Whitehouse Country Manor

Based on observation, resident interview, family interview, and staff interview, the facility failed to maintain a clean and homelike environment. This affected five (#9, #10, #11, #41, and #51) of five residents reviewed for environment. The facility census was 87. Findings include: 1. Observation on 10/04/23 at 9:10 A.M., revealed the blinds covering the window over Resident #41's were torn and broken a quarter of the way up the window on the right side of the window. Resident #41's bed was against the wall below the window with the head of the bed below the area where the blinds were torn, broken, and not covering the window. A black substance that smeared with touch was observed on the walls in Resident #41's room. Interview at the time of the observation on 10/04/23 at 9:10 A.M., with Resident #41, stated the window covering had been like that since Resident #41 moved in. Resident #41 stated I hate it because the sun shines in my eyes and at night gets the lights from the cars pulling in and out of the parking lot that shine in. Resident #41 stated, no good to say anything…

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 and staff interview, the facility failed to maintain a clean, functional, sanitary, and homelike environment for its residents. This had the potential to affect all 43 (#44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85 and #86) residents residing on the east wing of the building and affected seven residents (#3, #4, and #12) of 43 residents residing on the west wing of building. The facility censuses were 86. Findings include: Observations during tour of the facility on 10/04/23 between 9:10 A.M. and 10:15 A.M., revealed on the east wing, there was a strong foul odor noted as soon as one passed through the secure double doors. In the activity room/dining room, a cupboard door above sink, was hanging loosely off the cupboard by the right lower hinge; a missing front panel on the top drawer to the left of the sink; and sticky floors.…

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

Based on review of the Centers for Medicare & Medicaid Services (CMS) Payroll Based Journal (PBJ) report, staff interview, review of posted daily staff levels, and review of staff timecards, the facility failed to ensure eight hours of daily registered nurse (RN) coverage. This affected all 80 residents of the facility. Findings include: Review of the CMS PBJ report, dated July 2022, revealed the facility had a high number of days without RN coverage. Interview on 10/26/22 at 2:25 P.M. of Scheduler #304 revealed the facility utilized agency staff to cover open shifts to ensure the daily requirement of RN coverage. Review of the daily posted staffing from 09/01/22 through 10/25/22 revealed the facility did not have RN coverage on the following dates: 09/05/22, 09/14/22, 09/18/22, 09/22/22, 09/23/22, 09/24/22, 10/16/22 and 10/22/22. Additionally, on 09/17/22 the facility only had RN coverage for four hours. Review of timecards confirmed the facility did not have RN coverage for eight hours on each of the above dates. Interview on 10/27/22 at 6:59 A.M. of the Administrator confirmed…

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, review of the Pot Sink Sanitation Record, review of manufacturer's recommendations, review of work orders, and review of facility policy, the facility failed to ensure foods were properly stored and labeled after opening. Additionally, the facility failed to ensure adequate sanitization of dishes. This affected all 79 residents who received food from the kitchen. The facility identified one resident (#69) who did not receive food from the kitchen. The facility census was 80. Findings include: 1. Observation on 10/24/22 at 8:36 A.M. of kitchen revealed the reach in refrigerator in the food preparation area had an opened and undated package of turkey luncheon meat wrapped in plastic wrap; an opened and undated package of roast beef luncheon meat wrapped in plastic wrap; three packages of opened, unlabeled and undated cheese wrapped in plastic wrap; a plastic container of unlabeled and undated pears; a plastic container of unlabeled and undated gravy; a metal container of unlabeled and undated spaghetti sauce; and a plastic container of undated…

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 review of maintenance work orders, the facility failed to maintain a clean and sanitary environment for 41 residents (Resident #05, #07, #08, #09, #14, #15, #16, #17 #18, #22, #23, #24, #29, #32, #33, #39, #41, #42, #43, #45, #47, #48, #53, #55, #56, #57, #60, #63, #66, #67, #68, #72, #73, #74, #76, #130, #131, #132, #133, #134, and #230) residing on the secured unit. The facility census was 80. Findings include: Interview on 10/24/22 at approximately 12:00 P.M. with State Tested Nurse Aide (STNA) #347 revealed black mold was all over and growing in the soiled utility room located on the secured unit of the facility. STNA #347 reported the door was opened and closed frequently throughout the day and she was concerned about residents breathing in the mold spores. STNA #347 reported the mold had been reported to administration and remained unaddressed for over one year. Observation on 10/24/22 at 4:07 P.M. black mold was located all over the back and lower left walls of the soiled utility room. A large section of drywall was cut out of the…

