Buckeye Terrace Rehabilitation And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, hospital visit summary review, hospital discharge summary review, review of drainage guidelines for the PleurX, (a thin, flexible tube that's placed in your chest to drain fluid from your pleural space, to make it easier to breathe) and interview, the facility failed to provide necessary and adequate care for Resident #60 who had a PleurX chest tube. The facility failed to ensure nursing staff were properly educated on the tube and failed to ensure the PleurX chest tube was routinely monitored, assessed (for proper placement), monitored for signs/symptoms of infection, accessed, and drained. This affected one resident (#60) of one resident reviewed for chest tubes. The facility census was 58. Findings Include: Review of the closed medical record for Resident #60 revealed an initial admission date of 01/16/25 with diagnoses including acute and chronic…

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 review of a facility policy, the facility failed to provide a dignified dining experience. This affected one (Resident #61) of two residents reviewed for feeding assistance. The facility census was 62 residents. Findings include: Review of Resident #61's medical record revealed an admission date of 06/30/18 with diagnoses that included dementia, dysphagia (difficulty swallowing), and hemiplegia. Review of Resident #61's Minimum Data Set (MDS) dated [DATE] revealed that Resident #61 required partial to moderate assistance with eating. Review of Resident #61's care plan revised 05/09/19 revealed the resident required nursing assistance and supervision to eat. Resident #61's care plan was silent for an intervention that included standing while feeding the resident. Review of Resident #61's speech therapy dysphagia discharge notes on 05/28/24 were silent for recommendations for nursing to stand while feeding the resident her meals. Observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interview. review of the Electronic Information Dissemination and Collection (EIDC) portal and review of a facility policy, the facility failed to report an incident of alleged sexual abuse to the state survey agency andfailed to implement their abuse policy after an allegation of sexual abuse. This affected one (Resident #23) of three residents reviewed for abuse. The facility census was 62. Findings include: Medical record review revealed Resident #23 was admitted to the facility on [DATE] with a diagnoses of schizophrenia, post traumatic seizures, traumatic brain injury, and depression. Review of Resident #23's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. allegation made on 10/18/24. Interview with Resident #23 on 10/22/24 at 10:20 A.M. revealed on 10/18/24, Resident #38 placed Resident #23's hand on his clothing over his penis. Resident #23 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.

Based on medical record review, resident and staff interview and review of facility policy, the facility failed to implement their abuse policy after an allegation of sexual abuse. This affected one (Resident #23) of three residents reviewed for abuse. The facility census was 62. Findings include: Review of Resident #23's medical record revealed an admission date of 06/30/23 with a diagnosis of schizophrenia, post traumatic seizures, traumatic brain injury, and depression. Review of Resident #23's Minimum Data Set (MDS) assessment on 07/24/24 revealed that Resident #23 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Review of Resident #23's medical record revealed that the progress notes were silent for an allegation of sexual abuse affecting Resident #23 on 10/18/24. Interview with Resident #23 on 10/22/24 at 10:20 A.M. revealed that on 10/18/24, Resident #38 placed Resident #23's hand on his clothing over his penis. Resident #23 stated that she told Resident #38 no, and he stopped. Resident #23 stated that she felt uncomfortable about it…

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 and staff interviews and policy review, the facility failed to provide appropriate levels of superstition for residents identified as fall risks. This affected one resident (Resident #42) of three residents reviewed for falls. Findings include: Review of the medical record for Resident #42 revealed an admission date of 05/12/22 with diagnoses that included epilepsy, muscle weakness, and post traumatic stress disorder. Review of Resident #42's Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #42 had a Brief Interview for Mental Status of 11, indicative of moderate cognitive impairment, and that Resident #42 needed supervision and/or touch assistance for showering and bathing. Review of Resident #42's care plan initiated 01/13/24 revealed that Resident #42 was at risk of falls due to abnormal posture, impaired gait, muscle weakness, and that he had a decreased awareness of his need for assistance. A care planned intervention is to remove any causes 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, observation, and staff interviews, the facility failed to provide nail and skin care for Resident #3, who was dependent on staff for personal hygiene. This affected one (Resident #3) out of three residents reviewed for activities of daily living (ADL). The facility census was 59. Findings include: Review of the medical record revealed Resident #3 was admitted on [DATE]. Diagnoses included anoxic brain damage, chronic obstructive pulmonary disease, metabolic encephalopathy, history of transient ischemic attack, attention deficit hyperactivity disorder, and chronic kidney disease. Review of the plan of care dated 04/11/24 revealed Resident #3 had an ADL self-care performance deficit. Interventions to anticipate needs and explain process. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had a brief interview mental status (BIMS) score of 99 which indicated Resident #3 was unable to complete the interview. Resident #3 was dependent on staff 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 and staff interview, the facility failed to assess pressure ulcers and put treatments in place in a timely manner for Residents #1, #2, and #3. The facility also failed to identify a pressure ulcer Resident #3 developed until it was a Stage III (full-thickness loss of skin, in which adipose (fat) is visible in the ulcer. Slough and/or eschar may be visible) pressure ulcer. This affected three (Resident #1, #2, and #3) out of three residents reviewed for pressure ulcers. The facility census was 59. Findings include: 1. Review of the medical record revealed Resident #3 was admitted on [DATE] with diagnoses that included anoxic brain damage, chronic obstructive pulmonary disease, metabolic encephalopathy, history of transient ischemic attack, attention deficit hyperactivity disorder, and chronic kidney disease. Review of the nursing admission care plan dated 04/10/24 revealed Resident #3 had a Stage II (partial-thickness skin loss involving the epidermis and dermis) pressure ulcer to sacrum…

