Arbors West

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 provided spenddown notifications when their accounts balances exceeded $1800.00. This affected two Residents (#17 and #43) of two reviewed with account balances over $1800.00. Facility identified 41 Residents (#1, #2, #4, #5, #6, #7, #10, #11, #12, #13, #15, #17, #18, #19, #21, #22, #24, #27, #28, #29, #30, #31, #33, #36, #41, #43, #44, #45, #46, #47, 49, #50, #53, #54, #55, #58, #62, #64, #66, #137, and #232) with Resident fund accounts. Facility census was 82. Findings include 1. Review of the medical record for Resident #17 revealed an admission date of 02/14/23. Diagnoses included respiratory failure, dementia, vascular disease, and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 4. Review of Resident #17's personal fund balance statements dated 01/02/24 revealed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility staff interview, and facility policy review, the facility failed to develop an accurate and comprehensive care plan for one (Resident #55) with Post Traumatic Stress Disorder (PTSD), of one reviewed for PTSD. The facility census was 82. Findings include: Resident #55 was admitted on [DATE] with diagnoses that included cerebral infarction, hemiplegia and hemiparesis affecting left non-dominant side, type two diabetes mellitus, fibromyalgia, dementia, depression, and PTSD. Review of the annual minimum data set (MDS) 3.0 dated 01/10/25 revealed Resident #55 was severely cognitively impaired with a brief interview for mental status (BIMS) score of 05/15. Resident #55 was noted to have delusions but no behaviors. Resident #55 had psychiatric/mood disorders of depression and post-traumatic stress disorder (PTSD) noted. Resident #55 received antidepressants and anticonvulsant medications with indication present. Review of the care plan for Resident #55 revealed no documentation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure they communicated with the dialysis center. This affected one Resident (#69) of one reviewed for dialysis. The facility identified two residents receiving care from dialysis centers (#69 and #132). Facility census was 82. Findings include Review of the medical record for Resident #69 revealed an admission date of 09/26/24. Diagnoses included end stage renal disease, diabetes, heart failure, and cognitive communication deficit. Review of pre dialysis communication assessment dated [DATE] revealed The following vital signs which were obtained on the morning of 03/21/25: Blood pressure of 131/68, Pulse of 61, Respirations of 16, Temperature of 97.9. The resident weight was 166.2 from 03/20/25 at 10:43 A.M. Review of post dialysis communication assessment dated [DATE] revealed: Blood pressure of 128/64 and Pulse of 62 obtained on 03/21/25 at 9:29 P.M. Respirations of 16 obtained on 03/21/25 at 8:31 A.M., Temperature of 97.9 obtained 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 facility staff interviews the facility failed to ensure individualized trauma informed care was implemented for one resident (Resident #55) of one reviewed for Post Traumatic Stress Disorder (PTSD). The facility census was 82. Findings include: Resident #55 was admitted on [DATE] with diagnoses that included cerebral infarction, hemiplegia and hemiparesis affecting left non-dominant side, type two diabetes mellitus, fibromyalgia, dementia, depression, and post-traumatic stress disorder. Review of the annual minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #55 was severely cognitively impaired with a brief interview for mental status (BIMS) score of five out of a possible 15. Resident #55 was noted to have delusions but no behaviors. Resident #55 had psychiatric/mood disorders of depression and post-traumatic stress disorder (PTSD) noted. Resident #55 received antidepressants and anticonvulsant medications with indication present. Review of the medical record for…

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

Based on medication administration observations, staff interview, record review, and facility policy review, the facility failed to follow ordered parameters for blood pressure medication administration for one (Resident #240) of three residents observed for medication administration. The facility census was 82. Findings include: Observation on 03/26/25 at 8:17 A.M. revealed Registered nurse (RN) #136 prepared seven medications for Resident #240 including Lisinopril (used to decrease blood pressure) 5 milligram (mg) tablet and Propranolol (used to decrease blood pressure) 10 mg tablet. After preparing the medications RN #136 entered the resident's room and obtained a blood pressure and pulse for Resident #240. Blood pressure was 105/69 and pulse was 80 beats per minutes. RN #136 continued to administer medications. Review of medication orders for Resident #240 revealed the orders read Lisinopril 5 mg once a day hold for a systolic blood pressure less than 110 millimeters of mercury (mmHg) and Propranolol 10 mg once a day hold for a systolic blood pressure less than 110 mmHg.…