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

Based on observation, resident interview, record review, staff interview and review of facility policy, the facility failed to assess a resident for self-administration of medications. This affected one (#46) of one resident reviewed for self-administration of medications. The facility census was 80. Findings include: Review of Resident #46's medical record revealed an admission date of 09/16/22. Diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), type II diabetes, atrial fibrillation, heart failure, dementia, major depressive disorder, atherosclerotic heart disease, hypertension and inflammatory disease of prostate. Review of the admission Minimum Data Set (MDS) assessment, dated 09/23/22, revealed Resident #46 had intact cognition. Review of physician orders revealed Resident #46 was prescribed albuterol sulfate HFA aerosol solution 109 micrograms/actuation (mcg/act) two puffs every six hours as needed for wheezing and fluticasone propionate solution 50 mcg/act spray in each nostril one time daily for congestion. Physician 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 medical record review, staff interview and review of facility policies, the facility failed to ensure timely physician notification and failed to notify the dietitian of a significant weight change for one (#46) of three residents reviewed for nutrition. The facility census was 80. Findings include: Review of Resident #46's medical record revealed an admission date of 09/16/22. Diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), type II diabetes, atrial fibrillation, heart failure, dementia, major depressive disorder, atherosclerotic heart disease, hypertension and inflammatory disease of prostate. Review of the admission Minimum Data Set (MDS) assessment, dated 09/23/22, revealed Resident #46 was cognitively intact. Additionally, Resident #46 required supervision with eating and had no significant weight loss. Review of a plan of care focus area, initiated 09/22/22, revealed Resident #46 was at risk for nutritional and hydration problems related to diagnoses of COPD, type II diabetes, congestive heart failure (CHF), dementia,…

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

Based on observation, resident interview, and staff interview, the facility failed to ensure resident rooms were maintained in good repair. This affected two (#37 and #75) of four residents reviewed for homelike environment. The facility census was 80. Findings include: Observation on 10/24/22 at 2:46 P.M. of Residents #37 and #75's room revealed no doors on the closet. One closet door was was leaning against the wall, next to the window, and the other door was missing. Interview of Residents #37 and #75 at the time of the observation revealed the closet doors had been broken for a couple of months and both expressed they wished the facility would do something to fix the doors. Residents #37 and #75 stated they were told the doors would not be replaced or repaired and a rod and curtain were going to be installed over the closet opening, but that had not been done either. Observation on 10/26/22 at 7:42 A.M. of Resident #37 and #75's room with the Administrator verified one closet door was leaning against the wall near the window and the other door was missing. Both Resident #37 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, resident and staff interview, and review of facility policies, the facility failed to ensure nail care was provided to residents dependent for care. This affected one (#75) of three residents reviewed for activities of daily living. The facility census was 80. Findings include: Review of Resident #75's medical record revealed an admission date of 08/06/12 and a readmission date of 04/25/19. Diagnoses included generalized anxiety disorder, pulmonary fibrosis, major depressive disorder, malaise, seizures, heart failure unsteadiness on feet, osteoarthritis, chronic stage II kidney disease, delusional disorders, peripheral vascular disease, hypertension, schizophrenia and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/13/22, revealed Resident #75 was cognitively intact and required limited assistance with personal hygiene. Review of a plan of care focus area revised 11/03/19, revealed Resident #75 had an activities of daily living (ADL) self-care performance deficit related to anxiety, depression, bipolar disorder and panic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and staff interview, the facility failed to follow physician's orders to [NAME] tubigrips to prevent and reduce edema for one (#44) of one resident reviewed for edema. The facility census was 80. Findings include: Review of Resident #44's medical record revealed an admission date of 03/06/21 and a readmission date of 09/06/22. Diagnoses included edema, complete traumatic amputation of one right lesser toe, complete traumatic amputation of right great toe, benign prostatic hyperplasia without lower urinary tract symptoms, type II diabetes, dementia, hypertension and schizophrenia. Review of the significant change Minimum Data Set (MDS) assessment, dated 09/20/22, revealed Resident #44 was severely cognitively impaired and required extensive assistance with Activities of Daily Living (ADLs), including extensive two person assistance with dressing. Review of the plan of care initiated 04/12/21 revealed Resident #44 had potential for fluid imbalance related to diuretic…

