Inniswood Health and Rehabilitation

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 antibiotics were not administered unnecessarily for two residents (#17 and #26) out of three residents reviewed for urinary tract infections. The facility census was 74. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 01/22/21 and diagnoses including Parkinson's disease with dyskinesia, recurrent urinary tract infections (UTIs), chronic kidney disease, urinary retention, obstructive uropathy, and neurogenic bladder. Review of the Minimum Data Set (MDS) 3.0 annual assessment dated [DATE] revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The assessment also noted Resident #26 had an indwelling catheter, frequent incontinence, impaired mobility, and was dependent for many activities of daily living. Review of the physician orders for Resident #26 revealed an order dated 12/10/24 for Cephalexin (an antibiotic)…

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 staff interview, review of facility self-reported incidents (SRI's), medical record review and review of facility policy, the facility failed to ensure an incident of potential sexual abuse was timely reported to the Administrator and to the state agency. This affected two residents (#36 and #67) of three residents reviewed for abuse. The facility census was 72. Findings include: Review of the medical record for Resident #36 revealed an admission date of 12/02/18 with diagnoses including hemiplegia affecting left side, adjustment disorder with anxiety, major depressive disorder, anxiety disorder, deaf, dysphagia, and history of unspecified adult abuse. Review of Resident #36's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had severely impaired cognition. Review of Resident #67's medical record revealed an admission date of 05/17/17 with diagnoses including schizophrenia, type two diabetes mellitus, schizoaffective disorder, major depressive disorder, sleep disorder, mild…

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 staff interview, review of facility self-reported incidents (SRI's), medical record review, and review of facility policy, the facility failed to ensure an incident of potential sexual abuse was thoroughly investigated. This affected two residents (#36 and #67) of three residents reviewed for abuse. The facility census was 72. Findings include: Review of the SRI created 12/24/24 at 8:33 A.M. revealed on 12/22/24 at 11:45 P.M. the night shift nurse found Resident #67 lying in Resident #36's bed on top of the covers with his pants down. Resident #36 was dressed and under the blankets. Resident #67 got out of bed and was directed out of the room. During subsequent interviews Resident #36 reported she was touched on the breast, but no sexual penetration took place. She reported she had been okay with it at the time but did not want it to happen again. Resident #67 was unable to be interviewed due to his cognition at the time but was moved to another hallway. Review of the facility investigation revealed 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.

Based on observations, staff interview, and facility policy review, this facility failed to ensure medication carts were locked at all times unless in use and under direct observation of the medication administration personnel. This had the potential to affect all 26 residents who were noted to be mobile on the 300 and 500 unit. The facility census was 74. Findings include: Observation on 08/28/24 at 8:15 A.M. of Registered Nurse (RN) #34 completing medication administration for residents who resided on the 500 unit revealed this units medication cart was noted to be unlocked and RN #34 was not in view of this medication cart and was noted to be in a residents room. Observation completed on 08/28/24 at 8:39 A.M. of Licensed Practical Nurse (LPN) #160 administer morning medication revealed there was a medication that was not available in the 300 unit medication cart. LPN #160 was noted to leave the 300 unit medication cart unlocked and walk away from the cart to a different facility unit to obtained the needed medication from the facility's medication storage room. During this time,…

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, medication administration observation, staff interviews, and medication administration policy review, the facility failed to ensure an medication error rate of 5% or less when medication that was noted to be delayed release was crushed, or capsule were opened during administration. Medication error rate was 9%. This affected two residents (Resident #6, and #32) of the four residents reviewed for medication administration. The facility census was 74. Findings included: 1. Review of the medical record for Resident #32 revealed an admission date of 04/23/21. Diagnoses included dementia, depression, and osteoarthritis. Review of Resident #32's quarterly Minimum data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 indicating an severely impaired cognition for daily decision making abilities. Review of the plan of care dated 06/26/23 revealed Resident #32 uses antidepressant medication related to depression and weight loss.…

