Majestic Care Of Whitehall

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to address pharmacy recommendations or initiate medication changes in a timely manner. This affected two (Residents #55 and #90) out of five residents reviewed for pharmacy recommendations. The facility census was 123. Findings include:1.Review of the medical record for Resident #90 revealed an admission date of 07/17/24 with diagnoses of insomnia, intellectual disabilities, muscle weakness, constipation, major depressive disorder, neuralgia, and neuritis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #90 is cognitively intact and is receiving psychotropic drugs. Review of the care plan dated 10/16/24 revealed Resident #90 receives psychotropic medication and is at risk for adverse side effects related to the use of antidepressants, anti anxiety medications, and sleep aids. Interventions include administering medications as ordered by the physician and reviewing quarterly and as needed to maintain the lowest…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, medication administration observation, and facility policy review, the facility failed to ensure staff administered medication following infection control procedures. This affected one (Resident #73) of four residents reviewed for infection control. The facility census was 123.Review of the medical record for Resident #73 revealed an admission date of 09/06/18 with diagnoses of end stage renal disease, hyperlipidemia, gastroesophageal reflux disease, polyneuropathy, hypertension, heart failure, and paroxysmal atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #73 is cognitively intact and requires set up or clean up assistance with eating. Observation of medication administration on 04/02/26 from 8:16 A.M. to 8:24 A.M. for Resident #73 revealed Licensed Practical Nurse (LPN) #511 began preparation of medications without practicing hand hygiene. Further observation revealed an Eliquis tablet 5 mg…

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 interview, the facility failed to ensure physician appointments were arranged as ordered. This affected one (Resident #16) of four sampled residents. The census was 118. Findings include: Review of Resident #16's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included Chronic Obstructive Pulmonary Disease, morbid obesity, cirrhosis of the liver, congestive heart failure, anxiety and hypertension. Review of the Annual minimum data set assessment dated [DATE] revealed his cognition was intact. He is continent of his bowel and bladder. Uses a wheelchair for mobility. Requires supervision or touching assistance with oral hygiene, toileting, bathing, dressing and personal hygiene. Review of the physicians orders revealed an order on 11/27/24 for a consult with Central Ohio Urology regarding a staghorn calculus (type of kidney stone with branches that can block urine flow and cause kidney failure) evaluation and treatment and consult Ohio…

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

Based on observation and staff interview, the facility failed to maintain a safe and functional environment when the transition strips (slim strips fitted at the base of doorways to bridge the gap between different floor surfaces or levels) were not in place to level the resident room floor and the hallway floor. This had the potential to affect eight residents (#14, #35, #41, #64 #65, #70, #105, and #115) of 22 residents residing on the [NAME] hallway. The facility census was 118. Findings Include: On 11/04/24 at 9:27 A.M., observations of Resident #14, #35, #41, #64 #65, #70, #105, and #115 rooms revealed the transition strips were missing in the doorway causing an unleveled surface entering and exiting the resident rooms. On 11/06/24 at 12:05 P.M., interview with the Director of Nursing (DON) revealed the facility had removed carpet and replaced with different floor. The facility provided no additional information as to why the transition strips were not replaced.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and policy review, the facility failed to ensure Resident #59 was treated with respect and dignity. This affected one resident (#59) of nine sampled residents. The facility census was 118. Findings include: Review of the medical record for Resident #59 revealed an initial admission date of 10/28/22 with the diagnoses including but not limited to early onset Alzheimer's disease, chronic obstructive pulmonary disease, severe dementia with mood disturbance, psychotic disorder with delusions, major depressive disorder, hypertension, hyperlipidemia, osteoarthritis, mood disorder, sleep disorders, atrial fibrillation, anxiety disorder, insomnia, wandering in diseases, hypothyroidism, constipation, sleep apnea and drug induced secondary Parkinsonism. Review of the plan of care dated 10/28/22 revealed the resident needed assistance with activities of daily living due to impaired mobility, weakness, debility, secondary Parkinsonism, dementia, osteoarthritis, anxiety,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure Resident #133's physician was notified of a blood pressure outside of the physician ordered parameters. This affected one (Resident #133) of nine sampled residents. The facility census was 118. Findings include: Review of the medical record for Resident #133 revealed an initial admission date of 05/31/24 with the latest readmission of 08/21/24 with the diagnoses including but not limited to end stage renal disease (ESRD), puncture wound with foreign body of thorax, osteonecrosis of multiple sites, chronic obstructive pulmonary disease (COPD), stenosis of vascular prosthetic devices, implants and grafts, dependence on hemodialysis, renal osteodystrophy, chronic kidney disease (CKD), endocarditis, atrial fibrillation, seasonal allergic rhinitis, bipolar disorder, hypertension, hyperlipidemia, constipation, anemia and nicotine dependence. Review of the plan of care dated 06/07/24 revealed the resident was at risk 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 medical record review and staff interview, the facility failed to ensure sutures were removed as physician ordered for Resident #133. This affected one resident (#133) of nine sampled residents. The facility census was 118. Findings Include: Review of the medical record for Resident #133 revealed an initial admission date of 05/31/24 with the latest readmission of 08/21/24 with the diagnoses including but not limited to end stage renal disease (ESRD), puncture wound with foreign body of thorax, osteonecrosis of multiple sites, chronic obstructive pulmonary disease (COPD), stenosis of vascular prosthetic devices, implants and grafts, dependence on hemodialysis, renal osteodystrophy, chronic kidney disease (CKD), endocarditis, atrial fibrillation, seasonal allergic rhinitis, bipolar disorder, hypertension, hyperlipidemia, constipation, anemia and nicotine dependence. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review 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, staff interview and facility policy review, the facility failed to maintain appropriate infection control practices during the administration of eye drops to prevent potential infection. This affected one resident (#70) of two residents observed for eye drop administration. The facility census was 118. Findings Include: On 11/04/24 at 9:33 A.M., observation of medication administration revealed Licensed Practical Nurse (LPN) #210 applied (donned) a pair of gloves at the medication administration cart, gathered Resident #70's medications which included a nasal spray and eye drops and entered the resident's room. The LPN assisted Resident #70 to take her oral medications. The LPN then used a tissue and wiped the tip of the Fluticasone 50 micrograms (mcg) nasal spray applicator. The LPN then administered two sprays of the Fluticasone 50 mcg in each nostril. The LPN using the same gloves administered one eye drop in each of the resident's eyes. LPN #210 verified the lack of infection control practices by not washing hands and changing gloves between the Fluticasone…

