Embassy Of Willard

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review of the facility's policy, the facility failed to ensure comprehensive care plans were developed and the facility failed to implement fall interventions in the resident's care plan. This affected three (#2, #14 and #25) of 16 residents reviewed for care plans. The facility census was 37. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 06/28/19 and a readmission date of 11/07/21. Diagnoses included infection pressure ulcer of sacral (bony area at the base of the spine) region, cellulitis (bacterial skin infection) of left lower limb, end stage renal disease, type II diabetes mellitus, hypotension, and morbid (severe) obesity due to excess calories. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/16/21, revealed Resident #2 was cognitively intact and had one stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present…

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

Based on medical record review, resident and staff interview, and review of the facility's policy, the facility failed to ensure residents received vision services. This affected one (#4) of one resident reviewed for vision services. The facility census was 37. Findings include: Review of the medical record for Resident #4 revealed an admission date of 05/14/21 and a readmission date of 09/14/21. Diagnoses included type II diabetes mellitus with diabetic polyneuropathy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/14/21, revealed Resident #4 was cognitively intact and did not wear corrective lenses. Interview on 11/07/21 at 9:49 A.M. with Resident #4 revealed he was unaware if vision services were available at the facility. Resident #4 stated he wore eyeglasses but had not had any since his admission because he had broken them and was not able to get out to see his eye doctor. Interview on 11/09/21 at 12:11 P.M. with Social Services Director (SSD) #246 verified Resident #4 had not been seen by the eye doctor since his admission to the facility. SSD #246 stated…

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

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure the resident's fall interventions were implemented to reduce the risk of injury. This affected one (#5) of one resident reviewed for falls. The facility census was 37. Findings include: Review of the medical record for Resident #5 revealed an admission date of 07/09/21. Diagnoses included type II diabetes mellitus with diabetic chronic kidney disease, cerebral infarction (stroke) without residual deficits, altered mental status, chronic kidney disease, stage III, vascular dementia without behavioral disturbance, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/14/21, revealed Resident #5 was severely cognitively impaired and required extensive two person assist with bed mobility, transfers, dressing, toilet use, and personal hygiene. In addition, Resident #5 had two or more falls since admission. Review of the plan of care, initiated 07/20/21, revealed Resident #5 was at risk for falls and potential injury.…

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 review of the facility's policy, the facility failed to ensure a physician order was obtained for oxygen administration and failed to date oxygen tubing per physician order. This affected one (#25) of one resident reviewed for oxygen administration. The facility identified eight residents receiving oxygen therapy. The facility census was 37. Findings include: Review of the medical record for Resident #25 revealed an admission date of 08/11/21. Diagnoses included anxiety disorder and chronic obstructive pulmonary disease (COPD). Review of the admission Minimum Data Set (MDS) assessment, dated 08/24/21, revealed Resident #25 was moderately cognitively impaired and received oxygen therapy. Review of the physician's orders for Resident #25, dated 08/18/21, revealed an order to change and date oxygen tubing every Wednesday on night shift. There was no order for oxygen administration. Observation on 11/07/21 at 10:10 A.M. of Resident #25's oxygen tubing revealed the tubing was not labeled with the date it was changed.…

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 the facility's policy, the facility failed to ensure a resident with dementia was adequately assessed and an individualized plan of care was developed to meet the resident's needs. This affected one (Resident #5) of three residents reviewed for dementia care. The facility census was 37. Findings include: Review of the medical record for Resident #5 revealed an admission date of 07/09/21. Diagnoses included altered mental status and vascular dementia without behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/14/21, revealed Resident #5 was severely cognitively impaired and had a diagnosis of non-Alzheimer's dementia. Review of the plan of care initiated on 07/20/21 revealed no goals or interventions related to dementia care were identified for Resident #5. Interview on 11/09/21 at 10:14 A.M. with the Director of Nursing (DON) revealed Resident #5 had significant behavior concerns upon admission and was admitted to the facility after another facility refused to accept him back due…