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 medication administration observation, staff interview and facility policy review, this facility failed to ensure infection control measures were maintained during medication administration. This affected two residents (Resident #32 and #42) out of the four residents observed during medication administration. The facility census was 74. Findings include: 1. Review of the medical record for Resident #32 revealed an admission date of 04/23/21. Diagnoses included dementia, depression, and osteoarthritis. Review of Resident #32's quarterly Minimum data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 indicating an severely impaired cognition for daily decision making abilities. Review of the plan of care dated 06/26/23 revealed Resident #32 uses antidepressant medication related to depression and weight loss. Resident is at risk for complications related to antidepressant medication including, dry mucous, constipation, urinary retention,…

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 staff interview the facility failed to maintain effective pest management. This had the potential to affect all 83 residents. Findings include: Observation on 01/02/24 at 8:39 A.M. in the kitchen under the dishwasher revealed two live cockroaches. Director of Dietary #115 verified the cockroaches at the time of the discovery, and verbalized seeing cockroaches occasionally. Observation on 01/02/24 at 10:26 A.M. in Resident #17 room revealed two live cockroaches on Resident #17's bathroom counter where one toothbrush was laying uncovered. Director of Maintenance #269 verified the pests at the time of the discovery. Interview on 01/02/24 at 10:26 A.M. with Director of Maintenance #269 confirmed they have had an outbreak of cockroaches in the kitchen, 200's and 300's hall. Observation on 01/02/24 at 10:35 A.M. in Resident #10 room revealed one live cockroach on the bathroom counter. State Tested Nursing Assistant (STNA) #128 verified the pests at the time of discovery, stating the pests were everywhere. Observation on 01/04/24 at 10:21 A.M. of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview the facility failed to ensure Minimum Data Set (MDS) assessments were accurate to reflect resident care needs. This affected two (Resident #23 and #42) of 21 residents reviewed for accurate MDS assessments. The facility census was 83. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 06/13/2023. Diagnosis included malignant neoplasm of the oropharynx, dysphagia, gastrostomy status, and vascular dementia. Review of the plan of care dated 06/14/23 and revised 12/18/23 revealed Resident #23 had a potential nutritional and/or hydration problem related to the diagnosis of tube feed dependence, receiving nothing by mouth (NPO). Interventions included to provide tube feeding, flushes, and supplement as ordered. Review of Resident #23's quarterly MDS 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03 indicating the resident had severely impaired cognition for daily decision making…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure Pre-admission Screening and Resident Review (PASARR) were accurate regarding resident mental health diagnoses. This affected one (Resident #61) of two residents reviewed for PASARR. The facility census was 83. Findings Include: Review of the medical record for Resident #61 revealed an initial admission date of 09/26/18 with the diagnoses including starvation, psychosis, adult failure to thrive, congestive heart failure (CHF), non-compliance with medical treatment regimen, dementia with behavioral disturbances, delusional disorder, paranoid personality disorder, altered mental status, gastro-esophageal reflux disease (GERD), visual hallucinations, hypertension, vitamin B deficiency, anxiety disorder, restlessness and agitation, glaucoma, auditory hallucinations, constipation and insomnia. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment…

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 preadmission screening and record review (PASRR) assessment and referral for level II services were completed. This affected one (Resident #81) of two residents reviewed for PASRR documents. The census was 83. Findings Include: Resident #81 was admitted to the facility on [DATE]. His diagnoses were spinal stenosis, muscle weakness, cervical disc disorder, adjustment disorder with mixed anxiety and depressed mood, generalized anxiety disorder, schizoaffective disorder, osteoarthritis, hypertension, hyperlipidemia, deaf nonspeaking, legal blindness, chronic kidney disease, depression, and insomnia. Review of his Minimum Data Set (MDS) assessment, dated 10/25/23, revealed he had a severe cognitive impairment. Review of Resident #81 PASRR document and determination letter, dated 08/11/23, revealed he was approved for short term nursing stay, starting 08/22/23, for 90 days; which would end on 11/20/23. Review of the remainder of his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to notify the state mental health agency of significant changes in a resident's mental/physical health condition. This affected one (Resident #61) of two Pre-admission Screening and Resident Review (PASARR) documents reviewed. The census was 83. Findings Include: Review of the medical record for Resident #61 revealed an initial admission date of 09/26/18 with the diagnoses including starvation, psychosis, adult failure to thrive, congestive heart failure (CHF), non-compliance with medical treatment regimen, dementia with behavioral disturbances, delusional disorder, paranoid personality disorder, altered mental status, gastro-esophageal reflux disease (GERD), visual hallucinations, hypertension, vitamin B deficiency, anxiety disorder, restlessness and agitation, glaucoma, auditory hallucinations, constipation and insomnia. Review of the significant change MDS assessment dated [DATE] revealed the resident had a severe cognitive deficit. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure a self-releasing wheelchair seatbelt was only used during transportation to workshop for Resident #1. This affected one resident (Resident #1) of one residents reviewed for transportation devices. Findings Include: Review of Resident #1's medical record revealed Resident #1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #1's admitting diagnoses included intellectual disabilities, type two diabetes, and impaired communication. Further review revealed Resident #1 required assistance from staff for activities of daily living (ADL) tasks. Review of Resident #1's signed physician orders revealed Resident #1 may attend workshop on Mondays and Wednesdays. Further review revealed Resident #1 received transportation to workshop on Mondays and Wednesdays and the resident must be ready 15 minutes prior to pick up time. Review of an email dated 07/12/21 from the administrator for the transport…