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 interview, and staff interview, the facility failed to maintain a safe, clean and comfortable environment. This affected two rooms on the 400 unit (room [ROOM NUMBER] and 408). The census was 137. Findings include: 1. On 09/19/24 at 2:35 P.M. observation of room [ROOM NUMBER] revealed a night stand with a drawer missing and finish coming off of it, food debris on floor, the wall had patches of drywall showing and the privacy curtain had dark stains. On 09/23/24 at 8:57 A.M. and 12:00 P.M. observations of room [ROOM NUMBER] revealed a mat to the floor with dark stains, a night stand with a drawer missing and finish coming off of it, there was food debris on floor, the wall had patches of drywall showing and the privacy curtain had dark stains. On 09/25/24 at 3:55 P.M. observations of room [ROOM NUMBER] revealed a mat to the floor with dark stains, a night stand with a drawer missing and finish coming off of it, there was food debris on floor, wall with patches of drywall showing 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, medical record review, and staff interview, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition and personal hygiene. This affected three of five residents reviewed for personal hygiene (Residents #9, #24, and #30). The facility census was 137. Findings include: 1. Review of the medical record for Resident #24 revealed an admission date of 08/24/23 and diagnoses including cerebral infarction, diabetes, dysphagia, protein-calorie malnutrition, and malignant neoplasm of the prostate. The resident had physician's orders for a dysphagia advanced texture diet, nectar thickened liquids, and must have one to one supervision for all meals. Review of a Minimum Data Set assessment completed 08/06/24 revealed the resident had range of motion impairment on one side in upper and lower extremity, required substantial/maximal assistance with eating, and was dependent upon staff for personal hygiene 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 resident interview, record review, and staff interview, the facility failed to ensure a resident was provided with proper treatment and assistive devices to maintain vision. This affected one of eight open sampled records reviewed (Resident #55). The facility census was 137. Findings include: Review of the medical record for Resident #55 revealed an admission date of 08/25/22 and a diagnosis of paranoid schizophrenia. A Minimum Data Set assessment completed 06/30/24 indicated the resident wore corrective lenses. The resident had a physician's order 08/25/22 that he may be seen by the optometrist. There was no evidence the resident had been seen by any physician related to his vision since admission. Interview with Resident #55 on 09/17/24 at 11:55 A.M. revealed he needed new glasses. He stated he was unable to see with his current glasses. Interview with Licensed Practical Nurse #168 on 09/19/24 at 10:30 A.M. revealed she was aware that Resident #55 was asking for new glasses. She stated the social worker was supposed to put him on a list to see the eye doctor about a month…

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, resident interview, and staff interview, the facility failed to ensure a resident received physician ordered assistance devices to prevent falls. This affected one of three residents reviewed for falls (Resident #89). The facility census was 137. Findings include: Review of the medical record for Resident #89 revealed an admission date of 08/16/24 and diagnoses including cerebral infarction, diabetes, end stage renal disease, and schizophrenia. Review of a Minimum Data Set assessment completed 08/22/24 revealed the resident had intact cognition and required substantial/maximal assistance with transfers. Review of nursing progress notes and incident and accident investigation forms revealed the following incidents noted: On 08/17/24 10:15 A.M.: noted sleeping on floor. Resident is a new admission to the facility and has intermittent periods of confusion. Re-oriented to room and bright color tape applied to call light as reminder. On 08/18/24 10:30 P.M.: noted on floor and having seizure like activity. Hematoma to center of forehead. Sent to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, review of the infection control log and facility policy and procedure, the facility failed to ensure proper infection control techniques were maintained when providing incontinence care. This affected one resident (#9) observed for incontinence care. The census was 137. Findings include: Review of Resident #9's medical record revealed she was readmitted to the facility on [DATE]. Review of the admission minimum data set assessment (MDS) dated [DATE] revealed her cognition was intact. She was dependent on staff for toileting, shower/bathing and required partial to moderate assistance for personal hygiene. The resident was frequently incontinent of urine and always incontinent of bowel. Observation on 09/19/24 at 9:10 A.M. of incontinence care to Resident #9 revealed State Tested Nurses Aide (STNA) #150 used hand sanitizer and prepared water and put on gloves. The STNA provided privacy, washed from side to side and down the middle of the vaginal area,…

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, and staff interview, the facility failed to ensure a resident with a gastrostomy tube received the appropriate enteral feeding as ordered by the physician. This affected one of seven open sampled records reviewed (Resident #24). The facility census was 137. Findings include: Review of the medical record for Resident #24 revealed an admission date of 08/24/23 and diagnoses including cerebral infarction, diabetes, dysphagia, protein-calorie malnutrition, and malignant neoplasm of the prostate. The resident had a gastrostomy tube and had physician's orders for an enteral feeding of Glucerna 1.5 calorie at 100 cc's per hour. The enteral feeding was to run from 6:00 P.M. until 6:00 A.M. only. He also received a meal tray during the day. Review of a Minimum Data Set assessment completed 08/06/24 revealed the resident had range of motion impairment on one side in upper and lower extremity, required substantial/maximal assistance with eating, and was dependent upon staff for personal hygiene and transfers. The plan of care dated 12/08/23 stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to ensure residents were adequately monitored while receiving medications for blood pressure control. This affected two (Residents #71 and #140) of five residents reviewed for medication administration. The census was 137. Findings include: 1. Review of Resident #71's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included chronic obstructive pulmonary disease (COPD), atrial fibrillation, and hypertension. Review of the Minimum Data Set (MDS) assessment, dated 03/14/24, revealed Resident #71 had severe cognitive impairment. Review of Resident #71 current physician orders, dated 04/14/24, revealed he had an order for Metoprolol Succinate ER (beta blocker used to treat heart arrhythmia's and high blood pressure) tablet 50 milligrams (mg) by mouth twice daily. The medication was to be held if his systolic blood pressure was less than 100 or pulse was less that 60. On 07/12/24…