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 weigh a resident daily per physician order. This affected one (#46) of three residents reviewed for nutrition. Additionally, the facility failed to ensure nutritional supplements were provided as recommended by the dietitian. This affected one (#44) of three residents reviewed for nutrition. The facility census was 80. Findings include: 1. Review of Resident #46's medical record revealed an admission date of 09/16/22. Diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), type II diabetes, atrial fibrillation, heart failure, dementia, major depressive disorder, atherosclerotic heart disease, hypertension and inflammatory disease of prostate. Review of the admission Minimum Data Set (MDS) assessment, dated 09/23/22, revealed Resident #46 was cognitively intact. Additionally, Resident #46 had no behaviors and no significant weight loss. Review of a plan of care focus area, initiated 09/22/22, revealed Resident #46 was at risk for nutritional and…

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

Based on record review, staff interview, resident interview, and facility policy review, the facility failed to follow physician orders for post dialysis assessments, monitoring the fistula site for complications, and monitoring the fistula for the thrill and bruit for one (#31) of one residents reviewed for dialysis. The facility census was 80. Findings include: Review of Resident #31's medical record revealed an admission date of 09/16/22. Diagnoses included acute kidney failure with dialysis, schizophrenia, diabetes mellitus type 2, psychosis, human immunodeficiency virus (HIV), and a history of breast cancer. Review of Resident #31's quarterly Minimum Data Set (MDS) assessment, dated 08/26/22, revealed the resident had a high cognitive function. Review of Resident #31's most recent care plan revealed due to requiring dialysis the resident must have the arteriovenous fistula in the left arm assessed for signs and symptoms of infection or bleeding. If bleeding occurred the staff was to apply pressure and reinforce the dressing or call 911 for transport to the emergency room.…

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

Based on record review, staff interview, resident interview, and facility policy review, the facility failed to administered medications as ordered to one (#31) out of six residents reviewed for unnecessary medications. This had the ability to affect all residents. The facility census was 80. Findings include: Review of Resident #31's medical record revealed an admission date of 09/16/22. Diagnoses included acute kidney failure with dialysis, schizophrenia, diabetes mellitus type 2, psychosis, human immunodeficiency virus (HIV), and a history of breast cancer. Review of Resident #31's quarterly Minimum Data Set (MDS) assessment, dated 08/26/22, revealed the resident had a high cognitive function. Review of Resident #31's most recent care plan revealed medications were to be administered as ordered by the physician. Review of Resident #31's medical record revealed physician's order dated 10/28/21 for Sevelamer hydrochloride (HCl) (phosphorus lowering medication) tablet 800 milligrams (mg) for hyperphosphatemia with meals. Review of Resident #31's Medication Administration Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interview, review of a fall report and review of facility policy, the facility failed to ensure a resident's medical record reflected information related to a fall for one (#75) of one resident reviewed for falls. The facility census was 80. Findings include: Review of Resident #75's medical record revealed an admission date of 08/06/12 and a readmission date of 04/25/19. Diagnoses included generalized anxiety disorder, pulmonary fibrosis, major depressive disorder, malaise, seizures, heart failure unsteadiness on feet, osteoarthritis, chronic stage II kidney disease, delusional disorders, peripheral vascular disease, hypertension, schizophrenia and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/13/22, revealed Resident #75 was cognitively intact, required supervision for activities of daily living, including bed mobility, ambulation, dressing, and toilet use and limited assistance with personal hygiene. Further review…

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 ensure a register nurse worked eight hours a day, seven days a week. This had the potential to affect all 81 resident residing at the facility. The facility census was 81. Findings include: Review of the facility staffing records from 10/25/19 to 11/24/19 revealed a registered nurse (RN) did not work or worked less than eight hours in the facility on 10/25/19, 10/31/19, 11/01/19, 11/05/19, 11/08/19, 11/11/19, 11/19/19, 11/20/19, and 11/21/19. Interview on 11/25/19 at 4:33 P.M. with the Administrator verified the facility had no RN coverage for eight hours on 10/25/19, 10/31/19, 11/01/19, 11/05/19, 11/08/19, 11/11/19, 11/19/19, 11/20/19, and 11/21/19.