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 staff interview, the facility failed to ensure the residents had weekly skin assessments per physician orders, failed to record skin breakdown identified during a bath, and failed to report the skin breakdown to the nurse. This affected one (Resident #57) of three residents reviewed for pressure ulcers. The facility identified seven current residents with pressure ulcers. The facility census was 58. Findings include: Review of the medical record for Resident #57 revealed the resident was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus and neuromuscular dysfunction of bladder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was cognitively impaired. Resident #57 was dependent on staff for transfers and toileting. Review of the plan of care dated 12/16/22 revealed Resident #57 was at risk for skin breakdown related to diabetes mellitus type two, impaired mobility, weakness, incontinence, episodes…

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, record review, and family, resident, and staff interview, the facility failed to timely repair a resident's sink and ensure it was functional for the resident's use. This affected one (Resident #27) of three residents reviewed for functional sinks in resident rooms. The facility census was 63. Findings include: Review of the facility's maintenance requests revealed Resident #27 had two requests placed on 02/14/24 and 03/14/24 for the room's sink stopped up and both requests were marked as closed. Interview on 04/25/24 at 9:32 A.M. with State Tested Nursing Aide (STNA) #111 revealed the employee had knowledge of the clogged sink in Resident #27's room and stated it needed to be unclogged to work again. STNA #111 stated she would notify management of Resident #27's clogged sink. Interview on 04/25/24 at 9:36 A.M. with Director of Maintenance #109 confirmed knowledge of Resident #27's lack of water supply from the sink. Director of Maintenance #109 stated the sink was clogged, if water supply…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, self-reported incident (SRI) review, and policy review, the facility failed to protect Resident #24 from being verbally abused by Resident #9. This affected one (Resident #24) out of three residents reviewed for abuse. The facility census was 62. Findings include: Review of the medical record revealed Resident #9 was admitted on [DATE] with diagnoses that included history of transient ischemic attack, major depressive disorder, pulmonary embolism, heart failure, dementia without behavioral disturbance, and anxiety disorder. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #9 was cognitively impaired. As of 03/13/24, Resident #9 did not have a care plan in place for behaviors towards other residents. Review of medical record revealed Resident #24 was admitted on [DATE] with diagnoses that included fracture of right lower leg, type 2 diabetes mellitus, schizophrenia, bipolar, post-traumatic stress disorder, osteoarthritis of right knee, disorder 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, interview, self-reported incident (SRI), and policy review, the facility failed to follow the abuse policy when there were allegations of verbal abuse towards Resident #24. This affected one (Resident #24) out of three residents reviewed for abuse. Facility census was 62. Findings include: Review of medical record revealed Resident #9 was admitted on [DATE] with diagnoses that included major depressive disorder, dementia, and anxiety disorder. The quarterly Minimum Data Set, dated [DATE] revealed Resident #9 was cognitively impaired. Review of medical record revealed Resident #24 was admitted on [DATE] with diagnoses that included fracture of right lower leg, type 2 diabetes mellitus, schizophrenia, bipolar, post-traumatic stress disorder, osteoarthritis of right knee, disorder of psychological development, and anxiety disorder. The admission Medicare 5-day MDS dated [DATE] revealed Resident #24 was cognitively impaired. Review of nurse note dated 02/26/24 at 11:18 P.M. revealed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of self-reported incident (SRI), interview, and policy review, the facility failed ensure an allegation of verbal abuse against Resident #24 was reported immediately. This affected one (Resident #24) out of three residents reviewed for abuse. Facility census was 62. Findings include: Review of medical record revealed Resident #9 was admitted on [DATE] with diagnoses that included major depressive disorder, dementia, and anxiety disorder. The quarterly Minimum Data Set, dated [DATE] revealed Resident #9 was cognitively impaired. Review of medical record revealed Resident #24 was admitted on [DATE] with diagnoses that included fracture of right lower leg, type 2 diabetes mellitus, schizophrenia, bipolar, post-traumatic stress disorder, osteoarthritis of right knee, disorder of psychological development, and anxiety disorder. The admission Medicare 5-day MDS dated [DATE] revealed Resident #24 was cognitively impaired. Review of nurse note dated 02/26/24 at 11:18 P.M. revealed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of self-reported incident (SRI), interview, and policy review, the facility failed to thoroughly investigate an allegation of verbal abuse to Resident #24 and failed to prevent further potential abuse to Resident #24. This affected one (Resident #24) out of three residents reviewed for abuse. Facility census was 62. Findings include: Review of medical record revealed Resident #9 was admitted on [DATE] with diagnoses that included history of transient ischemic attack, major depressive disorder, pulmonary embolism, heart failure, dementia without behavioral disturbance, and anxiety disorder. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #9 was cognitively impaired. Review of medical record revealed Resident #24 was admitted on [DATE] with diagnoses that included fracture of right lower leg, type 2 diabetes mellitus, schizophrenia, bipolar, post-traumatic stress disorder, osteoarthritis of right knee, disorder of psychological development, and anxiety disorder.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide adequate bathing and hygiene for residents who required staff assistance with activities of daily living including personal hygiene. This affected two (Resident #26 and #71) out of three residents reviewed for bathing and hygiene. Facility census was 62. Findings include: 1. Review of the medical record revealed Resident #26 was admitted on [DATE] with diagnoses that included dementia, hemiplegia, and dysphagia. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was cognitively impaired. Resident #26 required substantial to maximal assist for bathing. Review of bathing documentation revealed Resident #26 received a shower and had hair washed on 02/01/24. Interview on 03/11/24 at 1:36 P.M. Regional Director of Clinical Services #103 verified there was no other documentation of Resident #26 being bathed or showered in February and March, 2024. 2. Review of the medical record revealed Resident #71 was admitted on [DATE] and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide treatment to a resident with diagnosed mental disorders. This affected one (Resident #1) out of three residents reviewed for medication administration. Findings include: Review of the medical record revealed Resident #1 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included pulmonary embolism, schizoaffective disorder, bipolar, and dementia. Review of physician orders revealed Resident #1 was ordered Abilify (antipsychotic) 300 milligram (mg) intramuscularly (IM) on the 28th of each month. Review of the medication administration record (MAR) revealed Resident #1 was administered Abilify 300 mg IM on 10/28/23. A medication note dated 11/28/23 at 4:27 P.M. revealed Abilify 300 mg was reordered and would be administered once the medication was delivered. Review of the MAR for November revealed Resident #1 was not administered Abilify 300 mg on 11/28/23 due to medication not being available. A medication administration note…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure a resident received appropriate foot care. This affected one (Resident #71) out of three reviewed for foot care. Facility census was 62. Findings include: Review of the closed medical record revealed former Resident #71 was admitted on [DATE] and discharged on 03/01/24 with diagnoses that included chronic obstructive pulmonary disease (COPD), epilepsy, dementia, cachexia, and major depressive disorder. A care plan dated 12/25/23 revealed Resident #71 had an activities of daily living (ADL) self-care performance deficit related to COPD, decreased mobility function, dementia, difficulty in walking, disorder of muscle, nicotine dependence, rheumatoid arthritis, symbolic dysfunction, history insomnia, polyneuropathy. Interventions include check Resident #71's nail length, trim, and clean on bath day and as necessary. Any changes were to be reported to the nurse. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #71 had mildly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of menus, review of food service invoices, observation, and interview, the facility failed to ensure adequate supply of food, post menu's timely, and failed to follow the menu. This had the potential to affect all 64 residents who received meals from the kitchen. The facility census was 64. Findings include: 1. Observation on 02/09/24 at 8:17 A.M., of the resident notification board revealed no evidence the meals for 02/09/24 were posted. The lunch and dinner meals were posted for yesterday 02/08/24. Interview on 02/09/24 at 8:27 A.M., with the Dietary Manager (DM) #58 confirmed he doesn't post breakfast menus and he hasn't posted the lunch and dinner menus yet but was getting ready to. Interview on 02/09/24 at 8:44 A.M., with Resident #10 revealed the kitchen staff don't post breakfast, lunch, or dinner menus on the board timely. The Resident reported she doesn't like meat and if she wanted an alternative, she would have to write her request on paper and place it in the box at the nurse's…