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 ensure a resident had an appropriate diagnosis for the use on an antipsychotic medication. This affected one (#32) of five reviewed for unnecessary medications. The census was 82. Findings include: Review of Resident #32's medical record revealed an admission date of 01/21/25. Diagnoses listed included malnutrition, Alzheimer's disease, heart failure, muscle weakness, and atrial fibrillation. Review of an admission Minimum Data Set (MDS) dated [DATE] revealed Resident #4 had severe cognitive impairment and did not have a psychotic disorder. Review of physician orders revealed an order dated 03/10/25 for Quetiapine Fumarate (antipsychotic medication Seroquel) 25 milligrams (mg) give one tablet by mouth at bedtime. Further review of physician orders revealed Seroquel 25 mg at bedtime for insomnia was originally ordered on 01/21/25 and continued with orders dated 02/02/25, and 03/08/25. Seroquel was discontinued…

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 medication administration observations, staff interview, record review, and facility policy review, the facility failed to ensure medications were administered as ordered resulting in a medication errors rate of 6.45 percent (%). This affected one resident (Resident #240) out of three residents observed for medication administration. The facility census was 82. Findings include: Observation on 03/26/25 at 8:17 A.M. revealed Registered nurse (RN) #136 prepared seven medications for Resident #240 including Lisinopril (used to decrease blood pressure) 5 milligram (mg) tablet and Propranolol (used to decrease blood pressure) 10 mg tablet. After preparing the medications RN #136 entered the resident's room and obtained a blood pressure and pulse for Resident #240. Blood pressure was 105/69 and pulse was 80 beats per minutes. RN #136 continued to administer medications. Review of medication orders for Resident #240 revealed the orders read Lisinopril 5mg once a day hold for a systolic blood pressure less than 110 millimeters of mercury (mmHg) and Propranolol 10 mg once a day hold…

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 facility staff interview the facility failed to maintain an accurate and complete record for one (Resident #53) who received hospice services. This affected one of one reviewed for hospice services. The facility census was 82. Findings include: Resident #53 was admitted on [DATE] with diagnoses that included non-traumatic chronic subdural hemorrhage, type two diabetes mellitus, anxiety, dementia, hypertension, polyosteoarthritis, atherosclerotic heart disease, peripheral vascular disease, chronic kidney disease stage III, mood disorder, neurocognitive disorder with lewy bodies, and aneurysm of carotid artery. Review of the annual minimum data set (MDS) 3.0 assessment dated [DATE] revealed the resident was unable to be interviewed because her responses were rarely understood. The staff reported Resident #53 had short-term and long-term memory problems. Resident #53 was also receiving hospice care. Review of the electronic medical record revealed the last hospice note scanned into 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 medication administration observations, staff interview, and facility policy review, the facility failed to ensure medications were administered in a manner to prevent contamination or infection. This affected one resident (Resident #240) out of three residents observed during medication administration observations. The facility census was 82. Findings include: Observation on 03/26/25 at 8:17 A.M. revealed Registered Nurse (RN) #136 prepared seven medications for Resident #240. The individual medications were stored in a unit dose dispensing system. Each individual medication was removed from the package and placed in the medication cup. RN #136 removed each medication from the package into her ungloved hand. Then dropped the medication into the medicine cup. Interview on 03/26/25 at 8:22 A.M. with RN #136 confirmed medications were removed from pharmacy unit dose packs into her bare hand. RN #136 stated she was not aware she should not touch the pills and should either place the pills directly into the cup or wear gloves. Review of the policy Medication Administration last…

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.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of facility surveillance footage, review of facility self-reported investigation, staff interviews, and review of facility policy, the facility failed to protect three residents (Resident #46, #74, and #75) from misappropriation when Former Licensed Practical Nurse (LPN) #200 misappropriated their pain medications. This had the potential to affect fifteen residents on the east unit under the care of Former LPN #200. The facility census at the time of the incident was 77 residents. Findings include: Review of medical record for Resident #46 revealed an admission date of 08/15/12. Diagnoses included multiple sclerosis, peripheral vascular disease, chronic pain, and osteoarthritis. The care plan dated 07/28/23 revealed Resident #46 was at risk for pain related to past medical history and diagnoses, with the goal to not experience a decline in overall function related to pain or have an interruption in normal activities due…

