Best Care Health And Rehabilitation

Based on medical record review, observation, resident interview, staff interviews, and review of facility policy, the facility failed to ensure adequate monitoring of a resident pain. This affected one (Resident #45) of four residents reviewed for pain management. The facility census was 66 residents. Findings include: Review of the medical record for Resident #45 revealed the resident an admission date of 09/18/24 with diagnoses including low back pain, restlessness and agitation, and need for assistance with personal care. Review of the admission physician's orders for Resident #45 dated 09/18/24 revealed the resident was ordered to receive the medications Zanaflex, gabapentin, and hydrocodone for pain. Review of the care plan for Resident #45 dated 09/18/24 revealed the resident had actual pain and potential for pain related to chronic low back pain. Interventions included the following: pain assessment quarterly and as needed, monitor for side effects of medications, monitoring what makes the pain worse. Review of the Minimum Data Set (MDS) assessment for Resident #45 dated…

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

Based on medical record review and staff interview, the facility failed to ensure a resident with post-traumatic stress disorder (PTSD) were appropriately assessed to identify the cause of the residents PTSD and minimize triggers and/or re-traumatization. This affected one (Resident #5) of one resident identified by the facility as having PTSD. The facility census was 66 residents. Findings include: Review of the medical record for Resident #5 revealed an admission date of 09/25/23 with diagnoses including cirrhosis of the liver, acute and chronic respiratory failure, diabetes mellitus type two, chronic obstructive pulmonary disease, congestive heart failure, Crohn's disease, chronic kidney disease, depression, and PTSD. Review of the Minimum Data Set (MDS) assessment for Resident #5 dated 09/17/24 revealed the resident was cognitively intact and had a diagnosis of PTSD. Review of the care plan for Resident #5 initiated 09/25/23 revealed the plan did not address the following: the cause of the resident's PTSD, triggers which might cause re-traumatization, interventions to reduce the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of the facility policy, the facility failed to ensure residents were free of significant medication errors. This affected one (Resident #228) of 13 facility-identified newly admitted residents and one (Resident #45) of five residents reviewed for unnecessary medications. The facility census was 66 residents. Findings include: 1. Review of the medical record for Resident #228 revealed an admission date of 09/13/24 with diagnoses including end stage renal disease, diabetes mellitus type two, chronic obstructive pulmonary disorder and fracture of right lower leg. Review of the admitting physician orders for Resident #228 dated 09/13/24 revealed Resident #228 was ordered Admelog insulin inject 30 units subcutaneously before meals and Tresiba inject 80 units subcutaneously two times daily. Review of the care plan for Resident #228 dated 09/13/24 revealed the resident had diabetes mellitus. Interventions included the following: administer medications as ordered,…

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 online resources per the Centers for Disease Control (CDC) regarding pneumococcal vaccinations, and review of facility policy, the facility failed to ensure residents were offered and received up to date pneumococcal vaccinations. This affected two (Residents #3 and #43) of five residents reviewed for vaccinations. The facility census was 66 residents. Findings include: 1. Review of the medical record for Resident #43 revealed an admission date of 02/16/24 with diagnoses including hypertension, presence of cardiac pacemaker, and intellectual disabilities. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #43 dated 08/19/24 revealed the resident had intact cognition. Review of the vaccination record for Resident #43 revealed the resident received one dose of Pneumovax 23 on 10/01/18. No other pneumococcal vaccines were documented as being offered or administered. 2. Review of the medical record for Resident #3 revealed an admission date of 12/20/19 with diagnoses including chronic obstructive pulmonary disease…

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

Based on observations, staff interview, and policy review, the facility failed to ensure only authorized personnel had access to the medication storage room. This had the potential to affect 80 of 80 residents residing in the facility. Findings include: Interview with Licensed Practical Nurse (LPN) #124 on 01/31/24 at 7:40 A.M. revealed the business office was supposed to place a petty cash box in the medication room each day when they left so that residents had access to petty cash in the evening or on weekends. Observations on 01/31/24 at 7:40 A.M. revealed there was a key pad lock on the medication room door on Station 1. Interview with the Director of Nursing on 01/31/24 at 7:45 A.M. confirmed the business office was to put the money box in the medication room every day so that money was available for residents in the evening and on weekends. Interview with Business Office Manager #201 on 01/31/24 at 7:50 A.M. revealed that she placed the money box in the Station 1 medication room every day when she leaves. At that time, she stated that she had the code to the medication room…