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, fall investigation review, staff interview, and guardian interview, this facility failed to ensure a residents guardian was notified of a change in condition including a witnessed fall. This affected one (Resident #119) of the five residents reviewed for notification. The facility census was 59. Findings include: Review of the medical record for Resident #119 revealed an admission date of 07/10/20 and a discharge date of 11/02/23. Diagnoses included dementia without behavioral disturbances, heart failure, schizoaffective disorder, and signs and symptoms involving the musculoskeletal system. Resident #119 was noted to have a guardian who was not a friend or family member. Review of Resident #119's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 06 out of 15 indicating the resident had a severely impaired cognition for daily decision making abilities. Resident #119 was noted to be independent with set up help…

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, fall investigation review, review of photo, staff interview, and guardian interview, this facility failed to complete a thorough investigation for an injury of unknown origin. This affected one (Resident #119) of the five residents reviewed for incident investigations. The facility census was 59. Findings include: Review of the medical record for Resident #119 revealed an admission date of 07/10/20 and a discharge date of 11/02/23. Diagnoses included dementia without behavioral disturbances, heart failure, schizoaffective disorder, and signs and symptoms involving the musculoskeletal system. Resident #119 was noted to have a guardian who was not a friend or family member. Review of Resident #119's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 06 out of 15 indicating the resident had a severely impaired cognition for daily decision making abilities. Resident #119 was noted to be independent with set up help…

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, discharge planning report, equipment invoice review, staff interview, and case manager interview, this facility failed to ensure a resident discharging from the facility was sent home with a sufficient supply of insulin and needed shower chair. This affected one (Resident #115) of the four residents reviewed for proper and safe discharging. The facility census was 59. Findings include: Review of the medical record for Resident #115 revealed an admission date of 07/07/23 and a discharge date of 10/04/23. Diagnoses included COIVD-19, severe protein-calorie malnutrition, Diabetes Mellitus 2, COPD, major depressive disorder recurrent, atherosclerotic heart disease, hypothyroidism, insomnia, anxiety disorder, hypertension, hyperlipidemia, nicotine dependence cigarettes, constipation. Resident #115 was noted to be her own responsible party. Review of Resident #115's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out…

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 and staff interview, the facility failed to maintain an odor free environment. This directly affected one (#48) resident with potential to affect the additional 48 (#1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #21, #22, #23, #24, #25, #26, #28, #29, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #49, #50, #51, #53, #55 and #56) who resided on the first floor of the facility. The census was 56. Findings include: Observation during the initial tour of the facility on 10/11/23 at 7:18 A.M. revealed a strong urine odor was noted starting down the 100 hallway. Additional observation at 10:24 A.M., outside of Resident #48's room, revealed the urine odor was stronger. Observation and interview with Housekeeping Supervisor #98 on 10/11/23 at 10:24 A.M. confirmed there was a very strong odor of urine in the room that permeated out into the 100 hallway. Observation at this time revealed Resident #48 was not in the room, but the odor of urine remained strong. Further interview with Housekeeping…

