diagnoses of congestive heart failure, muscle wasting and atrophy, atrial fibrillation, type II diabetes, urinary tract infection, and chronic respiratory failure. Review of the Minimal Data Set (MDS) assessment dated [DATE] revealed Resident #46 was cognitively intact. Resident #46 required assistance from staff for all activities of daily living and was totally dependent upon staff for maintaining personal hygiene. Resident #46 a stage IV pressure ulcer on her left heel. Review of the care plan dated 08/19/22 revealed Resident #46 was at risk for impaired skin related to advanced disease…

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

Based on observation, staff interview and facility policy review the facility failed to properly store and date food items to prevent contamination and spoilage. This had the potential to affect 59 of 62 residents as the facility identified there residents (Resident #39, #155, and #207) who did not eat by mouth . The census was 62. Findings include: Observation of the kitchen on 10/28/19 at 8:48 A.M. revealed a loaf of sliced white bread in a plastic crate open to air and stored in the dry food storage room in the corner where all the bread and buns were stored. Interview with Dietary Manager #203 on 10/28/19 8:53 A.M. verified the loaf of bread was open to air and should be closed when stored. Observation of the kitchen on 10/28/19 at 9:00 A.M. revealed a package of hot dog buns dated 10/17/19 stored with the bread products and a package of elbow macaroni noodles that were opened and undated. Interview with Dietary Aid # 264 on 10/28/19 at 9:05 A.M. confirmed that the package of hot dog buns were dated for 10/17/19 and that facility was supposed to use the bread prior to 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 personnel record review, staffing schedule review, phone email review, staff interview and facility policy review, the facility failed to implement their abuse policy when background checks were not conducted prior to employment and the facility allowed an employee to continue to work when the background check was not received within 30 days. This affected one State Tested Nursing Aide (STNA) #210 of nine personnel records reviewed for background checks. STNA #210 was permitted to work two shifts on Hallway #3, after the 30 days had elapsed. The facility identified Hallway #3 had 14 residents (#4, #6, #10, #12, #14, #23, #37, #39, #44, #46, #47, #48, #54 and #207) who resided there. The census was 62. Findings include: Review of the personnel file for STNA #210 revealed she was hired on 09/18/19. The file lacked a background check. Review of staffing schedule dated 10/26/19 and 10/30/19 revealed STNA #210 worked Hallway #3 from 6:00 P.M. to 6:30 A.M. Review of the administrator's phone email on 10/31/19 at 3:00 P.M. revealed he had submitted the background check for STNA…

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, interview, and facilities policy review the facility failed to provide dignity to residents with catheters. This affected two (Resident #18 and Resident #25) out of six residents with catheters. The facility census was 62. Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of 08/08/12 with diagnoses including heart failure, aphasia, urinary tract infection, diabetes mellitus, dementia, paraplegia, and urinary retention. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed cognitive status was not assessed and he had presence of a catheter. Review of physician note dated 10/19/19 revealed Resident #18 had poor cognition. Review of physician orders dated October 2019 revealed Resident #18 had a suprapubic catheter. Review of careplans revealed Resident #18 had diagnosis of obstructive uropathy that required use of an indwelling catheter. Goal was for Resident #18's dignity to be maintained without…

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 review of resident funds, staff and resident interview and facility policy review the facility failed to ensure personal funds money could be obtained on the weekends. This affected one (Resident #11) of four residents reviewed for personal funds. The facility identified 36 residents with personal funds. The facility census was 62. Findings include: Review of resident funds for Resident #11 revealed she had not made any withdrawals on the weekends from 08/01/19 through 09/30/19. Interview with Resident #11 on 10/28/19 at 10:33 A.M. revealed she didn't think she could take money out on the weekends from her personal account. Interview with Business Office Manager (BOM) #225 on 10/31/19 at 2:12 P.M. revealed there was a petty cash box left on the weekends at the charge nurse's station that only had $40.00 in it and stated that was all that was allowed on the weekends. She stated typically the residents get what they want before the weekend. Interview with Registered Nurse #241 on 10/31/19 at 2:28 P.M. who worked on the unit revealed she worked weekends and said there was 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 medical record review and staff interview the facility failed to notify a resident and/or the residents representative in writing the reason for the transfer to the hospital. This affected one (Resident #52) of two residents reviewed for transfer and discharge. The facility census was 62. Findings include: Review of Resident #52's medical record revealed an admission date of 07/07/17 with pertinent diagnosis of: chronic obstructive pulmonary disease, adult failure to thrive, atrial fibrillation, osteoarthritis, congestive heart failure, generalized anxiety disorder, chronic kidney disease, and major depressive disorder. Review of the 09/30/19 Minimum Data Set (MDS) assessment revealed the resident was severely cognitively impaired and required extensive assistance for bed mobility, transfer, dressing and persona hygiene. Resident #52 was always continent of bowel and bladder and used a wheelchair to aid in mobility. Review of a late entry progress note dated 10/15/19 revealed the resident was having…