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, resident interview, and policy review, the facility failed to ensure residents had access to their personal funds during times the business office was not open (evenings and weekends). The facility handled funds for 47 of 80 residents. This had the potential to affect any resident whose funds were handled by the facility. Findings include: Interview with Licensed Practical Nurse (LPN) #124 on 01/31/24 at 7:40 A.M. revealed the business office was supposed to place a petty cash box in the medication room each day when they left so that residents had access to petty cash in the evening or on weekends. She stated this was not always done. Observations of the medication room, at that time, with LPN #124 confirmed the petty cash box was not in the specified locked location. Interview with the Director of Nursing (DON) on 01/31/24 at 7:45 A.M. confirmed the business office was to put the money box in the medication room every day so that money was available for residents in the evening and on weekends. Interview with Business Office Manager #201 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.

Based on observations, staff interview, resident interview, medical record review, and grievance review, the facility failed to ensure that residents who are unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. This affected 24 of 26 residents on Station 1 who were incontinent of bowel and/or bladder (Residents #9, #10, #11, #20, #21, #29, #32, #33, #38, #42, #43, #45, #47, #49, #51, #52, #53, #60, #65, #67, #72, #74, #76, and #80). The facility census was 80. Findings include: Observations on 01/31/24 at 4:30 A.M. revealed there were two nurses (one Licensed Practical Nurse (LPN) and one Registered Nurse (RN) and five nursing assistants on duty for 80 residents. The facility is split up into three sections (Station 1, where 26 residents resided; Station 2, where 30 residents resided; and Station 3, where 24 residents resided). There were two nursing assistants on Station 1 for 26 residents, one nursing assistant on Station 2 for 30 residents, and two nursing assistants on Station 3 for 24 residents. 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 observations, record review, staff interview, resident interview, review of a grievance form, review of resident council meeting minutes, and review of staffing schedules and time sheets, the facility failed to maintain sufficient levels of staff to meet the total care needs of all residents. This affected 24 of 26 residents on Station 1 who were incontinent of bowel and/or bladder (Residents #9, #10, #11, #20, #21, #29, #32, #33, #38, #42, #43, #45, #47, #49, #51, #52, #53, #60, #65, #67, #72, #74, #76, and #80) and had the potential to affect all 80 residents residing in the facility. Findings include: Observations on 01/31/24 at 4:30 A.M. revealed there were two nurses (one Licensed Practical Nurse (LPN) and one Registered Nurse (RN) and five nursing assistants on duty for 80 residents. The facility is split up into three sections (Station 1, where 26 residents resided; Station 2, where 30 residents resided; and Station 3, where 24 residents resided). There was two nursing assistants on Station 1 for 26 residents, one nursing assistant on Station 2 for 30 residents, 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 observations, staff interview, and policy review, the facility failed to provide pharmaceutical services to meet the needs of each resident. This affected 20 of 27 residents who received narcotic medications (Residents #2, #4, #12, #14, #15, #20, #22, #24, #25, #33, #45, #51, #53, #55, #59, #61, #64, #67, #72, and #76) and one of three closed records reviewed (Resident #85). The facility census was 80. Findings include: 1. Review of the controlled medication shift change log for the four medication carts on Station 1 and Station 2 on 01/31/24 at 6:15 A.M. revealed nurses were to count the number of narcotic sheets in the cart at shift change to ensure that count sheets had not been removed inappropriately since the last shift. Review of all four shift change logs revealed that there were multiple missing count totals. Therefore, it would be difficult to determine if a narcotic sheet had been removed from the cart inappropriately during the shift. Station 1 had two carts titled Station 1 and 2A. The…

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

Based on medical record review, observations, staff interview, and policy review, the facility failed to ensure medical records were accurately documented. This affected three of 12 sampled residents (Residents #54, #64, and #75). The facility census was 80. Findings include: 1. Interview with Licensed Practical Nurse (LPN) #106 on 01/31/24 at 4:35 A.M. revealed she had already given Resident #64 his Haldol (antipsychotic medication) that was scheduled at 6:00 A.M. She confirmed it was given early. She did not have a reason other than there was only two nurses working that night and she had other duties to do between 5:00 A.M. and 6:00 A.M. Review of the medical record for Resident #64 revealed an admission date of 10/23/23 with diagnoses of cirrhosis of the liver and anxiety disorder. He had a physician's order dated 01/07/24 for Haldol 2 milligrams every six hours at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. for agitation. Review of the medication administration record for Resident #64 revealed LPN #106 documented that Haldol was administered on 01/31/24 at 1:05 A.M. and…