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 follow a physician ordered fluid restriction for Resident #55, who received hemodialysis to promote optimal cardiac and renal outcomes for the resident. The facility also failed to ensure dialysis communication forms were accessible to facility staff for review and reference. This affected one resident (#55) of one resident reviewed for hemodialysis/hydration. The facility census was 83. Findings Include: Review of the medical record for Resident #55 revealed an initial admission date of 03/24/23 and a re-entry date of 11/10/2023. Diagnosis included end stage renal disease, dependence on renal dialysis, and heart disease. Review of the plan of care dated 03/27/23 and revised 12/22/23 revealed Resident #55 had a potential for nutritional and/or hydration problem related to type two diabetes, end stage renal disease/hemodialysis, coronary artery disease, depression, anxiety, cerebral infarction, need for therapeutic diet with fluctuating anticipated…

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 medication monitoring was completed for the use of antipsychotic medications. This affected one resident (Residents #70) of five residents reviewed for unnecessary medications. The facility census was 83. Findings include: Review of Resident #70's medical record revealed the resident was admitted to the facility on [DATE] with admitting diagnoses including depression, hallucinations, schizophrenia, and high blood pressure. Further review revealed Resident #70 required staff assistance for Activities of Daily Living (ADL) task completion and medication administration. Review of Resident #70's signed physician orders revealed an order dated 04/21/21 for the use of the antipsychotic medication Risperdal one milligram (mg) given daily at bedtime related to schizophrenia. Review of Resident #70's Medication Administration Record (MAR) dated December 2023 revealed Risperdal was administered per physician order. Review of Resident #70's quarterly…

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, interviews and facility policy review, the facility failed to ensure one resident's (#32) physician ordered laboratory tests were completed as ordered. This affected one of 11 residents reviewed for nutrition. The facility census was 83. Findings Include: Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE] with the latest readmission of 08/18/23. Her diagnoses included encephalopathy, need for assistance with personal care, displaced subtrochanteric fracture of right femur, vitamin D deficiency, major depressive disorder, deaf nonspeaking, type II diabetes, mild intellectual disabilities, secondary malignant neoplasm of the breast, acquired absence of left breast and nipple and anxiety disorder. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the physician progress note dated 11/30/23, authored by Physician #502 revealed the physician 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 and staff interviews, the facility failed to ensure residents were not served food past the use-by date. This had the potential to affect 82 of 82 residents who receive food from the facility kitchen. One resident (Resident #23) receives nothing by mouth. The census was 83. Findings include: Observation in the facility kitchen on 01/02/24 from 8:39 A.M. to 9:23 A.M. revealed 102 cartons of 1% milk in the walk-in refrigerator that had a use by date of 01/01/24. Interview with Director of Dietary #115 on 01/02/24 at 9:14 A.M. confirmed the milk was past the use by date, and stated she thought the facility had a seven day look back policy on milk. Director of Dietary #115 confirmed the intent to use the milk past the use- by date. Interview with Director of Dietary #115 on 01/04/24 at 2:30 P.M. confirmed the facility did not have a policy for a look-back period on milk.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to maintain hospice documentation on-site for resident care. This affected one resident (Resident #2) of one resident reviewed for hospice services. The facility census was 83. Findings Include: Resident #2 was admitted to the facility on [DATE]. Her diagnoses were chronic kidney disease, diabetes, hypertension, hyperkalemia, depression, anxiety disorder, lumbar spina bifida, acquired absence of right and left leg above knee, and glaucoma. Review of her minimum data set (MDS) assessment, dated 12/14/23, revealed she had a significant cognitive impairment. Review of Resident #2's medical records revealed the facility had no hospice notes or orders on site for her. The hospice notes provided to the survey team on 01/08/24 had a fax date of 01/08/24, indicating all the hospice notes were sent to the facility on that day. Interview with Licensed Practical Nurse (LPN) #176 on 01/08/24 at 1:07 P.M. confirmed the facility did not have any hospice…