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, and staff interview, the facility failed to ensure medication rates were not five percent or greater. The medication error rate was 10 percent (three errors of 29 opportunities for error). This affected two of five residents observed during medication administration (Residents #8 and #52). The facility census was 137. Findings include: 1. Observations on 09/12/24 at 7:43 A.M. revealed Licensed Practical Nurse (LPN) #208 to administer medications to Resident #8. The resident had a physician's order for Folic Acid 1 milligram daily at 8:00 A.M. as a supplement. The medication was not available to administer. On 09/12/24 at 7:43 A.M. LPN #208 stated she did not know why the medication was not available from the pharmacy and the facility did not have any in stock to give to the resident. She stated she would have to call the pharmacy to determine why the medication was not sent to the facility. 2. Observations on 09/12/24 at 8:05 A.M. revealed LPN #208 to administer medications to Resident #52. The resident was given Guaifenesin 400 milligrams. (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 review of the facility policy, review of the hospital records, review of water temperature logs, record review, American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) recommendations and Center for Disease Control (CDC) guidance, and interviews with the local health department and staff, the facility failed to maintain a complete and accurate water management program to prevent the spread of Legionella. This affected one (Resident #9) of three residents reviewed for pneumonia and had the potential to affect all 129 residents residing in the facility. Findings include: Review of the medical record for Resident #9 revealed she was admitted to the facility on [DATE] with a diagnosis of chronic kidney disease stage IV. Review of the Minimum Data Set (MDS) 3.0 assessment completed 06/30/24 revealed she was cognitively intact and had no shortness of breath. Review of the progress note dated 07/29/24 revealed Resident #9's blood glucose (BG) was 40 earlier and now the BG was 60.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, review of the police report, and review of the facility policy, the facility failed to provide adequate supervision and a safe environment to prevent a resident from recurrent overdosing in the facility. This affected one (Resident #88) of one resident reviewed for safe environment. The facility census was 129. Findings include: Review of Resident #88's medical record revealed an admission date of 05/16/24 with a diagnosis including psychoactive substance abuse. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #88 was cognitively impaired and he can independently ambulate via an electric wheelchair. Resident #88 received antianxiety, antidepressant, and opioid medications. Review of Resident #88's physician orders starting on 05/25/24 revealed an order for Suboxone sublingual film 8-2 milligrams (mg), to be taken one film sublingually once a day for opioid dependence. Review of Resident #88's care plan dated 07/25/24 revealed he exhibited…

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, staff and resident interviews, and policy review, the facility failed to timely provide one resident (#63) with an operating electric wheelchair. This affected one (Resident #63) of three residents reviewed for accomodation of needs. The facility census was 130. Findings include: Medical record review revealed Resident #63 was admitted on [DATE] with diagnoses including right side hemiplegia from a stroke. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63's cognition was intact. The current care plan revealed the resident required two staff for lift transfers to his wheelchair. Interview and observation with Resident #63 on [DATE] at 7:12 A.M. revealed he had an electric wheelchair that was not working, but he would like to use this wheelchair instead of a standard wheelchair. Observation of the resident's room revealed the electric wheelchair was in the resident's bathroom not charging and the resident was in bed. Interview with Therapy…

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 reviews, review of a Self-Reported Incident investigation, policy review, and staff interviews, the facility failed to timely notify the responsible party and physician of an elopement incident from the secured unit for Resident #4. This affected one (#4) of three residents reviewed for elopement. The facility census was 130. Findings include: Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including dementia, psychosis, and anxiety. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had severely impaired cognition and was ambulatory. Review of an elopement assessment dated [DATE] revealed Resident #4 had no elopement history, was exit seeking, wandered, and resided on the secured unit. Review of a Self-Reported Incident involving the elopement of a different resident (#6) on 06/30/24 revealed the next day on 07/01/24 when investigating it was discovered that Resident #4 also got out of the secured…

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 reviews, review of a Self-Reported Incident (SRI) investigation, policy review, and staff interviews, the facility failed to ensure staff provided adequate supervision to prevent a resident, with altered mental status and exhibited exit seeking behaviors, from leaving the facility unsupervised. This affected one (Resident #6) of three residents reviewed for elopement. The facility census was 130. Findings include: Medical record review revealed Resident #6 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's dementia and anxiety. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had severely impaired cognition and was ambulatory. Review of the elopement assessment dated [DATE] revealed Resident #6 had no elopement history, wandered aimlessly, was exit seeking, and resided on the secured unit. Review of the facilities Self-Reported Incident investigation revealed an allegation of neglect was reported to the State Survey Agency.…

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 reviews, policy review, and interviews with residents, staff, and physician, the facility failed to provide a resident with timely physician services. This affected one (Resident #115) of seven residents reviewed for physician services. The facility census was 130. Findings include: Medical record review revealed Resident #115 was admitted [DATE] with diagnoses including cirrhosis of the liver, emotional distress, and generalized pain. Review of the resident's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #115 had intact cognition. Resident #115's physician was Physician #70. Further review of the medical record revealed the resident's most recent examination from Physician #70 was on 05/07/24. Resident #115 was not seen by a physician assistant, nurse practitioner, or clinical nurse specialist from 05/07/24 to 07/22/24. Interview with Resident #115 on 07/22/24 at 10:30 A.M. revealed Physician #70 had not examined him in 11 weeks and he had concerns about…

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

Based on personnel record review, staff interview, and facility policy review, the facility failed to administer and read tuberculin (TB) tests for newly hired staff as required. This had the potential to affect all 126 residents residing in the facility. Findings include: 1. Review of State Tested Nursing Aides (STNA) #644's personnel file revealed a hire date of 03/01/24. STNA #644 received the first step of TB skin test on 02/23/24 to the left forearm by with the negative results being read on 02/26/24. STNA #644 received the second step of TB skin test on 03/13/24 to the left forearm with no dated results available or recorded on STNA #644's Employee Immunization Record. Interview on 06/13/24 at 2:30 P.M. with Human Resource (HR) #720 confirmed STNA #644's second step TB skin test results were not recorded on the Employee Immunization Records for STNA #644. 2. Review of STNA #589's personnel file revealed a hire date of 06/14/23. STNA #589 received the first step of TB skin test on 06/06/23 to the right forearm with the negative results being read on 06/08/23. STNA #589 received…