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 resident and staff interviews, the facility failed to provide a dependent resident with oral hygiene. This affected one (#15) of three residents reviewed for activities of daily living (ADLs). The census was 56. Findings include: Review of Resident #15's medical record revealed an admission date of 06/28/23. Diagnoses included chronic obstructive pulmonary disease (COPD), emphysema, morbid obesity, tracheotomy, anoxic brain damage, stroke, and major depression. Review of Resident #15's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, and was assessed as dependent on staff for personal hygiene including oral care. Observation of Resident #15 revealed the resident received personal care on 10/11/23 at 9:24 A.M. and 11:53 A.M. Resident #15 received care from State Tested Nurse Aide (STNA) #96, STNA #99, STNA #100. Resident #15 was provided a bed bath including washing her face. Further observation revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident and staff interview, and review of mechanical lift manufacturer's instructions, the facility failed to safely operate a mechanical lift during a resident transfer. This affected one (#13) of three residents reviewed for accidents. The census was 56. Findings include: Review of Resident #13's medical record revealed admission to the facility on [DATE]. Diagnoses included coronary artery disease (CAD), heart attack, gout, morbid obesity, and vascular disease. Review of Resident #13's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, and was totally dependant on staff for transferring with two staff persons needed for assistance. Review of Resident #13's progress notes and physician orders dated 10/11/23 at 12:36 P.M. revealed the resident sustained a facial abrasion while being transferred in a mechanical (Hoyer) lift. Review of the notes revealed the facility nurse practitioner (NP) was in the facility and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident and staff interviews, and review of facility policy, the facility failed to maintain intravenous (IV) access in a proper manner. This affected two (#22 and #33) of two residents reviewed for IV access. The census was 56. Findings include: 1. Review of Resident #22's medical record revealed admission to the facility on [DATE]. Medical diagnoses included hepatic failure, severe septic shock, and encephalopathy. Review of Resident #22's hospital discharge records revealed the resident was discharged to the facility with physician orders for IV antibiotics to be administered through a peripherally inserted central catheter (PICC) line every eight hours for 21 days. Review of Resident #22's progress notes dated 10/06/23 at 1:38 P.M. revealed a peripheral IV (PIV) line was inserted into the resident's right arm. Review of physician orders dated 10/06/23 revealed a PIV line may be inserted until a new PICC line can be placed. The physician order identified to change…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were stored properly and discarded by expiration or use by date. This affected two residents (Resident #39 and Resident #49) out of five residents reviewed for pharmacy medication reviews and had the potential to affect all 58 residents residing in the facility. Findings include: 1. Observation on [DATE] at 07:28 A.M. revealed in the facility's main medication storage area had four unopened bottles of Aspirin 325 milligrams with the written date of 06/2023. Observation of the manufacturer's expiration date revealed date of 06/2023. Further observation in the facility's main medication storage area revealed two bottles of Docusate Sodium (stool softener) 100 milligrams with written date of 06/2023. Observation of the manufacturer's expiration date revealed date of 06/2023. Interview on [DATE] at 7:50 A.M. with the Director of Nursing (DON) confirmed the four bottles of expired Aspirin 325 milligrams and the two bottles…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interview, and facility policy review, the facility failed to monitor and determine Resident #39's ability to safely self administer all acquired medications. This affected one (Resident #39) of the five residents reviewed for unnecessary medication. Findings include: Review of the medical record for Resident #39 revealed an admission date of 09/11/22. Diagnosis included multiple sclerosis, chronic pain syndrome, adult failure to thrive and cocaine abuse. Review of Resident #39's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating resident had an intact cognition for daily decision making abilities. Resident #39 was noted to require extensive assistance from one staff member for eating and was noted to experience impairment to one upper and one lower extremity. Review of Resident #39's Medication Self-Administration Safety Screen dated 08/01/23 revealed medication that was being…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to complete a comprehensive resident centered care plan for the use of a positioning splint device. This deficient practice affected one resident (Resident #45) out of one resident reviewed for a positioning splint device. The facility census was 58. Findings include: Review of Resident #45's medical record revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including cardiomyopathy, stroke, metabolic encephalopathy, diabetes mellitus type 2, depression, high blood pressure, and chronic obstructive pulmonary disease. Review of Resident #45's Minimum Data Set (MDS) revealed Resident #45 was cognitively intact and required extensive assistance from staff for activities of daily living (ADL) tasks. Resident #45 was also frequently incontinent of bowel and bladder. Review of Resident #45's physician orders revealed an order dated 01/19/23 for the placement of a roll hand splint to the right hand for up to six hours as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to revise Resident #8's comprehensive care plan after a change in condition. This affected one (Resident #8) of 25 residents reviewed for comprehensive care plans. Findings Include: Resident #8 was admitted to the facility on [DATE]. His diagnoses were type I diabetes, difficulty walking, hereditary and idiopathic neuropathy, acquired absence of right foot, peripheral vascular disease, myasthenia gravis, hypertension, hypothyroidism, bipolar disorder, borderline personality disorder, major depressive disorder, old myocardial infarction, hypo-osmolality and hyponatremia, hypokalemia, and anemia. Review of Resident #8's Minimum Data Set (MDS) assessment, dated 06/13/23, revealed he was cognitively intact. Review of Resident #8 progress notes, dated 08/10/23, revealed he returned to the facility after having surgery to perform a below the knee amputation. Review of Resident #8 care plan revealed no care plan regarding…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to provide personal hygiene to Resident #1 who dependent on staff for care. This deficient practice affected one resident (Resident #1) out of two residents reviewed for personal hygiene. The facility census was 58. Findings include: Review of Resident #1 medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including epilepsy, congestive heart failure, blindness, depression, anxiety, and high blood pressure. Review of Resident #1 Minimum Data Set (MDS) Quarterly dated 08/18/23 revealed Resident #1 had impaired cognition, was always incontinent of bowel and bladder, required extensive assistance from staff for bed mobility, transfers, dressing, and personal hygiene including fingernail trimming and care. Resident #1 was dependent on the staff for bathing and locomotion off the unit. Further review revealed Resident #1 was receiving hospice services. Review of Resident #1's care plan dated 01/04/22 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 interview and record review the facility failed to follow physician orders to notify the physician of an abnormal blood glucose level. These deficient practice affected one resident (Resident #21) out of two residents reviewed for blood glucose levels. Findings Include:Reviewed of the medical record for Resident #21 revealed an admission date of 06/22/22. Diagnosis included type two diabetes mellitus, severe protein calorie malnutrition, and chronic pancreatitis. Review of Resident #21 quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating an intact cognition for daily decision making abilities. Resident #21 was noted to be 69 inches tall, weighted 133 pounds and was receiving insulin and diuretics daily. Review of Resident #21's plan of care, no date noted, revealed the resident has type 2 diabetes mellitus with hyperglycemia and diabetic neuropathy. Interventions include administering diabetic medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to verify placement of a percutaneous endoscopic gastrostomy (PEG) tube prior to medication administration. These deficient practices affected one resident (Resident #5) out one resident reviewed for PEG tube. Findings Include: Review of Resident #5 medical record revealed Resident #5 was admitted to the facility on [DATE] with admitting diagnoses including Chronic Obstructive Pulmonary Disease (COPD), hemiplegia affecting left non-dominant side, dysphagia, adult failure to thrive and gastrostomy status. Further review revealed Resident #5 received medications via the PEG tube. Review of Resident #5 Minimum Data Set (MDS) Quarterly dated 07/04/23 revealed Resident #5 requires extensive assistance for activities of daily living (ADL) tasks and dependent assistance from staff for feeding and medication administration. Review of Resident #5 physician orders revealed Resident #5 receives Enteral Feed of Jevity 1.5 at 325 milliliters every four…