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

Based on observations, medical record review, staff interview, and policy review, the facility failed to ensure a gastrostomy tube was checked for placement prior to the administration of fluids and medication. This affected one of three residents observed for medication administration (Resident #54). The facility census was 80. Findings include: Review of the medical record for Resident #54 revealed an admission date of 01/18/24 with diagnoses including adult failure to thrive and diabetes. Record review revealed the resident's medications were ordered to be given by mouth. However, observations on 01/31/24 at 5:35 A.M. revealed Registered Nurse (RN) # 149 to administer Levothyroxine 88 micrograms through Resident #54's gastrostomy tube in her stomach. RN #149 flushed the tube with water, administered the medication, then followed with an additional flush of water. RN #149 did not check for proper placement of the gastrostomy tube prior to administering the fluids and medication. Interview with RN #149 confirmed she did not check placement of the gastrostomy tube prior 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.

Based on staff interview, medical record review, and policy review, the facility failed to ensure residents were free from significant medication errors. This affected two of 80 residents residing in the facility (Residents #64 and #75). Findings include: 1. Interview with Licensed Practical Nurse (LPN) #106 on 01/31/24 at 4:35 A.M. revealed she had already given Resident #64 his Haldol (antipsychotic medication) that was scheduled at 6:00 A.M. She confirmed it was given early. She did not have a reason other than there was only two nurses working that night and she had other duties to do between 5:00 A.M. and 6:00 A.M. Review of the medical record for Resident #64 revealed an admission date of 10/23/23 with diagnoses of cirrhosis of the liver and anxiety disorder. He had a physician's order dated 01/07/24 for Haldol 2 milligrams every six hours at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. for agitation. Review of the medication administration record for Resident #64 revealed LPN #106 documented that Haldol was administered on 01/31/24 at 1:05 A.M. and 5:37 A.M. (even though…

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 state/federal economic stimulus and Medicaid guideline review, record review, financial record review and interview the facility failed to ensure each resident who received Medicaid and/or their financial representative were notified when the amount in the resident's personal funds account reached $200.00 less than the SSI resource limit as required. This affected four residents (#57, #74, #34 and #37) of 65 residents whose personal fund records were reviewed. Findings Include: Review of current state Medicaid resident trust guidelines revealed each resident who utilized Medicaid insurance may not keep more than $2000.00 in a trust account. Also, the same guidelines revealed COVID-19 stimulus checks (three total) did not count as monthly income; so they would not affect a resident's medical coverage. However, a resident who utilized Medicaid insurance and received stimulus payment(s) had 12 months to spend the money from the time they received it. Review of the federal COVID-19 stimulus documentation…

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 3. Record review revealed Resident #62 was admitted to the facility on [DATE] with diagnoses including encounter for orthopedic aftercare following surgical amputation, non-pressure chronic ulcer of the right heel and mid-foot, muscle weakness, cognitive communication deficit, peripheral vascular disease, non-pressure chronic ulcer of left heel and mid-foot, type two diabetes mellitus and chronic systolic heart failure. Review of documented weights revealed on [DATE] the resident weighed 143.5 pounds, on 07/11 the resident weighed 140.8 pounds, on [DATE] the resident weighed 136.8 pounds, and on [DATE] the resident weighed 136.6 pounds. Review of the care plan, dated [DATE] revealed the resident had the potential for nutritional problems. Interventions included to provide and serve supplements as ordered, provide and serve diet as ordered, monitor intake and record every meal, weigh per orders and monitor/record/report to the physician weight loss of more than three pounds in one week. Review of the admission…

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, interview and facility policy and procedure review the facility failed to maintain Resident #288's privacy when the resident was not properly dressed resulting in the resident being exposed to others in the hallway from in the room. This affected one resident (#288) of one resident reviewed for dignity. Findings Include: Review of Resident #288's medical record revealed an admission date of 07/22/22 with the admitting diagnoses of COVID-19, chronic kidney disease, congestive heart failure, atrial fibrillation and presence of pacemaker. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 07/29/22 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 10. The assessment revealed the resident required extensive assistance of two staff for bed mobility, dressing, toilet use, personal hygiene and limited assistance of two staff for transfers and ambulation. Review of the plan of care,…