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 evidence of education and administration of pneumonia immunizations. This affected two residents (Resident #35 and #84) of five residents reviewed for immunizations. The facility census was 83. 1. Review of Resident #35's medical record revealed Resident #35 was admitted to the facility on [DATE] with admitting diagnoses including asthma, chronic obstructive pulmonary disease (COPD), depression, high blood pressure, and chronic venous ulcer to lower left leg. Resident #35 required assistance from staff for activities of daily living (ADL) tasks. Review of Resident #35's immunization record revealed Resident #35 declined the Covid-19 immunization, the influenza immunization, and the annual Tuberculosis health questionnaire on 10/04/23. Interview on 01/08/24 at 11:30 A.M. with the Director of Nursing (DON) revealed the facility did not have information on when Resident #35 would have received any previous pneumonia immunizations. The DON…

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, facility policy and procedure review and interview facility failed to properly store food items in the dry storage, refrigerator and freezer locations to prevent contamination, spoilage or food borne illness. This had the potential to affect all 86 residents residing in the facility. Findings include: On 01/24/22 at 10:22 A.M. observation of the facility kitchen revealed in the dry storage area there was a large bag of dried noodles that had previously been opened that was tied and undated. There was an opened bag of butterscotch baking chips undated, bags of dry spiral pasta and elbow noodles that were open and undated, two bags of gravy mix were that were undated and a container with instant mash potatoes had a secured lid on it with no date. On 01/24/22 at 10:32 A.M. observation of the walk in refrigerator revealed a block of butter was uncovered and undated, three packs of yellow and white cheese slices were wrapped up and undated. A bag of shredded cheese was opened and undated and a large plastic tub with a lid on it was unlabeled and undated. A tray 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 observation, facility census review, review of the Centers for Disease and Prevention (CDC) guidance, facility policy and procedure review and interview the facility failed to ensure N95 masks were worn properly/correctly by staff working on the facility COVID-19 unit to prevent the spread of COVID-19 in the facility. This affected two staff (Licensed Practical Nurse (LPN) #203 and State Tested Nursing Assistant (STNA) #116 who were assigned to care for the 11 residents who resided on the COVID-19 unit and had the potential to affect all 86 residents residing in the facility as these staff could also work in other (non-COVID) areas of the facility. Findings include: On 01/24/22 review of the facility census and observation of the facility revealed a designated COVID-19 unit with a census of 11 residents on the unit who were in isolation for COVID-19. On 01/24/22 at 12:30 P.M. LPN #203 was observed on the COVID-19 unit wearing an N95 mask over top of a surgical mask. The lower elastic strap of the N95 mask was hanging below LPN #203's chin. LPN #203 was observed entering 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, facility policy and procedure review and interview the facility failed to ensure residents were weighed or re-weighed timely to identify/confirm weight loss or significant weight changes and/or failed to provide fluids to Resident #35 who needed/requested them. This affected four residents (#50, #75, #34 and #387) of seven residents reviewed for nutrition and one resident (#35) of two residents reviewed for hydration. Findings include: 1. Resident #50 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, muscle weakness, difficulty in walking, sensorineural hearing loss, hypertension, obesity, hyperlipidemia, lymphedema, atherosclerotic heart disease, iron deficiency, atrial fibrillation, major depressive disorder, type II diabetes, anemia, hypothyroidism. Review of the Minimum Data Set (MDS) 3.0 assessment, section C, dated 12/07/21 revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15.…