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 the facility's policy, the facility failed to ensure resident rooms were maintained in good repair and resident room equipment was in operable condition. This affected two residents (#4 and #25) of two residents reviewed for physical environment. The facility census was 37. Findings include: 1. Observation on 11/07/21 at 9:35 A.M. of Resident #4's room revealed the corner of the wall near the sink and the bathroom door was damaged, exposing cracked and crumbling drywall and the baseboard was broken and pulled away from the wall. On the wall to the right of the bathroom door was an area, approximately two inches above the baseboard, approximately seven inches in length of exposed drywall. Observation of an area to the right of the window revealed seven smaller areas of exposed drywall. In addition, the left closet door handle was broken in half, exposing sharp metal edges. Interview with Resident #4 at the time of the observation revealed the walls had been damaged for some time. Resident #4 stated he believed 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 and interview, the facility failed to provide information regarding contact information for State Survey Agency and State Long term Care Ombudsman in a written form the resident could understand. This had the potential to affect 45 residents residing in the facility. Findings include: Observation of the posting of the State Survey Agency and State Long Term Care Ombudsman Agency contact information on 05/20/19 at 8:30 A.M., 1:20 P.M., 05/21/19 at 10:30 A.M. and 05/23/19 at 3:10 P.M. revealed the postings were in a glass case across from the nurse's station near the conference room. The posting was high in the upper left-hand corner of the glass case. The State Agency's information was written in a font so small it was barely readable to a person or normal height, but a resident attempting to read it from a wheelchair would be unable to read and understand the information. Interview with Resident Council President #21 on 05/21/19 at 12;30 P.M. revealed he had concerns because he could not read and understand the contact information posted in the glass case from…

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 interview, the facility failed to post the survey results for the past three years in a location that was readily accessible. This had the potential to affect 45 residents residing in the facility. Findings include: Tour of the facility on 05/20/19 at 8:30 A.M. and 05/21/19 at 3:30 P.M. revealed the survey results for annual and complaint surveys within the last three years were not available for review by residents, visitors or staff. The observation was verified with the DON on 05/21/19 at 4:10 P.M. Interview with Resident Council President #21 on 05/21/19 at 12;30 P.M. revealed he could not find the survey results to review. A Group Meeting was held on 05/21/19 at 1:45 P.M. Resident #7 Resident # 8, Resident #16 and Resident #38 each of the residents voiced they did not know where the survey results for the past three years were located and did not know where to find them. Interview with the Director of Nursing (DON) on 05/21/19 at 5:30 P.M. verified she checked all the facility nurses' station and both lobby on the skilled and Assisted Living Areas 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 and interview, the facility failed to ensure adequate supplies of snack were available for residents. This had the potential to affect all 45 residents residing in the facility. Findings include: Observation of the snack refrigerator on 05/20/19 at 9:00 A.M. revealed the refrigerator contained 14 fruits cups from the previous night, 05/19/19. Interview with Resident Council President #21 on 05/21/19 at 12;30 P.M. revealed the council had concerns staff did not pass snacks at night on a consistent basis or there was an adequate amount/variety of snacks to choose from. Resident Council President #21 stated staff started at one end of the hall and when staff came to his room he chooses from packs of crackers. Resident #21 stated he choice would be a sandwich or something different than cheese or peanut butter crackers. A Group Meeting was held on 05/21/19 at 1:45 P.M. Resident #7 Resident # 8, Resident #16 and Resident #38 attended the meeting and expressed concerns they did not get snacks consistently or had a choice of snacks. Each resident stated they would…

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, interview and policy review, the facility failed to ensure a safe and sanitary kitchen environment. This affected all 45 residents receiving meals from the kitchen. The facility census was 45 residents. Findings include: 1. Observation and tour of the kitchen on 05/20/19 from 8:58 A.M. to 9:30 A.M. with Dietary Manager (DM) #2 revealed in the freezer there was an ice-covered plastic bag containing hot dogs that appeared to be freezer-burnt and in the reach-in cooler there was a bag of shredded cheddar cheese not sealed. At 9:06 A.M. observation of the interior of the ice machine revealed a pink-brown substance on the plastic lip that was palpable to touch and removable when a finger was swiped across it. At 9:08 A.M., observation of the dish machine and three compartment sink area revealed no test strips available to test the sanitizer and no evidence of logs to suggest monitoring of the sanitizer's strength and efficiency. At 9:16 A.M. while on tour of nourishment areas, 14 undated cups of fruit were observed on the assisted living (AL) wing's refrigerator. DM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure hair was appropriately contained during meal service and failed to implement a facility-wide Legionella plan. This had the potential to affect all 45 residents residing in the facility. Findings include: 1. Review of the facility's Legionella risk assessment dated [DATE] revealed recommendations including maintaining a documented Legionella management program and conducting an annual risk assessment. No further monitoring or testing in regard to Legionella was available for review. An interview with Maintenance Director (MD) #37 on 05/24/19 at 12:47 P.M. verified the facility's Legionella plan was not fully implemented. Review of the facility's Legionella testing policy, dated July 2018, revealed the maintenance director or designee was to perform a visual inspection of all water sources in the facility on a quarterly basis. Inspections were to be performed and documented as follows: flushing of little used outlets was to be done…