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 resident and staff interviews, observations, and review of the facility policy, the facility did not maintain a safe and sanitary living environment for the residents who utilized the common area refrigerators. This had the potential to affect all residents in the facility except for the 22 residents residing on the memory care unit. The facility census was 126. Findings include: Interview on 06/10/24 at 10:46 A.M. with Resident #113 stated he attempted to use the resident refrigerator for a personal food item. He stated there was no room in it and there were flies and gnats in it, and it was not clean. He stated it was the refrigerator in the activities area located on the 200 Hall. Observation on 06/10/24 at 11:02 A.M. of the refrigerator on the 200 hall activity area revealed there was no temperature log and a sign was posted on the front of it stating it was a resident refrigerator and to date all items. Inside the refrigerator, there was a spilled drink on the ground, it was full of undated food from various restaurants and grocery bags with mold-like substance on 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, staff interview, review of manufacture guidelines, and review of facility policy, the facility failed to remove two expired vials of Tubersol (tuberculin (TB) solution) from circulation. This had the potential to affect 66 residents who the facility identified were new admits to the facility in the last six months. The facility census was 126. Findings include: Observation on [DATE] at 8:35 A.M. revealed an opened partially used multiple dose of TB solution with the lot number 68154 and expiration date of [DATE]. The vial was in a plastic container without the original packaging box inside the refrigerator of the 300-hallway medication storage room. There was no open as of date written on the vial and no instruction on how to administer the solution. Interview on [DATE] at 8:45 A.M. with Licensed Practical Nurse (LPN) #510 confirmed the opened vial of TB solution, found in the 300-hallway medication storage room refrigerator, was without an open as of date written on the vial. LPN #510…

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 resident and staff interviews, observations, review of the facility's pest invoices, and review of the facility policy, the facility failed maintain effective pest control within the facility. This affected three residents (#7, #96, and #113) and had the potential to affect all residents in the facility except for the 22 residents residing on the memory care unit. The facility census was 126. Findings include: 1. Interview on 06/11/24 at 10:46 A.M. with Resident #113 revealed he attempted to use the resident refrigerator in the activities area located on the 200 Hall for a personal food item but there were flies and gnats inside of the refrigerator. Observation on 06/10/24 at 11:02 A.M. of the fridge on the 200 hall activity area revealed when opened, there were gnats and flies coming out it. Observation and interview on 06/10/24 at 11:12 A.M. with the Administrator verified there were flies and gnats inside the refrigerator on the 200 hall activity area. 2. Observation on 06/10/24 at 9:49 A.M. of Resident #7's room revealed the residents room had multiple flies and gnats…