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, staff interview, resident interview, and record review, the facility failed to respond to call lights in a timely manner. This affected two residents (#35 and #49) of three reviewed for call light response. Facility census was 73. Findings include: 1. Review of the medical record for Resident #35 revealed an admission date of 07/19/24. Diagnoses included diabetes, spinal muscular atrophy, chronic myeloid leukemia, respiratory failure with hypoxia, pulmonary fibrosis, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively intact and required set up assist for eating, and was dependent with toileting, oral hygiene, showering, and personal hygiene. Review of the plan of care dated 10/07/24 revealed the resident require two person assistance for bed mobility and toileting. Observation and interview on 10/09/24 at 9:25 AM with Resident #35 revealed her call light had been on since about 8:00 A.M. for incontinence care. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and resident interviews, the facility failed to ensure residents had linens placed on their beds to ensure a comfortable homelike environment. This affected one resident (#35) of three reviewed for environment. Facility census was 73. Findings include Review of the medical record for Resident #35 revealed an admission date of 07/19/24. Diagnoses included diabetes, spinal muscular atrophy, chronic myeloid leukemia, respiratory failure with hypoxia, pulmonary fibrosis, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively intact and required set up assist for eating, and was dependent with toileting, oral hygiene, showering, and personal hygiene. Review of the plan of care dated 12/10/23 revealed Resident #35 required two person assistance for bed mobility. Observations on 10/07/24 at 10:40 A.M., 11:10 A.M., and again at 3:30 P.M. of Resident #35's room revealed Resident #35 had no sheet on her mattress.…

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, staff and resident interviews, and record review, the facility failed to ensure residents received showers as scheduled. This affected one resident (#35) of three reviewed for Activities of Daily Living (ADLs). Facility census was 73. Findings include Review of the medical record for Resident #35 revealed an admission date of 07/19/24. Diagnoses included diabetes, spinal muscular atrophy, chronic myeloid leukemia, respiratory failure with hypoxia, pulmonary fibrosis, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively intact and required set up assist for eating, and was dependent with toileting, oral hygiene, showering, and personal hygiene. Review of the shower sheet dated 08/14/24 revealed a shower was provided. Review of the shower sheet dated 09/02/24 revealed no mention of a shower being provided. The form stated no skin issues were found. Review of the shower sheet dated 09/05/24 revealed no mention of a shower…

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, staff interview, and record review, facility failed to ensure residents received a full and nutritious meal. This effected one resident (#35) of three reviewed for nutritious meals. Facility census was 73. Findings Review of the medical record for Resident #35 revealed an admission date of 07/19/24. Diagnoses included diabetes, spinal muscular atrophy, chronic myeloid leukemia, respiratory failure with hypoxia, pulmonary fibrosis, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively intact and required set up assist for eating. Review of the plan of care dated 12/10/23 revealed resident was at risk for altered nutritional status with interventions to provide meals based on food preferences and as ordered update preferences on the tray ticket. Review of physician orders for 08/26/24 revealed an order for carb controlled diet. Review of the menu spread sheet for dinner meal on 10/08/24 revealed carb controlled diet should be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of hospital discharge orders, staff interview and review of medication information from Medscape, the facility failed to ensure a resident received anticoagulant medications as physician ordered resulting in significant medication errors. This affected one (#10) of three residents reviewed for medication administration. Facility census was 65. Findings include: Review of medical record for Resident #10 revealed admission date of 10/30/23. Diagnoses include atherosclerosis of native arteries of extremities with intermittent claudication in bilateral legs, peripheral vascular disease (PVD), chronic obstructive pulmonary disease (COPD) and diabetes mellitus (DM). Resident #10 was discharged on 11/02/23 to the emergency room, and then discharged home. Review of Resident #10's five-day Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview Mental Status (BIMS) score of 13 out of 15 indicating intact cognition. He was independent for eating, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, staff and resident interviews, and facility policy review, the facility failed to implement physician order for half grab bars for Residents #33 and #34, failed to implement physician order for a restorative program for Resident #8, and failed to implement physician order for a Blue Hand and Extension Splint for Resident #56. This affected four (Residents #8, #33, #34, and #56) of five residents reviewed for positioning/mobility. The facility identified 29 residents with contractures. The facility census was 61. Findings include: 1. Review of the medical record for Resident #8 revealed an admission date of 04/25/19. Diagnoses included dementia, depression, and left above the knee amputation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had severe cognitive impairments. Review of Resident #8's therapy notes revealed on 10/25/19, Occupational Therapy (OT) began treatment to Resident #8's right and left hand contractures. The 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 and staff interview, the facility failed to timely address pharmacy recommendations. This affected six (Residents #22, #25, #33, #34, #40, and #56) of six residents reviewed for unnecessary medications. The facility census was 61. Findings include: 1. Review of Resident #22's medical record revealed an admission dated of 01/30/20. Diagnoses included chronic kidney disease, type II diabetes mellitus, major depressive disorder, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively intact. Review of Resident #22's pharmacy recommendations dated 10/18/21, 02/15/22,and 03/17/22 revealed a complete blood count (CBC), basic metabolic panel (BMP), and hemoglobin A1C laboratory tests were requested to be drawn every six months. The pharmacy recommendation was not signed by a physician nor was there evidence in the medical record this was addressed by a physician. Review of Resident #22's pharmacy 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 medical record review, staff interview, and review of the facility's policy, the facility failed to timely address pharmacy recommendations to address psychotropic medication use. This affected five (Resident #25, #33, #34, #40, and #56) of six reviewed for unnecessary medications. The facility census was 61. Findings include: 1. Review of Resident #25's medical record revealed an admission date of 10/09/20. Diagnoses included vascular dementia and schizoaffective disorders. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was severely cognitively impaired. Review of Resident #25's pharmacy recommendations dated 03/17/22 was for a GDR of Trazodone (antidepressant medication) 25 milligrams (mg). The pharmacy recommendation was not signed by a physician. There was no documentation of the pharmacy recommendations being addressed by a physician. Review of Resident #25's pharmacy recommendations dated 02/15/22 and 03/17/22 revealed it was for a gradual dose reduction (GDR)…