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 Minimum Data Set (MDS) 3.0 assessments were accurate for Resident #71 related to the use of anti-depressant medications and for Resident #288 related to an ostomy appliance. This affected two residents (#71 and #288) of 26 residents whose MDS 3.0 assessments were reviewed. Findings Include: 1. Record review revealed Resident #71 was admitted to the facility on [DATE] with a diagnosis of depression. Review of the physician's orders revealed an order, dated 07/12/22 for the anti-depressant medication, Lexapro 20 milligrams (mg) to be administered once daily due to a diagnosis of depression. Review of the care plan, dated 07/12/22 revealed the resident was receiving anti-depressant medication. Interventions included to observe for side effects, consult the pharmacist as needed and provide medication as ordered. Review of the Medication Administration Record (MAR) for 07/2022 revealed the resident received the Lexapro as ordered once a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure baseline care planning was comprehensive and included information related to activities of daily living and/or wound care. This affected two residents (#52 and #62) of 26 residents whose assessments and care plans were reviewed. Findings Include: 1. Record review revealed Resident #52 was admitted to the facility on [DATE] with diagnoses including muscle weakness, atrial fibrillation, type two diabetes and cognitive communication deficit. Review of the facility baseline care plan summary, dated 07/02/22 revealed the plan failed to include information regarding the level of assistance the resident required with activities of daily living (ADL). Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 07/08/22 revealed the resident had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 (out of 15). The assessment revealed the resident required limited assistance from two staff members for bed…

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 closed record review and interview the facility failed to ensure a complete and accurate discharge summary was provided for Resident #13 at the time of discharge. This affected one resident (#13) of three residents reviewed for transfer/discharge. Findings Include: Review of Resident #13's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including end stage renal disease, difficult ambulation, dysphagia, cognitive communication deficit, hypertension, hypothyroidism, renal dialysis, urinary tract infection, atrial fibrillation, atherosclerosis, insomnia and glaucoma. Resident #13 was discharged home on [DATE]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/20/22 revealed the resident had no cognitive impairments. Review of the Discharge summary, dated [DATE] revealed the summary failed to include medications the resident was ordered/receiving, evidence of any prescriptions provided at discharge, information related to any upcoming…

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 residents who required staff assistance with activities of daily living received adequate and timely assistance with personal care to maintain proper hygiene/grooming/nail care. This affected three residents (#62, #75 and #288) of six residents reviewed for activities of daily living. Findings Include: 1. Review of Resident #75's medical record revealed an admission date of 07/13/20 with the admitting diagnoses of trochanteric bursitis of left hip, generalized muscle weakness, Alzheimer's disease, dementia with behavioral disturbances, low back pain, hypertension, thoracic aortic aneurysm and hearing loss. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 07/20/22 revealed the resident had clear speech, sometimes understood others, sometimes made herself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of zero (out of 15). 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 observation, record review and interview the facility failed to develop and implement a comprehensive and individualized activity program to meet the total care needs of Resident #74. This affected one resident (#74) of three residents reviewed for activities. Findings Include: Record review revealed Resident #74 was admitted to the facility on [DATE] with diagnoses including anxiety, muscle weakness, and cognitive communication deficit. Review of the care plan, revised 11/05/19 revealed the resident enjoyed activities including board games, trivia, bluegrass music and watching animal planet. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/20/22 revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15 (out of 15). The assessment revealed the resident required staff supervision with bed mobility, transfers, toileting and eating. On 08/01/22 at 3:30 P.M. interview with Resident #74 revealed the facility did not have…

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 adequate care and services were provided to residents receiving hospice care, care of non-pressure wounds and/or for diabetic blood sugar monitoring. This affected one resident (#61) of one resident reviewed for Hospice services, one resident (#62) of two residents reviewed for skin conditions and two residents (#62 and #71) of five residents reviewed for unnecessary medication use. Findings Include: 1. Record review revealed Resident #61 was admitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's disease, cognitive communication deficit and muscle weakness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/13/22 revealed the resident was assessed to have moderately impaired cognition. This assessment revealed the resident was assessed to require extensive assistance from two staff members for bed mobility, transfers and toileting and extensive…