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 provide notice to residents and or resident representative when the resident funds account reached $200 less than the Supplemental Security Income (SSI) resource limit for one person. This affected three (Residents #14, #55, and #87) of five residents reviewed for resident funds. The facility census was 126 residents. Findings include: Review of the medical records for Residents #14, #55, and #87 revealed they have Medicaid as a payor source. Review of the Resident Fund account for Resident #14 revealed on 04/29/24, the balance was $2,140.02. The balance remained at or above $2,110.02 through 06/13/24. Resident #14 did not receive a spend down notification until 06/03/24. Review of the Resident Fund account for Resident #55 revealed on 04/03/24, the balance was $2,242.31. The balance remained at or above $2,159.31 through 05/20/24. Resident #55 did not receive a spend down notification until 06/03/24. Review of the Resident Fund account for Resident #87 revealed that on 12/01/23, the balance was $3,234.71. 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 staff interview and record review, the facility failed to assess, document, and complete a transfer of a resident to the hospital for evaluation and treatment. This affected one (Resident #123) of one resident reviewed for hospitalizations. The facility census was 126. Findings include: Review of Resident #123's medical record revealed an admission date of 05/04/24 with diagnoses including Parkinson's disease, atrial fibrillation, type two diabetes mellitus, and chronic pain syndrome. Resident #123 had intact cognition and was able to make needs known. Resident #123 was discharged to the hospital on [DATE] for unknown reason. Review of Resident #123's baseline care plan dated 05/04/24 revealed Resident #123 required assistance for discharge planning. Review of the vital sign listing dated 05/06/23 at 10:40 A.M. revealed Resident #123's pain level was three out of ten. Review of the physician's order dated 05/06/24 at 1:45 P.M. by Physician #710 revealed an order to send Resident #123 to the emergency…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, resident and staff interview, and facility policy review, the facility failed to ensure residents who smoked had a personalized smoking care plan. This affected two (Residents #94 and #113) of the two residents reviewed for smoking. The facility census was 126. Findings include: 1. Review of the medical record for Resident #94 revealed an admission date of 09/20/21. Diagnoses included chronic obstructive pulmonary disease, acute and chronic respiratory failure, cognitive impairment, and long term, current use of opiate analgesic. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #94 had intact cognition for daily decision making abilities. Review of the Safe Smoking Review dated 06/10/24 revealed Resident #94 was not a cigarette/Tobacco smoker, Resident #94 smokes recreational marijuana intermittently. Educated on safe smoking practices and smoking policy provided, and resident agreeable. Review of the progress note 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 medical record review, staff interview, and review of the facility policy, the facility failed to provide a resident who required assistance from staff with activities of daily living (ADL) adequate assistance with eating. This affected one (Resident #56) of four residents reviewed for ADLs. The facility census was 126. Findings include: Review of the medical record for Resident #56 revealed an admission date of 09/09/21. Diagnoses included polyneuropathy, diabetes mellitus type two, chronic kidney disease, psychotic disorder hallucinations, adult failure to thrive, protein calorie malnutrition, and heart failure. Review of Resident #56's care plan last revised on February 2024 revealed Resident #56 was nutritional risk related to mechanically altered diet, abnormal labs, diuretic therapy, refusals to eat, and vitamin deficiency, behaviors such as refusal of care and hallucinations, failure to thrive and malnutrition with hospice care, oral health and dental problems due to missing teeth, chronic pain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to complete accurate pressure ulcer assessments. This affected one (Resident #24) of the three residents reviewed for pressure ulcer care. The facility census was 126. Findings include: Review of the medical record for Resident #24 revealed a re-entry date of 11/20/18. Diagnoses included multiple sclerosis, reduced mobility, contracture in left and right knee, and colostomy status. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #24 had intact cognition for daily decision making abilities. Resident #24 was noted to experience an impairment to bilateral lower extremities. Resident #24 was noted to have two stage three pressure ulcers (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed.) which were noted to be facility acquired and two stage four pressure ulcers (Full thickness tissue loss with bone, tendon or muscle. Slough of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, review of the facility policy, and record review, the facility failed to ensure a resident received treatment and care for good foot health. This affected one (Resident #99) of one resident reviewed for podiatry. The facility census was 126 residents. Findings include: Medical record review revealed Resident #99 was admitted on [DATE]. Diagnoses included dementia, type II diabetes mellitus, and Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #99 was severely impaired cognition. Resident #99 was dependent on staff for personal hygiene. Review of Resident #99's comprehensive care plan revealed the resident was at risk for complications due to diabetes mellitus. Interventions listed on her care plan included seeing a podiatrist for routine and as needed foot care, and a skin inspection weekly, paying particular attention to the feet. Review of Resident #99's weekly skin assessments dated 06/03/24 and 06/10/24 revealed no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, resident and staff interviews, and facility policy review, the facility failed to ensure residents were evaluated for safe smoking and provide adequate supervision and monitoring of residents who smoke. This affected two (Resident #94 and #113) of two residents reviewed for safe smoking. The facility census was 126. Findings include: 1. Review of the medical record for Resident #94 revealed an admission date of 09/20/21. Diagnoses included chronic obstructive pulmonary disease, acute and chronic respiratory failure, cognitive impairment, and long term, current use of opiate analgesic. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #94 had intact cognition for daily decision making abilities. Review of the Safe Smoking Review dated 06/10/24 revealed Resident #94 was not a cigarette/Tobacco smoker, Resident #94 smokes recreational marijuana intermittently. Educated on safe smoking practices and smoking policy provided, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident and staff interview, and review of the facility policy, the facility failed to ensure a resident had physician orders for oxygen administration. This affected one (Resident #94) of three residents reviewed for respiratory care. The facility census was 126. Findings include: Review of the medical record for Resident #94 revealed an admission date of 09/20/21. Diagnoses included chronic obstructive pulmonary disease (COPD) and acute and chronic respiratory failure. Review of Resident #94's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #94 had intact cognition. Review of the physician orders for Resident #94 revealed Resident #94 did not have any routine or as needed orders for oxygen administration. Resident #94 had orders dated 01/08/24 to apply two liters of oxygen at night for sleep apnea. Observation on 06/10/24 at 11:58 A.M. revealed Resident #94 sitting in the facility's courtyard with a oxygen tank on the back 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 record review, staff interviews, review of hospital records, and policy review, the facility failed to properly assess and treat Resident #11's pain after a fall with major injury. This affected one (#11) of two residents reviewed for pain management. The facility census was 126. Findings include: Review of the medical record for Resident #11 revealed an admission date of 08/04/16. Diagnoses included restlessness, agitation, and dementia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had memory problems and required assistance from staff with transferring. Review of Resident #11's active care plan revealed the resident was at risk for acute and/or chronic pain with an intervention to observe for symptoms of non-verbal pain which included: changes in breathing, vocalizations, mood/behavior, eyes, face and body signs and symptoms. Review of the progress note dated 05/25/24 at 8:05 A.M. revealed Resident #11 was on the floor. Resident #11 stated she was trying to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and staff interview, this facility failed to ensure residents with a diagnosis of post-traumatic stress disorder (PTSD) had the appropriate assessment and documented triggers regarding this diagnosis. This affected three (Residents #33, #92, and #104) of five residents reviewed for emotional needs and behaviors. The facility census was 126. Findings include: 1. Review of the medical record for Resident #33 revealed an initial admission date of 12/19/20 with a re-entry date of 04/04/22. Diagnosis included PTSD. Review of Resident #33's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 had intact cognition for daily decision making abilities with no behaviors noted. Resident #33 was noted to receive antipsychotic and antidepressants daily. Review of the plan of care last revised on 03/29/22 revealed Resident #33 had a diagnosis of anxiety, PTSD, and major depressive disorder. Resident #33 reports that she continuously struggles with symptoms of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Review of the medical record for Resident #83 revealed an admission date of 02/04/22. Medical diagnosis included hypertensive heart disease with heart failure. Review of quarterly Minimum Data Set (MDS) assessment, dated 05/01/24, revealed Resident #83 had severely impaired cognition. Review of Resident #83's physicians orders revealed an order dated 03/25/24 for hydralazine (a medication to lower blood pressure) 30 milligrams (mg) by mouth three times daily. The order included parameters to hold for a systolic blood pressure less than 100 or a heart rate greater than 100 beats per minute. Review of Resident #83's April 2024, May 2024, and June 2024 Medication Administration Record (MAR) revealed no correlating blood pressure or heart rate documented prior to medication administration. Review of Resident #83's electronic medical record contained no evidence that his blood pressure or heart rate was monitored prior to being administered his three times daily hydralazine. An interview on 06/13/24 at 8:51 A.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of the facility's infection control log, and facility policy review, the facility failed to provide adequate justification and monitoring regarding the use of an antibiotic. This affected one (Resident #38) of five residents reviewed for medications. The facility census was 126. Findings include: Medical record review revealed Resident #38 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease and acute and chronic respiratory failure. Review of the Minimum Data Set (MDS) assessment, dated 03/06/24, revealed Resident #38 was cognitively intact. Review of Resident #38's physician orders, dated 12/07/23, revealed the resident was prescribed and administered Azithromycin (antibiotic) 500 milligrams (mg) every Monday, Wednesday, and Friday for prophylactic. There was no evidence of monitoring the effectiveness of the antibiotic and no evidence of justification for the use of the antibiotic. Review of the facility's…