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, and staff interview, the facility failed to provide adequate social services oversight and assistance to Resident #54 related to benefit(s)/continued placement in the facility. This affected one resident (#54) of one resident reviewed for insurance benefits. The census was 58. Findings Include: Resident #54 was admitted to the facility on [DATE]. His diagnoses were encephalitis, chronic obstructive pulmonary disease, nontoxic goiter, mood disorder, anxiety disorder, alcohol abuse, hypertension, difficulty walking, and cognitive communication deficit. Review of his Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed the resident was cognitively intact. Review of Resident #54's progress notes, dated [DATE] and [DATE], revealed the resident told facility social services he had no apartment to go back to since he was in the nursing home. She documented they would continue a safe discharge process and appeal an insurance discontinuation. On [DATE], social…

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 provide evidence all pharmacy recommendations were addressed for Resident 349 in a timely and thorough manner. This affected one (Resident #49) of five residents reviewed for unnecessary medications. The census was 58. Findings Include: Resident #49 was admitted to the facility on [DATE]. Her diagnoses were chronic obstructive pulmonary disease, emphysema, morbid obesity, myopia, tracheostomy status, anoxic brain injury, hypertension, anemia, personal history of transient ischemic attack, major depressive disorder, anxiety disorder, and opioid dependence. Review of her Minimum Data Set (MDS) assessment, dated 07/03/23, revealed she was cognitively intact. Review of Resident #49 census documentation revealed she was discharged to the hospital on [DATE] with an anticipation of return. Review of Resident #49 pharmacy recommendations signed 08/10/23 revealed the recommendation to clarify the diagnosis of Amantadine and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure all staff protected and valued residents' private space when Laundry Manager #4 failed to knock or request permission to enter the shower room where Resident #25 was being assisted with a shower. This affected one resident (#25) of 61 residents residing in the facility. Findings include: Review of Resident #25's medical record revealed the resident was admitted to the facility on [DATE] with admitting diagnoses including multiple sclerosis, hemiplegia, history of cocaine abuse, and adult failure to thrive. Review of the annual [NAME] Data Set (MDS) 3.0 assessment, dated 08/09/23 revealed the resident had intact cognition, required total assistance from staff for activities of daily living (ADL) and bathing tasks and was incontinent of bowel and bladder. On 08/23/23 at 10:34 A.M. State Tested Nursing Assistant (STNA) #3 was observed assisting Resident #25 into the first-floor central shower room for a shower. Further observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to provide pressure ulcer wound care for Resident #40 in a manner to prevent the spread of infection. This affected one resident (#40) of one resident reviewed for pressure ulcer care/treatment. Findings include: Review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE] with admitting diagnoses including stroke, hemiplegia, chronic respiratory failure, tracheostomy, dysphasia, and the presence of a pressure injury to the sacrum region. Review of Resident #40's physician's orders revealed an order for wound care, cleanse and pack sacral wound with silver alginate and cover with a dry, clean dressing daily and as needed. On 08/23/23 beginning at 9:30 A.M. Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #2 were observed performing a sacral pressure ulcer dressing change. RN #1 placed a towel between Resident #40's buttocks and the bottom bed sheet as a barrier. During the procedure, RN #1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to provide tracheostomy care for Resident #40 in a manner to prevent the spread of infection. This affected one resident (#40) of one resident reviewed for tracheostomy care. Findings Include: Review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE] with admitting diagnoses including stroke, hemiplegia, chronic respiratory failure, tracheostomy, dysphasia, and the presence of a pressure injury to the sacrum region. Review of Resident #40's physician's orders revealed an order for tracheostomy care twice daily and replacement of the tracheostomy inner cannula daily. On 08/23/23 beginning at 9:00 A.M. Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #2 were observed performing tracheostomy care for Resident #40. While cleaning the inside of the external tracheal cannula, RN #1 placed the used cannula cleaning brush on the paper barrier located on Resident #40's chest. As RN #1 was completing…

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 interview the facility failed to provide a menu with a variety of foods and failed to create substitution logs and notify residents when the planned menu was not being followed. This had the potential to affect 46 of 46 residents who received meal trays from the kitchen. The facility identified two residents (#46 and #4) who received nothing by mouth. The facility census was 48. Findings include: 1. Review of the resident council meeting minutes, dated 07/21/21 revealed residents had concerns with the variety of food being served. Review of the resident council meeting minutes, dated 08/08/21 revealed residents had concerns with the types of food, portions and times of meals. The August 2021 meeting minutes revealed to review and make changes to the menus. On 11/21/21 at 10:18 A.M. interview with Resident #20 revealed she felt the facility served the same foods repeatedly. On 11/22/21 at 2:10 P.M. during a resident council meeting, four of nine residents present at the meeting revealed concerns related to food variety. The residents 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.