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 develop and implement a comprehensive pressure ulcer prevention and management program to ensure pressure ulcers were timely and accurately assessed, to ensure treatments were initiated timely and provided to promote healing of pressure ulcers and to prevent potential infection. This affected two residents (#283 and #288) of three residents reviewed for pressure ulcers. Findings Include: 1. Review of Resident #283's medical record revealed an initial admission date of 07/22/22 with the admitting diagnoses of chronic congestive heart failure, pressure ulcer of sacral region, chronic kidney disease, malaise, diabetes mellitus, non-pressure chronic ulcer to right lower leg and left lower leg, varicose veins of right and left lower leg. Review of the paper admission skin assessment dated [DATE] revealed the resident was admitted to the facility with a Stage II (partial-thickness loss of skin with exposed…

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 identify, obtain a physician's order and document the care of Resident #288's colostomy. This affected one resident (#288) of one resident reviewed for bowel and bladder. Findings Include: Review of Resident #288's medical record revealed an admission date of 07/22/22 with the admitting diagnoses of COVID-19, chronic kidney disease, congestive heart failure, atrial fibrillation and presence of pacemaker. Review of the resident's clinical health status evaluation, dated 07/23/22 revealed the resident was admitted to the facility with an ostomy. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 07/29/22 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 10 (out of 15). The assessment revealed the resident required extensive assistance of two staff for bed mobility, dressing, toilet use and personal hygiene and limited assistance from two…

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

Based on observation, record review and interview the facility failed to ensure meals provided to Resident #292 accommodated the resident's preferences and were nutritionally adequate. This affected one resident (#292) of seven residents reviewed for nutrition. Findings Include: Review of Resident 292's medical record revealed an initial admission date of 07/20/22 with the admitting diagnoses of fracture of lower end of right radius, difficulty walking, unsteadiness on feet, dementia, depression and insomnia. Review of the clinical health status evaluation revealed no documented diet preferences for the resident. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 07/27/22 revealed the resident had clear speech, understood others, made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 10 (out of 15). The assessment revealed the resident required supervision for eating. The resident's weight was coded as 133 pounds, with no weight loss. Review of the plan of care, dated 07/27/22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and interview the facility failed to accurately code residents Minimum Data Set Assessment (MDS) assessments when dialysis was not coded for Resident #13, discharge status was inaccurate for Resident #76, anticoagulant use was miscoded for Resident #2 and Resident #50, and hospice was miscoded for Resident #2. This affected four residents (Resident #13, #76, #2, and #50) out of 22 residents assessed for MDS accuracy. The facility census was 86. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 12/13/16 with diagnoses including but not limited to cognitive communication deficit, dependence of renal dialysis, end stage renal disease, and Alzheimer's. Review of physician orders dated November, 2019 revealed Resident #13 received dialysis three times a week on Tuesday, Thursday, and Saturday. Review of nursing note dated 06/29/19 revealed Resident #13 goes to dialysis three times a week. Review of nursing note dated 08/20/19…