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 the surety bond was sufficient to cover the total amount of all the resident's personal funds held in the facility account. This had the potential to affect 24 residents with personal funds managed by the facility. The facility census was 45. Findings include: Record review of the facility's surety bond revealed coverage of $10,000.00. Review of the trust account balance dated 05/24/19 revealed a balance of $10,662.02. Interview with on 05/24/19 at 9:20 A.M. with Business Manager #64 verified the resident funds exceed the surety bond.

Based on observation, menu spreadsheet review and interview, the facility failed to ensure dietary staff followed spreadsheets as written. This affected four residents (Resident #5, Resident #14, Resident #19 and Resident #31) of four residents identified by the facility as receiving mechanical soft diets. The facility census was 45 residents. Findings include: Review of the menu spreadsheet for Week 1, Day 3 corresponding to 05/21/19 revealed a lunch meal consisting of maple glazed fish, rosemary roasted potatoes, asparagus, fresh baked roll, chocolate satin pound cake, margarine and coffee or tea. Residents receiving a mechanical soft diet were to have a #6 scoop of ground fish with two ounces of gravy and asparagus had an x next to it on the spreadsheet. No alternate vegetables were listed. Observation of lunch meal service on 05/21/19 starting at 12:18 P.M. revealed [NAME] #41 collecting food temperatures with [NAME] #24 assisting. Portions for the food to be served were as follows: one filet glazed fish; one #8 scoop mashed potatoes; one #4 scoop baby carrots; one #4 spoodle…

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, policy review, menu spreadsheet review and interview, the facility failed to ensure dietary staff provided appropriate mechanically altered food. This affected four residents (Resident #5, Resident #14, Resident #19 and Resident #31) of four residents identified by the facility as receiving mechanical soft diets. The facility census was 45 residents. Findings include: Review of the menu spreadsheet for Week 1, Day 3 corresponding to 05/21/19 revealed a lunch meal consisting of maple glazed fish, rosemary roasted potatoes, asparagus, fresh baked roll, chocolate satin pound cake, margarine and coffee or tea. Residents receiving a mechanical soft diet were to have a #6 scoop of ground fish with two ounces of gravy and asparagus had an x next to it on the spreadsheet. No alternate vegetables were listed. Observation of lunch meal service on 05/21/19 starting at 12:18 P.M. revealed [NAME] #41 collecting food temperatures with [NAME] #24 assisting. Portions for the food to be served were as follows: one filet glazed fish; one #8 scoop mashed potatoes; one #4 scoop…

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 interview, the facility failed to ensure residents were dressed appropriately to maintain their dignity. This affected one (Resident #40) of four residents reviewed for dignity. The facility census was 45. Findings include: Review of Resident #40's medical record revealed an admission date of 04/30/18 with diagnoses including weakness, mild cognitive impairment, major depressive disorder anxiety and weakness. An annual minimum data set (MDS) assessment dated [DATE] indicated the resident had mild cognitive impairment and needed the extensive supervision of one person for dressing. Observation on 05/20/19 at 12:18 P.M. revealed Resident #40 seated on her bed. Resident #40 was wearing white socks that each had her initials largely written on each sock in black permanent marker. The initials were roughly two inches by two inches in size. Observation on 05/20/19 at 3:43 P.M. revealed Resident #40 seated next to two other residents. While she had shoes on at this time, the initials were still…

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

Based on record review and interview, the facility failed to ensure a notice was given to residents when their account balance reached within $200 of the resource limit. This affected one (Resident #5) of 24 residents. The census was 45. Findings include: Review of the resident fund accounts on 05/21/19 revealed Resident #5 was receiving Medicaid benefits. The account revealed a balance of $2,004.04 on 03/31/18 and on 04/30/19 a balance $2,064.44. A notification letter was issued to the Power of Attorney on 05/08/19 revealing an account balance of $2,064.44. Interview on 05/21/19 at 5:12 P.M. with Business Office Manager #64 revealed the spend down notice was not provided when the resident's balance came within $200 of Social Security resource limit.