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

Based on review of infection control records, observation, staff and resident interview, and policy review, the facility failed to ensure to residents were permitted to eat in the dining room. This affected two (Resident #12 and #17) of two residents reviewed for dining services. This had the potential to affect all 128 residents in the facility who receive meals from the kitchen. The census was 128. Findings include: Review of the infection control records for COVID-19 revealed the last case of COVID-19 was on 09/15/22. Observations on 09/26/22 from 8:00 A.M. to 8:30 A.M. and 12:00 P.M. to 12:30 P.M., and on 09/27/22 from 8:00 A.M. to 8:30 A.M. and 12:00 P.M. to 12:30 P.M., revealed no residents were in the dining room eating meals. Interview with Resident #12 on 09/28/22 at 8:42 A.M. revealed every time there was an outbreak of COVID-19 the dining room was closed. The interview further revealed the dining room had remained closed and she would like to participate in dining services. Interview with Resident #17 on 09/28/22 at 11:49 A.M. revealed she would like to go to the dining…

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 and resident interviews, review of the facility handbook, review of timesheets, and facility policy review, the facility failed to ensure a qualified social worker was on-site full-time when the facility had greater than 120 beds. This had the potential to affect all 128 residents who resided in the facility. The census was 128. Findings include: Interview on 09/27/22 at 8:38 A.M. with Resident #32 revealed the facility did not have a full-time social worker on-site. Resident #32 stated a social worker was on-site two days a week. Interview on 09/28/22 at 11:15 A.M. with the Nursing Home Administrator (NHA) and Regional Nurse (RN) #420 revealed the facility's social worker recently walked out on the job without notice. The facility had two interim social workers who were on-site at the facility three to four days per week between the two of them. Interview on 09/29/22 at 1:18 P.M. with Social Services (SS) #501 revealed she and SS #500 were the interim social workers for the facility. SS #501 stated she was on-site two days a week. The previous full-time social worker…

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 and resident interview, and policy review, the facility failed to ensure care conferences were provided for residents. This affected five (Resident #32, #41 #48, #56, and #86) of five residents reviewed for care conferences. The census was 128. Findings include: 1. Medical record review for Resident #86 revealed an admission date of 04/19/22. Medical diagnoses included chronic obstructive pulmonary disease (COPD) and bipolar disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/28/22, revealed Resident #86 was cognitively intact. Review of the medical record for Resident #86 revealed there was no care conference held with the resident upon admission or quarterly. Interview with Resident #86 on 09/26/22 at 1:16 P.M. revealed she couldn't remembers if she had been invited to or attended a care conference. Interview with the Administrator and Regional Nurse #420 on 09/28/22 at 11:15 A.M. confirmed there was no evidence of quarterly care conferences 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 medical record review, resident and staff interviews, review of incident reports, review of Self-Reported incidents (SRIs), and facility policy review, the facility failed to implement their abuse policies and procedures. This affected four (Residents #63, #72, #93 and former Resident #128) of six residents reviewed for abuse. The facility census was 128. Findings include: 1. Review of the medical record for Resident #72 revealed an admission date on 03/09/20. Medical diagnoses included unspecified dementia, chronic obstructive pulmonary disease (COPD), unspecified psychosis, alcohol abuse, and alcoholic cirrhosis of liver. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had mild cognitive impairment. Resident #72 required limited assistance from one staff to complete activities of daily living (ADLs). No behaviors were noted in the assessment. Review of the quarterly MDS assessment dated [DATE] revealed Resident #72 had severely impaired cognition. Resident #72…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interviews, review of incident reports, review of Self-Reported incidents (SRIs), and facility policy review, the facility failed to ensure allegations of abuse were reported to the state survey agency. This affected four (Residents #63, #72, #93, and former Resident #128) of six residents reviewed for abuse. The facility census was 128. Findings include: 1. Review of the medical record for Resident #72 revealed an admission date on 03/09/20. Medical diagnoses included unspecified dementia, chronic obstructive pulmonary disease (COPD), unspecified psychosis, alcohol abuse, and alcoholic cirrhosis of liver. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had mild cognitive impairment. Resident #72 required limited assistance from one staff to complete activities of daily living (ADLs). No behaviors were noted in the assessment. Review of the quarterly MDS assessment dated [DATE] revealed Resident #72 had severely impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interviews, review of incident reports, review of Self-Reported incidents (SRIs), and facility policy review, the facility failed to timely investigate allegations or suspected incidents of abuse. This affected four (Residents #63, #72, #93, and former Resident #128) of six residents reviewed for abuse. The facility census was 128. Findings include: 1. Review of the medical record for Resident #72 revealed an admission date on 03/09/20. Medical diagnoses included unspecified dementia, chronic obstructive pulmonary disease (COPD), unspecified psychosis, alcohol abuse, and alcoholic cirrhosis of liver. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had mild cognitive impairment. Resident #72 required limited assistance from one staff to complete activities of daily living (ADLs). No behaviors were noted in the assessment. Review of the quarterly MDS assessment dated [DATE] revealed Resident #72 had severely impaired…

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, medical record review, staff interview, and facility policy review, the facility failed to ensure residents were provided appropriate supervision while smoking. This affected one (#49) out of three residents reviewed for accidents. Additionally, the facility failed to provide safe smoking areas. This had the potential to affect all 36 residents (#1, #5, #12, #13, #14, #16, #19, #20, #23, #28, #30, #31, #33, #34, #37, #45, #49, #52, #55, #61, #62, #64, #71, #80, #81, #83, #86, #93, #98, #101, #104, #122, #126, #128, #129, and #130) identified by the facility who smoke. The census was 128. Findings include: 1. Review of the medical record for Resident #49 revealed an admission date of 01/11/22 and diagnoses including chronic obstructive pulmonary disease (COPD), hemiplegia and hemiparesis, congestive heart failure (CHF), and nicotine dependence. Review of the quarterly Minimum Data Set assessment, dated 07/05/22, revealed Resident #49 had impaired cognition. Review of the nurses notes, dated 07/16/22 at 11:51 A.M., revealed Resident #49 was found in the smoking…