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 and staff interview the facility failed to refer a resident with a new diagnosis of schizophrenia for a pre-admission screening and resident review (PASARR). This affected one (Resident #35) of one resident reviewed for PASARR. The facility census was 86. Findings include: Record review of Resident #35 revealed an admission date of 10/11/17 with pertinent diagnoses of: malignant neoplasm of rectum, anus, and anal canal, lymphedema, schizophrenia, bipolar disorder, major depressive disorder, anxiety disorder, and viral hepatitis B. Review of the 09/18/19 quarterly Minimum Data Set (MDS) revealed the resident was cognitively intact and required limited assistance for transfer, walk in room, dressing, toilet use and personal hygiene. The resident was always continent of bowel and bladder and used a walker to aid in mobility. Review of the medical record on 11/05/19 revealed a new diagnosis of schizophrenia on 06/26/19. The medical record did not have a PASARR for her new serious mental disorder completed. Interview with the Director of Nursing (DON) on 11/07/19…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, and record review the facility failed to develop comprehensive care plans for Resident #32 for anti-anxiety medication use, Resident #2 for oxygen use, and Resident #41 for dental. This affected three (Resident #2, #32 and #41) of 22 residents reviewed for care plans. The facility census was 86. Findings include: 1. Record review of Resident #32 revealed an admission date of 12/04/18 with pertinent diagnoses of: venous insufficiency, heart failure, atherosclerotic heart disease of native coronary artery, atrial fibrillation, hyperlipidemia, , hypothyroidism, and major depressive disorder. Review of the the 09/15/19 quarterly Minimum Data Set (MDS) assessment revealed the resident was cognitively intact and used an anti-anxiety medication seven times during the seven day look back period of the MDS. Review of a Physician Order dated 07/12/19 revealed an order for buspirone (an anti-anxiety medication) give 25 milligrams (mgs) by mouth two times a day 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, and interview the facility failed to update and revise residents care plans. This affected one resident ( Resident #13) out of 22 residents assessed for careplan accuracy when Resident #13's care plan did not reflect she had glasses and her loop recorder was not careplanned. The facility census was 86. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 12/13/16 with diagnoses including but not limited to cognitive communication deficit, hypertension, depression, anxiety, dependence of renal dialysis, end stage renal disease, and Alzheimer's. Review of Resident #13's annual minimum data set (MDS) assessment dated [DATE] revealed she had impaired vision and no glasses. Review of quarterly MDS dated [DATE] revealed she had adequate vision. Review of care conference note dated 02/28/19 revealed Resident #13's daughter reported that Resident #13 would be receiving new eye glasses from eye doctor. Review of nurses notes dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and interview the facility failed to adequately and accurately assess diabetic foot ulcers and provide geri sleeves per plan of care for Resident #13 and failed to provide ordered ACE bandages in place for Resident #35. This affected two residents (Resident #13 and Resident #35) out of five residents reviewed for care and treatment of skin areas. The facility census was 86. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 12/13/16 with diagnoses including but not limited to cognitive communication deficit, hypertension, depression, anxiety, foot drop to left and right foot, dependence of renal dialysis, end stage renal disease, and Alzheimer's. Review of Resident #13's annual minimum data set (MDS) assessment dated [DATE] and the quarterly MDS dated [DATE] revealed she had moderate cognitive deficits and no skin issues. Review of nurses notes dated 09/06/19 revealed Resident #13's daughter came 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, and interview the facility failed to provide Resident #13 with ordered assistive devices (glasses) daily. This affected one resident ( Resident #13) out of three residents reviewed for ancillaries. The facility census was 86. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 12/13/16 with diagnoses including but not limited to cognitive communication deficit, hypertension, depression, anxiety, dependence of renal dialysis, end stage renal disease, and Alzheimer's. Review of Resident #13's annual minimum data set (MDS) assessment dated [DATE] revealed she had impaired vision and no glasses. Review of quarterly MDS dated [DATE] revealed she had adequate vision. Review of care conference note dated 02/28/19 revealed Resident #13's daughter reported that Resident #13 would be receiving new eye glasses from eye doctor. Review of nurses notes dated 03/11/19 revealed Resident #13 was to see facility eye doctor and needed to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interviews the facility failed to appropriately date and label oxygen tubing for a resident on continuous oxygen. This affected one resident (Resident #5) of two residents reviewed for respiratory care. Findings include: Record review of Resident #5 revealed that this resident was admitted to the facility on [DATE] with the following medical diagnoses: right below the knee amputation, heart failure, dysphagia, abnormal posture, tibial fracture, chest pain, ischemic heart disease, pressure ulcers, depression, peripheral vascular disease, cognitive communication deficit, muscle weakness, vascular dementia, hypertension, chronic obstructive pulmonary disease, liver disease, osteoarthritis, falls, left femur fracture, and diabetes mellitus type II. This resident is alert to name only with a current BIMS score of 5 on the most recent MDS assessment completed on 10/29/19, indicating severe cognitive impairments. This resident has a verified Full Code order, and has drug…

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 , resident interview, record review, and staff interview the facility failed to ensure pain management was provided to residents consistent with professional standards of practice when they failed to monitor and record pain levels for a resident who was coded for pain on the Minimum Data Set assessment and who had a decrease in her pain medication. This affected one (Resident #72) of one resident reviewed for pain. The facility census was 86. Findings include: Record review of Resident #72 revealed an admission date of 04/19/19 with most recent admission of 10/15/19 with pertinent diagnoses of: low back pain, sciatica right side, type 2 diabetes mellitus with diabetic neuropathy, long term use of insulin, gastro-esophageal reflux disease, major depressive disorder, convulsions, hyperlipidemia, heart failure, hypertension, muscle weakness, unspecified abnormalities of gait and mobility, presence of right artificial knee joint, cognitive communication deficit, and morbid obesity due to excess calories. Review of the 10/22/19 admission 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.