Based on observation, staff interview, and review of facility policies, the facility failed to store and prepare foods in a safe and sanitary manner. This had the potential to affect all 81 residents who received food from the kitchen. The facility census was 81. Findings include: Observation on 11/24/19 at 8:36 A.M. of the dry stock room revealed an open, partially used, one gallon jug of teriyaki sauce labeled by the manufacturer to refrigerate after opening. The jug was labeled as opened on 10/03/19. Interview on 11/24/19 at 8:38 A.M. with Dietary Staff (DS) #104 verified the jug of teriyaki sauce was opened on 10/03/19, stored on the dry storage shelf, and not in the refrigerator as required. DS #104 threw the partially used gallon jug of teriyaki sauce in the trashcan. Observation on 11/24/19 at 3:17 P.M. of DS #127 pureeing the dinner meal found DS #127 wearing a cowboy hat on the top of his head with no hairnet containing his hair. DS #127 also had a beard and mustache and was not wearing a beard guard. Interview on 11/24/19 at 3:25 P.M., Dietary Manager #176 verified DS #127…

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

Based on staff interview, review of facility trust account information, and review of facility surety bond, the facility failed to ensure the surety bond was efficient to cover the total balance of the resident account balances. This affected 74 current residents identified by the facility with current trust accounts handled by the facility. Resident #5, #19, #25, #29, #46, #74, and #278 did not have personal fund accounts handled by the facility. Facility census was 81. Findings include: Review of the resident trust accounts on 11/26/19 at 10:10 A.M. with Business Office manager(BOM) #137 identified 74 residents with current accounts. The current total balance was $66,478.02. Review of the financial surety bond dated 10/01/18 indicated the bond covered the facility for up to $50,000.00. Interview on 11/26/19 at 12:25 P.M., the Administrator verified the facility resident fund account balance exceeds the current financial surety bond total.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, review of facility Self-Reported Incidents, and review of facility policies, the facility failed to follow their policy to investigate and report of allegations of sexual abuse to the state survey agency. This affected four (#3, #4, #8, and #63) of four reviewed for abuse. The facility census was 81. Findings include: 1. Review of Resident #4's medical record revealed an admission date of 05/29/18. Diagnoses included morbid obesity, symbolic dysfunctions, post traumatic stress disorder, dystonia, anxiety disorder, insomnia, and schizoaffective disorder. Review of Resident #4's Minimum Data Set (MDS) assessment, dated 06/03/19, revealed Resident #4 was cognitively intact. Resident #4 required supervision with walking, locomotion, dressing, and personal hygiene. Resident #4 displayed the behavior of wandering one to three days during the review period. Review of the progress notes revealed on 11/19/19 Resident #4 was in Resident #63's room when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, review of facility Self-Reported Incidents, and review of facility policy, the facility failed to report of allegations of sexual abuse to the state survey agency. This affected four (#3, #4, #8, and #63) of four reviewed for abuse. The facility census was 81. Findings include: 1. Review of Resident #4's medical record revealed an admission date of 05/29/18. Diagnoses included morbid obesity, symbolic dysfunctions, post traumatic stress disorder, dystonia, anxiety disorder, insomnia, and schizoaffective disorder. Review of Resident #4's Minimum Data Set (MDS) assessment, dated 06/03/19, revealed Resident #4 was cognitively intact. Resident #4 required supervision with walking, locomotion, dressing, and personal hygiene. Resident #4 displayed the behavior of wandering one to three days during the review period. Review of the progress notes revealed on 11/19/19 Resident #4 was in Resident #63's room when Housekeeper #167 observed Resident #4…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, review of facility investigations, and review of facility policies, the facility failed to thoroughly investigate allegations of sexual abuse. This affected four (#3, #4, #8, and #63), of four reviewed for abuse. The facility census was 81. Findings include: 1. Review of Resident #4's medical record revealed an admission date of 05/29/18. Diagnoses included morbid obesity, symbolic dysfunctions, post traumatic stress disorder, dystonia, anxiety disorder, insomnia, and schizoaffective disorder. Review of Resident #4's Minimum Data Set (MDS) assessment, dated 06/03/19, revealed Resident #4 was cognitively intact. Resident #4 required supervision with walking, locomotion, dressing, and personal hygiene. Resident #4 displayed the behavior of wandering one to three days during the review period. Review of the progress notes revealed on 11/19/19 Resident #4 was in Resident #63's room when Housekeeper #167 observed Resident #4 touching Resident #63'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 observation, staff interview, review of daily temperature log, nd review of manufacturer's storage recommendations, the facility failed to store medication requiring refrigeration at the proper temperature in accordance with manufacturer recommendations. This had the potential to affect nine residents (# 8, #13, #18, #21, #23, ##39, #42, #68, and #128) identified by the facility as having orders for medications being stored in the refrigerator. The census was 81. Findings