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

Based on medical record review, staff and resident interview, review of the daily staffing sheet and time punches, review of the activity calendar, review of participation logs, and policy review, the facility failed to ensure there was sufficient nursing staff to meet the residents needs. This affected one (#41) of one reviewed for activities and had the potential to affect all 45 residents on the 200 hall (#3, #7, #8, #12, #17, #18, #19, #22, #23, #26, #28, #32, #34, #40, #41, #42, #46, #48, #50, #56, #57, #60, #68, #74, #79, #81, #85, #86, #87, #88, #93, #94, #96, #97, #100, #109, #110, #114, #116, #118, #121, #122, #127, #129, and #382). This also affected one (#37) of five residents reviewed for activities of daily living and had the potential to affect all 21 residents who resided on the 300 hall (#1, #6, #9, #14, #25, #31, #36, #53, #55, #61, #62, #65, #70, #84, #99, #104, #105, #107, #112, #119, and #125). The census was 128. Findings include: 1. Medical record review for Resident #41 revealed an admission date of 06/08/22. Medical diagnoses included chronic obstructive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff and resident interview, and facility policy review, the facility failed to properly store and label medication as well as ensure medication was not expired. This affected two (#9 and #105) residents and had the potential to affect six residents (#2, #10, #13, #95, #112, and #285) with medications stored in the 100 hall medication storage room refrigerator, four residents (#18, #46, #81, and #85) who received medication from the 200 Short Hall medication cart, and 11 residents (#9, #25, #31, #53, #55, #61, #66, #70, #99, #112, and #119) who received medications from the 300 hall medication cart. The facility census was 128. Findings include: 1. Review of the medical record for Resident #105 revealed an admission date of 08/29/22. Diagnoses included chronic obstructive pulmonary disease, end stage renal disease, and renal dialysis dependent. Review of the Minimum Data Set (MDS) Medicare five day assessment revealed Resident #105 was cognitively intact. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of beneficiary notices, the facility failed to provide the appropriate beneficiary notices (Notice of Medicare Non-Coverage and Advanced Beneficiary Notice) to three residents. This affected three (Residents #44, #92, and #115) of three residents reviewed for beneficiary notices. The facility census was 128. Findings include: 1. Review of the medical record for Resident #44 revealed an admission date on 03/11/22. Medical diagnoses included chronic hepatic failure without coma, Type II Diabetes Mellitus with hyperglycemia, unspecified viral hepatitis C, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had intact cognition. Resident #44 required supervision to limited assistance from one to two staff to complete activities of daily living (ADLs). Review of the beneficiary notices list from the last six months revealed Resident #44 was cut from Medicare Part A therapy services on 05/30/22 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 observation, staff and resident interview, and facility policy review, the facility failed to ensure a homelike environment was provided for residents. This affected one (#9) out of 128 residents reviewed during the screening process. The census was 128. Findings include: Observation on 09/27/22 at 11:00 A.M. revealed Resident #9 was sitting in bed with only a shirt on and looking out his window which had window blind that was not down and the window overlooked the parking lot. Interview on 09/28/22 at 3:02 P.M. with Resident #9 revealed his window blind was broken and would not go down. Resident 9 stated his window was overlooking the parking lot. Resident #9 stated the shower curtain was hanging and broken in the shower in his room. Resident #9 stated maintenance was aware of his window blind and shower curtain however maintenance had never come back to fix either. Observation on 09/28/22 at 3:10 P.M. revealed Resident #9's window blind would not go down. The window blind was open roughly 18 inches from the window ledge. Unit Manager #318 tried to pull the window blind…

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 Pre-admission Screening and Resident Reviews (PASARRs), and review of facility policy, the facility failed to ensure an updated PASSAR was completed after a resident experienced a significant change or was diagnosed with a newly evident serious mental disorder. This affected three (Residents #7 #48, and #110) of six residents reviewed for PASARR screenings. The facility census was 128. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date on 09/15/20. Medical diagnoses included vascular dementia with behavioral disturbance (09/15/20), psychotic disorder (06/01/21), major depressive disorder (12/07/21), anxiety disorder (12/07/21), and post-traumatic stress disorder (PTSD) (12/21/15). Review of Resident #7's current physician orders dated September 2022 revealed Resident #7 had orders for the following psychotropic medications: Mirtazapine (antidepressant medication) 15 milligrams (mg) daily at bedtime for depression…

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

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure Pre-admission Screening and Resident Reviews (PASARR) were completed timely. This affected one (Resident #41) of six residents reviewed for PASARR screenings. The facility census was 128. Findings include: Medical record review for Resident #41 revealed an admission date of 06/08/22. Medical diagnoses included schizoaffective disorder. Review of quarterly Minimum Data Set assessment, dated 09/13/22, revealed Resident #41 was cognitively intact. Review of Resident #41's medical record revealed there was not a PASARR completed upon admission. Interview with the Director of Nursing (DON) on 09/27/22 at 3:30 P.M. confirmed Resident #41 did not have a PASARR completed upon admission and a PASSAR should have been completed. Review of the policy entitled Pre-admission Screening and Resident Review dated 08/01/20 revealed the purpose of Pre-admission Screening and Resident Review (PASRR) is to identify the best services and location for residents and/or those considering 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 medical record review, observation, staff interview, and resident interview, the facility failed to get ensure residents who were dependent on staff assistance for activities of daily living were provided assistance with getting out of bed. This affected one (#37) out of four residents reviewed who were dependent on staff assistance for activities of daily living. The census was 128. Findings include: Review of medical record for Resident #37 revealed an admission date of 01/12/21. Diagnoses included hemiplegia and hemiparesis following a cerebral infarction, and dementia. Review of the Minimum Data Set assessment, dated 09/13/22, revealed Resident #37 was cognitively impaired. Resident #37 required extensive two-person physical assist with bed mobility, transfers, toilet use, bathing, and personal hygiene. Resident required extensive one-person physical assist for eating. Resident #37 used a wheelchair to ambulate in the facility. Resident #37 was able to use her voice to speak very softly, but most of the time pointed with hands, answered with a head shake, or voiced…