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, review of Food and Drug Administration (FDA) information, review of a HealthDay News Study and facility policy and procedure review, the facility failed to provide adequate justification for the use of antibiotics as a preventative measure for COVID-19. This affected six residents (#14, #33, #35, #49, #57 and #67) of six residents prescribed antibiotics. Findings include: Review of Resident #14, #33, #35, #49, #57 and #67's medical records, dated from 12/30/21 to 01/14/22 revealed the residents were treated with Azithromax (an antibiotic medication used to treat infection) or Cipro (an antibiotic medication used to treat infection) after testing positive for COVID-19. On 01/25/22 at 1:11 P.M. interview with the Director of Nursing (DON) confirmed the residents were prescribed antibiotics after testing positive for COVID-19. The DON failed to provide any other evidence these residents met any type of criteria for the antibiotic use. Review of information on the FDA website (https://www.fda.gov) revealed the following FDA response to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 5. On 01/27/22 from 11:00 A.M. to 11:05 A.M. an environmental tour of the 200 hallway was conducted with the Administrator. The following concerns were observed and verified with the Administrator at the time of the observations: The bathroom wall in room [ROOM NUMBER] beside the commode had exposed and missing drywall. There were rust stains around the commode was well as black stains on the floor. The bathroom in room [ROOM NUMBER] had cracked tile on the floor, rust stains around the commode as well as black stains on the floor. The floor under a fall mat in room [ROOM NUMBER] had a red wet liquid under the mat that had been present since initial observations on 01/26/22. Based on observation, record review and interview the facility failed to maintain a safe, functional and sanitary environment for all residents. The facility also failed to maintain resident equipment in good repair for Resident #67 and Resident #38. This affected two residents (#38 and #67) and three of the four hallways in the facility.…

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

Based on observation, record review, facility policy and procedure review and interview the facility failed to provide Resident #35 with dignity and respect related to the use of an indwelling urinary catheter. This affected one resident (#35) of four residents reviewed for dignity. Findings include: Review of Resident #35's medical record revealed an initial admission date of 03/19/18 with the latest readmission of 05/29/19. Resident #35 had diagnoses including congestive heart failure, personal history of COVID-19, dementia, ataxia, dysphagia, degenerative disc of lumbar region, anemia, urinary retention, urinary tract infection (UTI), scoliosis, hypertension, major depressive disorder, osteoporosis, osteoarthritis, benign prostatic hyperplasia (BPH) and deafness. Review of the plan of care, dated 03/20/18 revealed the resident had a suprapubic catheter related to BPH with lower urinary tract symptoms, bladder spasms and had minimal urinary output. Interventions included catheter care with rounds and as needed, empty and report output to nursing every shift, irrigate catheter with…

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 policy and procedure review and interview the facility failed to ensure Resident #387, who presented with communication difficulties was able to adequately and effectively communicate needs with staff and staff were able to communicate with resident through the use of an interpreter, communication board or other effective measures. This affected one resident (#387) of three residents reviewed for communication. Findings include: Record review for Resident #387 revealed the resident was admitted to the facility on [DATE] with diagnoses including atherosclerosis of native arteries of right leg with ulceration of other part of foot, COVID-19, pain in unspecified foot, hypertension and type 2 diabetes. Review of the resident's initial nursing assessment, dated 12/29/21 revealed a communication board should be used when communicating with the resident. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/14/22 revealed Resident #387 was cognitively intact 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.

Based on observation, record review and interview the facility failed to ensure Resident #8, who required staff assistance from staff for personal hygiene received timely and adequate assistance with shaving to maintain proper grooming and hygiene. This affected one resident (#8) of four residents reviewed for activities of daily living (ADL) care. Findings include: Review of Resident #8's medical record revealed an admission date of 08/01/18 with diagnoses including dementia with behavioral disturbance, cerebral infarction, chronic kidney disease, peripheral vascular disease, glaucoma, cardiomegaly, diabetes mellitus, anoxic brain damage, hypertension, anemia, chronic obstructive pulmonary disease, major depressive disorder, congestive heart failure and unspecified malignant neoplasm. Review of the plan of care, dated 08/02/18 revealed the resident had a self-care deficit related to dementia, edema, incontinence, hypertension, depression and natural progression of disease process. Interventions included one to two person assist with activities of daily living/care as needed,…