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 and staff interview the facility failed to ensure a resident with a newly evident mental disorder was referred for a pre-admission screening and resident review (PASARR) upon a significant change. This affected one (Resident #47) of one resident reviewed for PASARR. The facility census was 62. Findings include: Record review of Resident #47 revealed an admission date of 11/30/17 with pertinent diagnoses of: Parkinson disease, left femur fracture, adult failure to thrive, muscle weakness, basal cell carcinoma of skin of scalp, anxiety disorder, psychosis, bipolar disorder, depressive episodes, osteoarthritis, pain, cognitive communication deficit, vitamin deficiency, vitamin b12 deficiency, hypertensive heart disease, chronic hepatitis, idiopathic hypotension, and nicotine dependence. Review of a 07/26/19 significant change Minimum Data Set (MDS) assessment revealed the resident was rarely or never understood and requires extensive assistance for bed mobility, dressing, eating, toilet use, and personal hygiene. The resident used a wheelchair to aid in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and facility policy review the facility failed to develop a comprehensive care plan to address the behavioral and refusal of care needs. This affected one (Resident #155) of one resident reviewed for the behavioral/emotional care area. The facility census was 62. Findings include: Review of Resident #155's record revealed an admission date of 08/22/19 with diagnoses including major depressive disorder recurrent with severe psychotic symptoms,, primary insomnia, other speech and language deficits following cerebral infarction (stroke), type two diabetes mellitus, and other encephalopathy (a brain disease that alters brain function or structure. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #155 had severely impaired decision making skills and short/long term memory problems. The MDS further revealed Resident #155 needed the extensive assistance of two people for bed mobility, dressing, toileting and personal hygiene and was totally dependent 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 update and revise resident care plans. This affected one (Resident #18) out of 20 residents reviewed for accurate care plans. The facility census was 62. Findings include: Review of the medical record for Resident #18 revealed an admission date of 08/08/12 with diagnoses of heart failure, aphasia, urinary tract infection, diabetes mellitus, dementia, paraplegia, and urinary retention. Review of the quarterly minimum data set assessment dated [DATE] revealed cognitive status was not assessed and Resident #18 had range of motion impairments to upper and lower bilateral extremities. Review of physical therapy discharge note dated 08/23/19 revealed Resident #18 was educated on the importance of continuing to wear hip abductor brace in order to decrease contractures and improve neutral position. Staff to get him up out of bed daily and apply the abductor brace daily. Physical therapy discharge instructions included 24 hour care and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview the facility failed to provide appropriate care for residents with catheters. This affected one (Resident #25) out of six residents with catheters. The facility census was 62. Findings include: Review of the medical record for Resident #25 revealed an admission date of 07/20/12 with diagnoses of paraplegia, bladder disorder, depression, and neuromuscular dysfunction of the bladder. Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #25 had some moderate cognitive deficits and presence of a catheter. Review of physician orders dated October 2019 revealed supra pubic catheter to straight drain and privacy bag at all times. Review of careplan revealed Resident #25 had suprapubic catheter and intervention included to keep drainage bag below the level of the bladder. Observation was conducted on 10/28/19 at 5:08 P.M. of Resident #25 resting in bed and catheter drainage bag was placed up by Resident #25's head on the bed frame…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and facility policy review the facility failed to notify the physician of a significant weight loss for Resident #50 and failed to implement fluid restrictions for Resident #31. This affected two (Resident's #31 and #50) of two residents reviewed for change in condition. The facility census was 62. Findings include: 1- Review of Resident #50's medical record revealed an admission date of 05/21/19 and a readmission date of 09/26/19 with diagnoses including anemia, muscle weakness, dysphagia following cerebral infarction, mild intellectual disabilities and anorexia. Review of the Minimum Data Set (MDS) quarterly review dated 10/17/19 revealed Resident #50 was moderately cognitively impaired and required the extensive assistance of two people for bed mobility and transfers. The resident required extensive assistance of one person for dressing and toileting, and supervision and set up care for eating. Resident #50 had a weight loss of five percent (%) or more in one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview and facility policy review the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS) was completed correctly and timely, behaviors were monitored for an antipsychotic medication, and recommendation from the pharmacy was completed. This affected one (Resident #1) of five reviewed for unnecessary medications. In addition, the facility failed to ensure resident's blood sugars were reported to the physician and pharmacy recommendations were completed. This affected one (Resident #42) of five reviewed for unnecessary medications. The facility census was 62. Findings include: 1. Medical record review for Resident #1 revealed an admission date of 06/17/09. Medical diagnoses included hypertension, atrial fibrillation, diabetes, depression, anxiety, manic depressive, and schizophrenic. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact. Her functional status was supervision for bed mobility,…

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

Based on medical record review, observation, staff interview, and facility policy review the facility failed to ensure infection prevention procedures were followed. The facility failed to properly clean Resident #205's perineal area during indwelling Foley catheter care. This affected one (Resident #205) of two residents reviewed for catheter care. The facility census was 62. Findings include: Record review of Resident #205 revealed an admission date of 10/22/19 with diagnoses of: fracture of unspecified parts of unbearable spine and pelvis, fracture of upper end of right humerus, orthostatic hypotension, anemia, cerebral infarction, polyneuropathy, and retention of urine. Review of a physician order dated 10/23/19 revealed change Foley catheter as needed. Observation of indwelling Foley catheter care for resident #205 on 10/30/19 at 3:22 P.M. revealed Licensed Practical Nurse (LPN) #252 got her materials ready including soap, water, wash cloths, and a wash basin. LPN #252 preceded to clean the Foley catheter tubing with soap and water and then rinsed the catheter tubing. LPN #252…

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.