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

Based on medical record review, staff and resident interview, review of a activity calendar, review of participation records, and policy review, the facility failed to ensure activities were provided to meet the needs/interests of the residents. This affected one (#41) of one resident reviewed for activities. The census was 128. Findings include: Medical record review for Resident #41 revealed an admission date of 06/08/22. Medical diagnoses included chronic obstructive pulmonary disease, schizoaffective disorder, and diabetes. Review of the activity evaluation, dated 07/11/22, revealed it was somewhat important for Resident #41 to have books, newspaper, and magazines to read, to listen to music she liked, to be around animals, keep up with the news, do things with groups of people, and do favorite activities. It was very important to participate in religious services or practices. Review of the September 2022 activity calendar revealed church services were scheduled for 09/04/22 at 3:00 P.M. Review of the participation log, dated 09/04/22, revealed Resident #41's name was not on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure wound treatments were completed according to physician orders. This affected two (#9 and #56) of seven residents reviewed for wound treatments. The census was 128. Findings include: 1. Review of the medical record for Resident #9 revealed an admission on [DATE]. Diagnoses included cellulitis of the right lower limb, erythema intertrigo, non-pressure chronic ulcer of unspecified part of lower leg with severity, lymphedema, and obesity. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively intact. Resident #9 required supervision and setup help for bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and bathing. Review of the plan of care, dated 02/08/22, revealed Resident #9 was at risk for refusing treatments and medications at times. Interventions included administer medications as ordered, allow resident to vent feelings, approach…

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, medical record review, staff and resident interview and policy review, the facility failed to ensure pressure ulcer interventions and treatments were initiated timely. This affected two residents (#29 and #106) out of six residents reviewed for pressure ulcers. The facility identified six residents with pressure ulcers. The census was 128. Findings include: 1. Review of the medical record for Resident #29 revealed an admission date of 04/06/15 and the diagnoses of chronic obstructive pulmonary disease (COPD), cerebral infarction, and spastic hemiplegia. Review of the Minimum Data Set (MDS) assessment, dated 08/28/22, revealed Resident #29 required extensive two staff assistance for bed mobility, personal hygiene and toilet use. The assessment indicated Resident #29 had two stage four pressure ulcers. Review of the care plan, dated 08/28/18, revealed Resident #29 was at risk for skin breakdown related to decreased mobility, weakness, and moderate protein calorie malnutrition with interventions to provide treatments as ordered and monitor for skin breakdown. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure nutritional supplements were provided as ordered and weights were obtained as ordered. This affected one (#58) of four residents reviewed for nutrition. The facility identified there were 19 residents with unplanned significant weight loss. The census was 128. Findings include: Medical record review for Resident #58 revealed an admission date of 04/01/22. Medical diagnoses included diabetes, renal insufficiency, and non-Alzheimer's dementia. Review of Resident #58's weights revealed Resident #58 weighed 174.8 pounds on 04/01/22. Further review of the weights revealed Resident #58 weighed 151.0 pounds on 09/26/22. Review of quarterly Minimum Data Set, dated [DATE], revealed Resident #58 was severely cognitively impaired. Resident #58 required supervision with eating. Review of Resident #58's care plan dated 07/21/22 revealed Resident #58 was at risk for malnutrition related chronic disease with noted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure residents who utilized oxygen had a physician order for oxygen. Additionally, the facility failed to ensure oxygen tubing was dated. This affected two (#60 and #86) of two residents reviewed for respiratory care. The facility identified 20 residents who received oxygen therapy. The census was 128. Findings include: 1. Medical record review for Resident #86 revealed an admission date of 04/19/22. Medical diagnoses included chronic obstructive pulmonary disease (COPD) and bipolar disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86 was cognitively intact. Review of Resident #86's physician orders since 04/19/22 revealed there was no order for oxygen. Observation of Resident #86 on 09/26/22 at 1:27 P.M. revealed she used oxygen and her tubing was not dated. Observation on 09/27/22 at 2:28 P.M. revealed Resident #86's oxygen tubing was not dated. Interview…

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

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure residents received appropriate dialysis management services. This affected two residents (#105 and #106) out of two residents reviewed for dialysis. The facility identified 11 residents who received dialysis services. The census was 128. Findings include: 1. Review of the medical record for Resident #106 revealed an admission date of 08/29/22 and the diagnoses of diabetes type two, chronic obstructive pulmonary disease (COPD), end stage renal disease (ESRD), dependence on renal dialysis, and heart failure (HF). Review of the care plan, dated 10/03/22, revealed Resident #106 required hemodialysis due to ESRD and was to receive in house dialysis with intervenitons to assess bruit and thrill every shift, do not draw blood or take blood pressure in arm with graft, and administer medications as ordered. Prior to 10/03/22, there were no care planned interventions to address Resident #106's dialysis services. Review of Resident #106's physician orders new orders were…

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, medical record review, staff interview, and facility policy review, the facility failed to ensure a medication error rate of less than five percent (%). Out of 29 opportunities, three errors were observed which equaled an error rate of 10.34%. This affected one (Resident #48) out of three residents observed during medication administration. The census was 128. Findings include: Review of the medical record for Resident #48 revealed an admission date of 04/13/22 and the diagnoses of acute respiratory failure with hypoxia. Review of the quarterly Minimum Data Set assessment, dated 07/05/22, revealed Resident #48 had the diagnoses of respiratory failure. Review of Resident #48's care plan, dated 10/03/22, revealed he was at risk for respiratory distress related to other acute respiratory failure with hypoxia with interventions to administer medications as ordered. Review of Resident #48's physician orders revealed orders for Artificial Tears Solution 0.5-0.6% (Polyvinyl Alcohol-Povidone) with instructions to instill two drops in both eyes four times a day for dry…

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, medical record review, staff interview, and policy review, the facility failed to ensure an indwelling Foley catheter was cleaned in accordance with proper infection control procedures. This affected one (#56) of one resident reviewed for catheter care. The facility identified there were four residents in the facility with catheters. The census was 128. Findings include: Medical record review for Resident #56 revealed an admission date of 08/03/16. Medical diagnoses included multiple sclerosis, neurogenic bladder, and paraplegia. Review of the care plan, dated 03/11/20, revealed Resident #56 had an alteration in elimination related to a Foley catheter. Her diagnoses was neurogenic bladder. Her interventions were to provide Foley catheter care per orders and routine. Review of physician orders, dated 09/29/21, revealed Foley catheter care was to be provided every shift and as needed. Review of quarterly Minimum Data Set assessment, dated 07/12/22, revealed Resident #56 was cognitively intact. Observation of catheter care on 09/29/22 at 1:08 P.M. 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.