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 and staff interviews, and facility policy review, the facility failed to conduct or invite the resident to attend care conferences. This affected two (Residents #45 and #57) of three residents reviewed for care planning. The facility census was 61. Findings include: 1. Review of Resident #45's medical record revealed an admission date of 06/19/18. Diagnoses included cerebral vascular infarction (stroke), epilepsy, chronic obstructive pulmonary disease (COPD), and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 was cognitively intact, able to make decisions, and able to communicate without limitations. Review of the Interdisciplinary and Social Work notes revealed Resident #45 had not attended a care conference since 10/16/20. There was no evidence Resident #45 refused to attend or declined an invitation to any additional care conferences. Interviews on 04/05/22 at 10:15 A.M. and 04/06/22 at 1:20 P.M. with Resident #45 revealed he had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure the resident's Minimum Data Set (MDS) assessments were accurately completed. This affected two (Residents #8 and #30) of 20 residents reviewed for MDS assessments. The facility census was 61. Findings include: 1. Review of Resident #30's medical record revealed an admission date of 09/19/19. Diagnoses included muscle weakness. Review of the quarterly MDS assessment dated [DATE] revealed Resident #30 was coded as having a wound infection. Further review of Resident #30's medical record from 10/01/21 through 04/07/22 revealed no documentation of any wound infections. Interview on 04/07/22 11:15 A.M. with Licensed Practical Nurse (LPN) #31 confirmed Resident #30's quarterly MDS assessment dated [DATE] was coded incorrectly for wound infection. LPN #31 confirmed there was no documentation of Resident #30 having a wound infection from 10/01/22 through 04/07/22. 2. Review of the medical record for Resident #8 revealed an admission date…

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, resident and staff interviews, review of fall reports, and review of facility policy, the facility failed to implement the appropriate fall procedure following Resident #40's fall and failed to implement fall interventions for Resident #34 who had a history of multiple falls. This affected two (Residents #34 and #40) of four residents reviewed for falls. The facility census was 61. Findings include: 1. Review of the medical record for Resident #40 revealed an original admission date on 03/16/18. Diagnoses included congestive heart failure, infarction (stroke), chronic pain, generalized muscle weakness, difficulty in walking, and seizures. Review of the physician orders dated 12/20/21 revealed Resident #40 had an order for a low bed when sleeping for fall precautions. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 had intact cognition. The resident required limited assistance to extensive assistance from one to two…