Based on observation, record review and interview the facility failed to ensure meals/food items from the kitchen were palatable and served at the proper temperature. In addition, the facility failed to ensure pureed food items were prepared properly to conserve appearance and palatability. This had the potential to affect 46 of 46 residents who received meal trays from the kitchen. The facility identified two residents (#46 and #4) who received nothing by mouth. The facility census was 48. Findings include: 1. On 11/21/21 at 9:24 A.M. interview with Resident #20 revealed dietary concerns. The resident revealed he felt the food was served cold and was unappealing. On 11/21/21 at 9:55 A.M. interview with Resident #2 revealed dietary concerns. The resident revealed she felt the food was cold and did not taste good. On 11/21/21 at 1:15 P.M. interview with Resident #32 revealed dietary concerns. The resident voiced concerns food was served cold. On 11/22/21 observation of the lunch meal revealed the main meat entree was a pork cutlet. At 11/22/21 at 1:00 P.M. following the delivery 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.

Based on record review, interview, and observations, the facility failed to consider the views of residents and act promptly upon resident concerns regarding the variety of food. This affected nine residents (Residents #7, #18, #20, #24, #33, #35, #38, #40, #43) with the potential to affect all 46 residents that consumed food from the kitchen. Findings include: Interviews on 11/22/21 at 2:10 P.M. with nine resident council members (Residents #7, #18, #20, #24, #33, #35, #38, #40, #43) during the resident council meeting revealed four of nine revealed concerns of food variety. The residents revealed these concerns come up frequently during resident council meetings. Review of resident council meeting minutes, dated 07/21/21, revealed concerns of the variety of food, specifically vegetables, with interventions to review substitutes for fall menu. Resident council minutes, dated 08/18/21, revealed concerns related to types of food, timing of meals, and seasonal menu, with interventions to review and make changes to the menus. Review of the spring summer menu for 2021 revealed a lack 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.

Based on review of the facility resident personal needs accounts (PNA) and staff interviews, the facility failed to ensure a surety bond was in place to potentially cover any loss of residents PNA account funds. This affects 21 of 21 residents (Resident #2, #3, #4, #6, #7, #10, #13, #19, #21, #22, #23, #24, #25, #28, #31, #35, #36, #38, #39, #40 and #41) whose personal funds were secured by the facility. Findings include: Review of the facility PNA accounts identified total balance of $31,499.58 as of 11/29/21 for the 21 residents. The facility surety bond was identified to cover a loss of up to $24,000 and had been in effect since 09/18/17. Interview with Business Office Manager #7 on 11/29/21 at 8:40 A.M. confirmed the facility current surety bond does not cover the total amount of funds in the account.

Based on observations and staff interviews, the facility failed to ensure all residents had a privacy curtain that would allow full visual privacy. This affected 21 residents (Resident #4, #6, #7, #8, #9, #11, #14, #16, #17, #18, #19, #21, #22, #27, #37, #43, #45, #46, #49, #201 and #452) of 21 residents reviewed for privacy. Findings include: Observation on 11/21/21 at 11:16 A.M. of Resident #1's room revealed the privacy curtain was observed to be several feet too short to provide the resident full visual privacy. Observation on 11/22/21 at 7:47 A.M. of Resident #17's room revealed both beds in the room did not have privacy curtains that extend all the way around their bed to allow for full visual privacy. Interview on 11/22/21 at 10:42 A.M. with Administrator revealed the facility completed an audit and provided the listing of residents that do not have privacy curtains that provide residents full visual privacy. The interview revealed privacy curtains in the following residents rooms were not long enough to provide full visual privacy: Resident #4, #6, #7, #8, #9, #11, #14, #16,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview and facility policy review, the facility failed to develop comprehensive plan of care for Resident #8, #14, #20, #26. This affected four residents (Resident's #8, #14, #20, and #26) of 24 residents reviewed for comprehensive care plans. Findings Include: 1. Review of Resident #8's medical record revealed an admission date of 04/27/20. Diagnoses included but were not limited to encephalotpathy, cerebral infarction with left sided hemiparesis, contracture of left hand, seizures, and Alzheimer's disease, dysphagia, essential hypertension, and dementia with behavioral disturbance. Review of the Resident #8's nursing admit/readmit screener, dated 04/27/20, revealed the resident had a contracture to his left arm and leg. Review of Resident #8's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/09/21, revealed the resident had unclear speech, sometimes understood others, sometimes makes himself understood, and had a moderate cognitive impairment. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, facility policy and procedure review and interview the facility failed to ensure all multi-use medications were dated when opened and failed to ensure medications were discarded once expired. This affected five residents (#12, #6, #450, #16 and #33) and had the potential to affect 26 residents who resided on the Eastside unit and 14 residents who resided on the Westside unit who received medication(s) from the observed medication carts. The facility census was 48. Findings include: 1. On [DATE] at 11:01 A.M. observation of the medication cart on the Westside unit with Licensed Practical Nurse (LPN) #45 revealed a stock bottle of Aspirin 325 milligrams (mg) with an expiration date of 03/2021 and a stock Allergy Relief 10 mg with expiration date of 10/2020. On [DATE] at 11:01 A.M. observation of the medication cart on the Westside unit with LPN #45 revealed the medication cart contained resident medications that had not been dated when opened/first used. The cart contained Lantus insulin for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to follow a spreadsheet or diet guide for residents on a therapeutic diet and failed to ensure Resident #9 was provided a diet as ordered by the physician. This affected five residents (#3, #9, #23, #201 and #451) of 48 residents residing in the facility identified to receive a therapeutic diet. Findings include: 1. On 11/22/21 from 11:50 A.M. to 12:40 P.M. observation of the lunch meal service revealed residents were given pork cutlet, buttered noodles, mixed vegetables, corn bread and pears. Residents on a liberalized renal diet and cardiac diet were given the same meals as those on the regular meal. Review of the spreadsheet for the lunch meal on 11/22/21 revealed a description of what residents on regular, mechanical soft, puree, mechanical soft finger food, and finger food diets were to receive. There was no description of the food to be provided to residents on a liberalized renal diet or cardiac diet. Review of the menu for the lunch…