include: Observation on 11/25/19 at 8:14 A.M., revealed the medication refrigerator located in the East Wing nurses' station had an internal temperature of 50 degrees Fahrenheit. Additional observation on 11/25/19 at 11:38 A.M. revealed the internal temperature of the refrigerator to be 53 degrees Fahrenheit. Resident medication found to be stored in the fridge included three Lantus insulin vials, one unopened pen of Victoza insulin, and two unopened boxes containing vials of Risperdal. Review of the daily temperature log revealed no the East Wing medication refrigerator temperature was not documented as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, review of the facility investigation, and review of facility policy on abuse, the facility failed to prevent resident to resident sexual abuse when one resident (#8) was fondled without consent by another resident (#3). This affected one (#8) of four residents reviewed for abuse. The facility census was 81. Findings include: Review of the medical record revealed Resident #8 was admitted on [DATE]. Diagnoses included dementia, bipolar disorder, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/03/19, revealed the resident was severely cognitively impaired. Review of Resident #8's the nurse progress notes dated 10/19/19 at 1:37 P.M. revealed an incident involving another resident fondling the private area of Resident #8. The event was discovered by a staff member who walked in to get Resident #8 up for lunch. An additional progress note dated 10/19/19 at 10:37 P.M. revealed contact was made with the resident's wife to inform her 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, and staff interview, the facility failed to provide written notification of hospital transfer to residents, the residents' representatives, and to the Ombudsman for one (#64) of three residents reviewed for transfer/discharge. The facility census was 81. Findings nclude: Review of Resident #64's medical record revealed an admission date of 02/01/07. Resident #64 was transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnoses included contracture of right knee, hypokalemia, hypertension, paraplegia, abnormal posture, contracture of left shoulder, anemia, hernia, convulsion, chronic sinusitis, anxiety disorder, sepsis, and multiple sclerosis. Review of Resident #64's Minimum Data Set (MDS) assessments revealed a Discharge MDS assessment with return anticipated was completed on 09/03/19. Review of Resident #64's progress notes revealed on 09/03/19 Resident #64 was transferred to the hospital. There was no evidence Resident #64 or her representative 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of policy, the facility failed to provide notification of bed hold policy to one (#64) of three residents reviewed for transfer/discharge. The facility census was 81. Findings include: Review of Resident #64's medical record revealed an admission date of 02/01/07. Resident #64 was transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnoses included contracture of right knee, hypokalemia, hypertension, paraplegia, abnormal posture, contracture of left shoulder, anemia, hernia, convulsion, chronic sinusitis, anxiety disorder, sepsis, and multiple sclerosis. Review of Resident #64's Minimum Data Set (MDS) revealed a Discharge MDS with return anticipated was completed on 09/03/19. An Entry MDS was completed 09/09/19. Review of Resident #64's progress notes revealed on 09/03/19 Resident #64 was transferred to the hospital. There was no evidence Resident #64 or her representative were provided notification of the bed hold policy.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to ensure a pressure reducing cushion was in place as care planned for one (#69) of two residents reviewed for skin breakdown. The facility had seven residents with pressure ulcers. The facility census was 81 residents. Findings include: Review of the medical record revealed Resident #69 admitted to the facility on [DATE]. Diagnoses included muscle wasting and atrophy, lack of coordination, cognitive communication deficit, symbolic dysfunction, hypertension, osteoporosis, anxiety disorder, disorder of kidney and ureter, dysphagia, dysthymic disorder, vascular dementia with behavioral disturbance, bipolar disorder, chronic obstructive pulmonary disease, persistent mood disorder, and schizophrenia. Review of the Minimum Data Set (MDS) assessment, dated 11/05/19, identified the resident as alert with moderate cognitive impairment, required two staff for the completion of activities of daily living, frequently incontinent of bowel…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview and facility policy, the facility failed to implement a care plan intervention for falls. This affected one (#3) of two residents review for falls. The facility census was 81. Findings include: Review of the medical record for Resident #3 revealed the resident was admitted to the facility on [DATE]. Diagnoses included repeated falls, unsteadiness on feet, fracture of the lower end right radius, unspecified lack of coordination, post traumatic stress disorder, mild intellectual disabilities, dementia, generalized anxiety disorder, hypertension, convulsions, major depressive disorder, and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/23/19, revealed the resident was moderately impaired for cognition Review of Resident #3's care plan revealed the resident was at risk for falls due to behaviors, psychotropic medication, and seizures. One intervention included non-skid strips to the right side of bed. Observation on…

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