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

Based on medical record review, staff interview, observation, and review of the facility's policy, the facility failed to ensure a resident's enteral nutrition (tube feeding) was being administered as ordered. This affected one (Resident #30) of two residents reviewed for tube feeding. The facility identified two residents residing in the facility currently receiving tube feeding. The facility census was 61. Findings include: Review of Resident #30's medical record revealed an admission date of 09/19/19. Diagnoses listed included aphasia, dysphagia, muscle weakness. Resident #30 was assessed as being severely cognitively impaired, requiring extensive assistance with activities of daily living (ADLs), and had a feeding tube. Review of the physician orders dated 03/08/22 revealed an order for Jevity 1.5 (enteral nutrition) 75 milliliters per hour (ml/hr) times 18 hours from 4:00 P.M. until 10:00 A.M. This totaled to be 1,340 ml for the 18 hours. Provide an alternative when necessary. Observation of Resident #30's tube feeding on 04/04/22 at 8:23 P.M. revealed a tube feeding bottle of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of a hospice contract, and facility policy review, the facility failed to ensure a hospice communication notes were kept on-site and were available to the facility staff for one resident (Resident #44). This affected one (Residents #44) of 20 residents reviewed for medical records. The facility census was 61. Findings include: Review of the medical record for Resident #44 revealed an admission date on 01/29/20. Diagnoses included Alzheimer's Disease, cerebral infarction (stroke), congestive heart failure, schizophrenia, and stage IV chronic kidney disease. Review of the care plan dated 01/29/20 revealed Resident #44 received hospice services and needed coordination of care related to end of life care. Interventions included the hospice provider to provide a schedule to the facility of their visits and care to be provided during visits and will notify facility of changes in the schedule or care to be provided. Review of the significant change Minimum Data…

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

Based on record review, staff interview, and policy review, the facility failed to offer residents pneumococcal immunization. This affected two (Resident #14 and #32) of five residents reviewed for immunizations. The facility census was 61. Findings include: 1. Review of Resident #14's medical record revealed an admission date of 01/21/22. Diagnoses included type two diabetes mellitus, and heart failure. Further review of Resident #14's medical record revealed no evidence the resident received or was ever offered the pneumococcal vaccine. 2. Review of Resident #32's medical record revealed an admission date of 01/25/22. Diagnoses included malignant neoplasm of prostate and anxiety. Further review of Resident #32's medical record revealed no evidence the resident received or was ever offered the pneumococcal vaccine. Telephone interview with Director of Nursing on 04/14/22 at 3:55 P.M. confirmed Resident #14 and #32 did not receive the pneumonia vaccine and there was no documentation of the vaccine offered or refused in the resident's medical records. Review of the facilities…

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 implement a gradual dose reduction for an antidepressant medication as ordered by physician for Resident #13, failed to follow up on pharmacy recommendations for Residents #46 and failed to ensure Resident #3 and #44 had a monthly medication regimen review. This affected four (Resident #3, #13, #44 and #46) of five residents reviewed for unnecessary medications. The facility census was 72. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 11/30/18 with diagnoses including anxiety, depression, and post traumatic stress disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/09/19, revealed Resident #13 had no cognitive deficits and received antidepressant medications. Review of the care plan revealed Resident #13 had depression and used antidepressant medication. Intervention included to administer medications as ordered. Review of the physician orders, dated June 2019, revealed Resident #13 was on the following antidepressant medications:…

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

Based on medical record review and staff interview, the facility failed to ensure the advance directives for residents were accurate. This affected three (Resident #15, #19 and #64) of 24 residents reviewed during the initial pool part of the survey process. The facility census was 72. Findings include: 1. Review of Resident #64's medical record revealed an admission date of 05/31/16. Diagnoses included Alzheimer's disease, schizophrenia, adult failure to thrive, chronic obstructive pulmonary disease, chronic pancreatitis, dementia with behavioral disturbance, kwashiorkor, depression, muscle weakness, neuropathy, psychosis and thrombocytopenia. Review of the annual Minimum Data Set (MDS) assessment, dated 06/07/19, revealed Resident #64's cognition was intact. Review of the resident's electronic medical record revealed active orders in the electronic charting system for Do Not Resuscitate Comfort Care Arrest (DNRCCA) as a code status. Review of the resident's hard medical record revealed there were two forms under the code status tab. There was a DNRCCA form which was unsigned by 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 record review and staff interview, the facility failed to complete an updated pre-admission screening and resident review (PASARR) following a significant change. This affected one (Resident #53) of twenty-four residents reviewed for PASARR. The facility census was 72. Findings include: Review of Resident #53's medical record revealed being admitted on [DATE] with diagnoses including adjustment disorder with mixed disturbances. Review of the Minimum Data Set (MDS) assessment, dated 04/03/19, revealed the resident was cognitively intact. Review of Resident #53's PASARR, dated 04/25/13, revealed the resident had a diagnosis of developmental disability. The PASARR did not identify Resident #53 had a diagnosis of Bipolar disorder. Review of Resident #53's medical record, dated 12/19/18, revealed the resident received a new diagnosis of Bipolar disorder. Interview on 06/25/19 at 12:55 P.M. with Corporate Social Service Director (SS) #300 confirmed Resident #53's PASARR, dated 04/25/13, revealed the resident…