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, facility policy and procedure review and interview the facility failed to maintain appropriate infection control practices during a pressure ulcer dressing change for Resident #28 and during blood glucose monitoring using a shared glucometer to prevent the spread of infection. This affected one resident (#28) of three residents reviewed for pressure ulcers and five residents (#12, #34, #44, #17 and #450) of five residents observed for blood glucose monitoring. Findings include: 1. On 11/22/21 at 11:20 A.M. Licensed Practical Nurse (LPN) #45 was observed performing blood glucose monitoring using a shared glucometer. LPN #45 obtained supplies from the east medication administration cart, applied a pair of disposable gloves and walked to Resident #12's room. LPN #45 placed a barrier on the resident's bedside table and placed the supplies on the barrier. She then cleansed the resident's left index finger and obtained the required blood using a single use lancet. LPN #45 then walked to the medication administration cart and cleansed her hands with 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, staff interview, and facility policy review, the facility failed to ensure Resident #10 advanced directives were accurate. This affected one resident (Resident #10) out of three residents reviewed for advanced directives. Findings include: Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including but not limited to atherosclerotic heart disease of native coronary artery, acute and chronic respiratory failure with hypercapnia, and dementia without behavioral disturbance. Review of the Resident #10's physician order for 05/13/20 revealed the resident was DNRCC. Review of Resident #10's care plan, dated 05/14/21, revealed the resident had the Advanced Directive: Do Not Resuscitate Comfort Care (DNRCC). Interventions included assess advance directive upon admission, quarterly, annually, and with significant change to ensure the resident wishes were maintained regarding advanced directive. Review of Resident #10's annual Minimum Data Set (MDS)…

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 review of the facility policy review, the facility failed to ensure Resident #26's pre-admission screening and resident review (PASARR) was updated with current mental health diagnosis. This affected one resident (Resident #26) of the 24 residents reviewed for PASARR. Findings include: Review of the medical record for Resident #26 revealed an admission date of 08/05/21. Diagnoses included encephalopathy, COVID-19, Chronic respiratory failure, diabetes mellitus type two, hallucinations, mood disorder, pressure ulcer of sacral region, unspecified stage, and schizoaffective disorder. Review of Resident #26's PASARR, dated 12/14/20, revealed Resident #26 had mood disorder, panic or other severe anxiety disorder and bi-polar disorder checked under serious mental illness/ Review of Resident #26's quarterly Minimum Data Set (MDS) assessment, dated 10/08/21, revealed Resident #26 was cognitively intact. Resident #26's cognition was moderately impaired. Review of Resident #26's medical diagnoses history revealed the resident received diagnoses for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure two residents (Resident #8 and #19) who were dependent on staff for personal hygiene were shaved. This affected two residents (Resident #8 and #19) of three residents reviewed for activities of daily living. Findings include: 1. Review of Resident #8's medical record revealed an admission date of 04/27/20. Diagnoses included encephalopathy, cerebral infarction with left sided hemiparesis, dysphagia, hypertension, contracture of left hand, seizures, Alzheimer's disease, major depressive disorder, hyperlipidemia, osteoarthritis, dementia with behavioral disturbances, gastro-esophageal reflux disease and anemia. Review of Resident #8's nursing admit/readmit screener, dated 04/27/20, revealed the resident had no teeth but did have both full upper and lower dentures. The assessment indicated the resident had a contracture to his left arm and leg. Review of Resident #8's quarterly Minimum Data Set…

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

Based on interview, observation, and record review, the facility failed to ensure Resident #26 had a pressure reducing mattress in place per physician orders. This affected one resident (Resident #26) of the three residents reviewed for pressure ulcers. Findings include: Review of the medical record for Resident #26 revealed an admission date of 08/05/21. Diagnoses included encephalopathy, COVID-19, chronic respiratory failure, diabetes mellitus type two, hallucinations, mood disorder, pressure ulcer of sacral region, unspecified stage, and schizoaffective disorder. Review of Resident #26's quarterly Minimum Data Set (MDS) assessment, dated 10/08/21, revealed Resident #26 was cognitively intact, required extensive assistance with two-person for bed mobility and transfers, and was total dependent for toileting and bathing. The assessment indicated she was at risk for pressure ulcers and had one stage four pressure ulcer. Review of Resident #26's physician order, dated 08/06/21, revealed orders for a pressure reducing mattress and a specialized air loss mattress. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to ensure Resident #8's left arm splint and foot positioning device was in place to prevent a decline in range of motion (ROM). This affected one resident (Resident #8) of one reviewed for limited range of motion. Findings include: Review of Resident #8's medical record revealed an admission date of 04/27/20. Diagnoses included encephalopathy, cerebral infarction with left sided hemiparesis, dysphagia, hypertension, contracture of left hand, seizures, Alzheimer's disease, major depressive disorder, hyperlipidemia, osteoarthritis, dementia with behavioral disturbances, gastro-esophageal reflux disease, and anemia. Review of Resident #8's nursing admit/readmit screener, dated 04/27/20, revealed the resident had a contracture to his left arm and leg. Review of the Occupational Therapy (OT) Discharge summary, dated [DATE], revealed the resident would wear a left arm splinting device for four hours on and four hours off. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, and facility policy review, the facility failed to ensure Resident #19's fall interventions were in place at all times and bed rails were safely installed and inspected to prevent risk of resident entrapment. This affected one resident (Resident #19) of one resident reviewed for accident hazards. Findings include: Resident #19 was admitted on [DATE] with diagnosis including fracture of the hip, asthma, dementia without behaviors, anxiety, dysphagia, difficulty walking, muscle wasting and atrophy of right lower leg, osteoarthritis, repeated falls, seizures, encephalopathy, and heart disease. Resident #19's annual Minimum Data Set (MDS) assessment, dated 10/13/21, revealed the resident's cognition was severely impaired. Resident #19 required limited assistance of one-person physical assist for bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #19 was occasionally incontinent of bowel and bladder. Review of the care plan revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Resident #46 was provided oxygen therapy as ordered. This affected one resident (#46) of two residents reviewed for respiratory services/oxygen. Findings include: Review of Resident #46's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including stroke and chronic respiratory failure with tracheotomy (trach). Review of the current physician's orders revealed the resident had an order for oxygen at two liters via trach mask with humidification. On 11/22/21 at 7:27 A.M. and 11:00 A.M. Resident #46 was observed with humidification running, however there was no oxygen bled into the tracheotomy system at these times. The resident was not receiving any oxygen at the times of the observation. On 11/22/21 at 12:48 P.M. observation and interview with Respiratory Therapist (RT) #120 revealed the resident's humidification to his trach was not set up correctly. RT #120 verified the resident was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to comprehensively monitor and assess for weight changes to determine if the changes were a result of fluid loss/hemodialysis for Resident #14. This affected one resident (#14) of one resident reviewed for hemodialysis. Findings include: Review of the medical record for Resident #14 revealed an admission date of 09/21/21. Resident #14 had diagnoses including end stage renal disease (ESRD), diabetes mellitus with diabetic neuropathy, hyperlipidemia, anemia, and dependence on renal dialysis. Review of the care plan, dated 09/22/21 revealed the resident had potential for nutritional problems related to multiple medical diagnosis including ESRD on hemodialysis, asthma, diabetes mellitus type two and morbid obesity. The care plan revealed diuretic use and hemodialysis treatments may cause weight fluctuations. Supplements used for additional nutritional support. The plan was updated on 11/15/21 to reflect a significant weight loss times three weeks which was…