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 complete weekly skin assessments and monitor non-pressure related skin impairment/wounds for Resident #62 and Resident #387. This affected two residents (#62 and #387) of three residents reviewed for non-pressure skin conditions. Findings include: 1. Review of the medical record for Resident #62 revealed the resident was admitted to the facility on [DATE] with diagnoses including gas gangrene, type one diabetes mellitus with diabetic neuropathy, chronic kidney disease stage three, peripheral vascular disease, anemia, acquired absence of left leg below knee, acute osteomyelitis of right ankle and foot, and acquired absence of other right toes. Review of Resident #62's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/04/21 revealed the resident had intact cognition and was at risk of developing pressure ulcers. Review of the plan of care, dated 11/09/21 revealed the resident was at risk for alteration to skin integrity related to gas gangrene…

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 staff interview the facility failed to ensure Resident #35's indwelling urinary catheter was properly positioned to prevent backflow of urine and possible urinary tract infections and failed to provide catheter and perineal care in a manner to decrease the risk of urinary tract infections. The facility also failed to ensure a urinalysis and culture and sensitivity were obtained timely as ordered for Resident #42 who was symptomatic of a urinary tract infection. This affected one resident (#35) of one resident reviewed for indwelling urinary catheter use and one resident (#42) of five residents reviewed for infections. The facility identified two residents with indwelling urinary catheters. Findings include: 1. Review of Resident #35's medical record revealed an initial admission date of 03/19/18 with the latest readmission of 05/29/19. Resident #35 had diagnoses including congestive heart failure, personal history of COVID-19,…

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 review or complete pharmacy recommendations in a timely manner for Resident #38, Resident #54 and Resident #72. This affected three residents (#38, #54 and #72) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of the medical record for Resident #38 revealed an admission date of 12/20/17 with diagnoses including moderate protein-calorie malnutrition, deaf non-speaking, unspecified dementia without behavioral disturbance, dysphagia, chronic kidney disease, unspecified open-angle glaucoma, hyperlipidemia, hypertension, cerebral infarction, major depression, unspecified psychosis not due to a substance or known physiological condition. Review of a pharmacist recommendation, dated 07/20/21 revealed a recommendation for a review of a gradual dose reduction (GDR) related to the resident receiving antipsychotic medications, including Abilify 2.5 milligrams (mg), Citalopram 10 mg, Mirtazapine 15 mg and Trazodone 25 mg. Review of the medical record 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 record review and interview the facility failed to ensure an as needed (PRN) psychoactive medication for Resident #54 was limited to 14 days or continued only with an evaluation by the physician or certified nurse practitioner (CNP) for the appropriateness of continued use. This affected one resident (#54) of five residents reviewed for unnecessary medication use. Findings include: Review of the medical record for Resident #54 revealed an admission date of 08/16/21 with diagnoses including chronic obstructive pulmonary disease, depression, emphysema, osteoarthritis, foot drop and anxiety. Review of physician's orders revealed an order, dated 09/03/21 for the psychoactive, anti-anxiety medication Lorazepam (Ativan) 0.5 milligrams (mg) one tablet every four hours as needed (PRN). A pharmacy recommendation, dated 11/23/21 identified the resident had a PRN order for Lorazepam medication for more than 14 days without a reasoning or an end date. The pharmacy recommendation to discontinue the medication or provide a reason/rationale for continued use was not addressed by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy and procedure review and interview the facility failed to maintain a medication error rate of less than five percent. The facility medication error rate was calculated to be 5.88 percent and included two medication errors of 34 medication administration opportunities. This affected one resident (#387) of seven residents observed for medication administration. Findings include: Record review for Resident #387 revealed the resident was admitted to the facility on [DATE] with diagnoses including atherosclerosis of native arteries of right leg with ulceration of other part of foot, COVID-19, pain in unspecified foot, hypertension and type 2 diabetes mellitus. Review of the physician's orders, dated 12/30/21, revealed an order for Humalog solution 100 unit (insulin Lispro (Human) to be given before meals (for diabetes) per sliding scale. If the resident's blood sugar was 151 to 200 give one unit, for blood sugar 201 to 250 give two units for blood sugar 251 to 300…

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.