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

Based on observation, record review, and resident and staff interviews, the facility failed to accurately update the resident's plan of care to reflect any change of condition. This affected two (Resident #6 and #72) of the 24 residents reviewed for plan of cares. The facility's census was 72. Findings include: 1. Review of Resident #6's medical record revealed an admission date of 07/25/18. Diagnoses included delirium, anxiety, and muscle weakness. Review of Resident #6's Minimum Data Set (MDS) assessment, dated for 06/05/19, revealed the resident had intact cognition. Review of the resident's plan of care, dated 03/02/19, indicated resident was non-compliant with the facility's smoking policy including a history of smoking in his room and refusing to wear the recommended smoking apron for protection from dropped ashes or a dropped cigarette. Review of a smoking assessment, dated 06/21/19, revealed Resident #6 was no longer required to be supervised while smoking and no longer needed to wear a smoking apron. Observation on 06/27/19 at 9:00 A.M. of Resident #6 smoking outside 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.

Based on record review, observation, and resident and staff interview, the facility failed to ensure resident's had their assistive hearing devices to maintain hearing abilities. This affected one (Resident #72) of one resident reviewed for hearing. The facility's census was 72. Findings include: Review of Resident #72's medical chart revealed an admission date of 12/19/17 with the diagnoses of dementia without behaviors, cognitive communication deficit, difficulty hearing in right ear, and traumatic subdural hemorrhage without loss of consciousness. Review of the plan of care, dated 12/19/17, revealed the resident was at risk for a deficit related to hearing deficit to her right ear. There was no mention of hearing aids in the resident's plan of care. Review of the Minimum Data Set (MDS) assessment, dated 06/04/19, revealed the resident's cognition was intact and the resident had no assistive devices related to a hearing deficit ordered for this resident. Review of Resident #72's inventory list did not have hearing aids listed on it as items the resident should have. Interview 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 record review, observation, resident and staff interview, and review of the facility's smoking policy, the facility failed to ensure residents who smoked, returned their smoking items back to the nurse after each smoking incident and failed to ensure a resident was supervised during smoking. This affected three (Resident #6, #8 and #67) of the four residents reviewed for smoking. This facility also failed to ensure all ordered fall preventions were in place for the resident's safety. This affected one (Resident #72) of five residents reviewed for accidents. The facility's census was 72. Findings include: 1. Review of Resident #6's medical record revealed an admission date of 07/25/19 with the diagnoses of anxiety, delirium, type two diabetes mellitus, and cognitive communication deficit. The plan of care, dated 03/02/18, revealed the resident was a smoker. Review of the Smoking Assessment, dated 06/21/19, revealed the resident was not required to be monitored by facility staff while smoking. Interview on 06/27/19 at 10:00 A.M. with Resident #6 revealed residents who smoke…

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, medical record review, and facilities policy review, the facility failed to ensure oxygen tubing was dated for two residents (Residents #65 and #72) and failed to have current physician orders for use of oxygen for one resident (Resident #65). This affected two (Resident #65 and Resident #72) of 16 residents assessed for respiratory therapy. The facility census was 72. Findings included: 1. Review of the medical record for Resident #65 revealed an admission date of 06/14/19 with diagnoses including congested heart failure, hypertension, and chronic atrial fibrillation. Review of the admission Minimum Data Set (MDS) assessment, dated 06/21/19, revealed he had no cognitive deficits. Review of the care plan revealed Resident #65 was on oxygen therapy related to congestive heart failure. Review of the physician orders, dated 06/2019, revealed there were no orders for oxygen therapy until after surveyor intervention. On 06/26/19, a new physician order revealed an oxygen saturation was to be obtained every shift and as needed, oxygen tubing 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.