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

Based on observation, record review, facility policy and procedure review and interview the facility failed to provide adequate pharmaceutical services to ensure medications for administration were not left unattended with Resident #40. This affected one resident (#40) of six residents reviewed for medication administration. Findings include: On 11/21/21 at 7:40 A.M. Resident #40 was observed to have a full cup of medications on her bedside stand sitting in front of her. The observation revealed no staff were within viewing of the resident at that time. At the time of the observation, interview with Resident #40 revealed the nurse had left the medications with her this morning and indicated she would take them with her meal which would be served in about a half hour. Record review revealed no assessment of the resident's ability to self administer medications and no physician order for medications to be left at the resident's bedside for self-administration. On 11/21/21 at the time of the observation, interview with Registered Nurse (RN) #39 revealed she had taken medications to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure pharmacy recommendations were addressed in a timely manner for Resident #33 and Resident #19. This affected two residents (#19 and #33) of seven residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #33's medical record revealed an original admission date of 10/12/14 with the latest readmission of 04/23/20. Resident #33 had diagnoses including end stage heart failure, chronic respiratory failure, congestive heart failure, severe morbid obesity, diabetes mellitus, diverticulitis of large intestine, lymphedema, obstructive sleep apnea, osteoarthritis, gout, anemia, pain, gastro-esophageal reflux disease, atrial fibrillation, peripheral vascular disease, major depressive disorder, hypertension, anxiety and kidney failure. Review of the pharmacy recommendation, dated 11/20/20 revealed the pharmacist recommended laboratory testing to obtain a complete metabolic panel (CMP), Digoxin level, HgbA1c, magnesium level,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure Resident #33 and Resident #19's medication regimens were free of unnecessary medications. The facility failed to obtain physician ordered daily weights to monitor the effectiveness of diuretic medication and failed to obtain laboratory testing (PT/INR) to monitor the effectiveness of anti-coagulant medication for Resident #33 and failed to ensure Resident #19 was not administered duplicate doses/excessive doses of anti-seizure medication. This affected two residents (#19 and #33) of seven residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #33's medical record revealed an original admission date of 10/12/14 with the latest readmission of 04/23/20. Resident #33 had diagnoses including end stage heart failure, chronic respiratory failure, congestive heart failure, severe morbid obesity, diabetes mellitus, diverticulitis of large intestine, lymphedema, obstructive sleep apnea, osteoarthritis, gout, anemia,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #19, Resident #36 and Resident #51 were free from significant medication errors. This affected three residents (#19, #36 and #51) of seven residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #36's medical record revealed an admission date of 07/10/20. Resident #36 had diagnoses including diabetes mellitus, frontotemporal dementia, peripheral vascular disease, hypertension, psychotic disorder with delusions, schizophrenia and chronic pain syndrome. Review of the resident's plan of care, dated 07/24/20 revealed the resident had diabetes mellitus. Interventions included to administer medications as ordered by the physician, dietary consult for nutritional regimen and ongoing monitoring, fasting serum blood sugar as ordered by the physician, monitor/document/report as needed any signs/symptoms of hyperglycemia/hypoglycemia and offer substitutes 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 record review, facility policy and procedure review and interview the facility failed to ensure Resident #53 was transported back to the facility timely following a scheduled physician's appointment. This affected one resident (#53) of one resident reviewed for outside services. Findings include: Review of Resident #53's medical record revealed and original admission date of 06/04/19 with the latest readmission of 07/08/20. Resident #53 had diagnoses including chronic obstructive pulmonary disease, heart failure, peripheral vascular disease, schizoaffective disorder, major depressive disorder, hypertension, schizophrenia, diabetes mellitus, vascular dementia, dysphagia and encephalopathy. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/15/20 revealed the resident had clear speech, understood others, made himself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 12. Review of a physician's order revealed an order for a scheduled vascular appointment on 08/13/21 at 1:00 P.M.…

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.