Based on record review and staff interview, the facility failed to ensure appropriate beneficiary notification for residents discharged from Part A services. This affected two residents (Resident #10 and Resident # 92) of three reviewed for beneficiary notices. The census was 45. Finding include: 1. Review of Resident #10's beneficiary notice revealed a discharged notice from Part A services with remaining benefit days left. The resident remained living in the facility. A Notice of Medicare Non-Coverage (NOMNC) was signed on 02/21/19 for services ending on 02/25/19. There was no evidence Resident #10 received the Skilled Nursing Advanced Beneficiary Notice (SNF-ABN). 2. Review of Resident #92's beneficiary notice revealed a discharge notice from Part A services with remaining benefit days left. The resident remained in the facility. A NOMNC was signed on 05/06/19 for services ending 05/08/19. There was no evidence Resident #92 received the SNF-ABN. Interview on 05/21/19 04:42 P.M. with Medical Records Clerk #61 revealed she only provided residents with Part A coverage a Notice 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 observation and interview, the facility failed to provide a safe, clean comfortable environment. This affected two rooms in the facility. The census was 45. Finding include: Observation on 05/24/19 at 2:49 P.M. with the Maintenance Direct #37 and Maintenance Assistant #48 revealed the door frame on room [ROOM NUMBER] was broken off on the right side from the door handle down to the floor, leaving a jagged wooden edge exposed near the door handle. The door to room [ROOM NUMBER] had a large scrape about three inches wide running straight across the lower section. The brown finish was scraped off exposing a white base coat. The tray table in room [ROOM NUMBER] had a half inch thick stiff rubber facing that wrapped along the side of tray table. The rubber tubing was broken and was hanging of the side of the table leaving a rough edge. The night stand had a facing along the right side of the dresser that had pulled away and was sticking out. Interview on 05/24/19 at 3:10 P.M. with Maintenance Director #37…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement care plans for which involved pressure areas, bowel care, dementia care, hydration and dialysis services. This affected five (Residents #10, #17, #19, #29 and #38) of 13 residents reviewed for the development and implementation of care plans. The facility census was 45 . Findings include: 1. Review of Resident #29's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including insomnia, transient ischemic attack and cerebral infarction without residual deficits, disorientation, Type II diabetes, depression, Dementia in other diseases classified elsewhere without behavioral disturbance, and anxiety. Review of Resident #29's significant change of condition assessment dated [DATE] revealed the resident was an extensive assist of one person for bed mobility, transfers and toilet use. Review of Resident #29's nursing notes from 05/01/19 to 05/23/19 revealed no evidence 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 observation, interview and record review, the facility failed to ensure revisions were made to plans of care for hydration and supervision during meals. This affected two (Resident #10 and Resident #38) of 13 residents reviewed for care plan revision to ensure coordination of care. The facility census was 45. Findings include: 1. Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of dysphagia, urinary tract infections, abnormal posture, muscle weakness and Parkinson's Disease. Review of Resident #38's plan of care revealed the resident had an activities of daily living (ADL) Self Care Performance Deficit. Interventions included for eating, that the resident was able to feed self after set up. Observation of Resident #38 at the lunch meal on 05/20/19 at 12:43 P.M. revealed his meal was placed in front of him by State Tested Nursing Assistant (STNA) #17. STNA #17 removed the lid to the plate and did not offer to cut up the chicken and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident was provided assistance with dining. This affected one (Resident #38) of five residents observed for assistance during meals. The facility census was 45. Findings include: Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of dysphagia, urinary tract infections, abnormal posture, muscle weakness and Parkinson's Disease. Review of Resident #38's plan of care revealed the resident had an activities of daily living (ADL) Self Care Performance Deficit. Interventions included for eating, that the resident was able to feed self after set up Observation of Resident #38 at the lunch meal on 05/20/19 at 12:43 P.M. revealed his meal was placed in front of him by State Tested Nursing Assistant (STNA) #17. STNA #17 removed the lid to the plate and did not offer to cut up the chicken and dumplings, which was in a small high rim dessert bowl. Resident #38 picked up the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation. interview and record review, the facility failed to ensure a resident received appropriate pressure ulcer care to prevent the development of an avoidable Stage II pressure ulcer (characterized by partial-thickness skin loss into but no deeper than the dermis) from a pressure relieving cushion on his adaptive wheelchair. This affected one (Resident #29) of two residents observed with a pressure ulcer. The facility census was 45. Findings include: Review of Resident #29's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of insomnia, transient ischemic attack and cerebral infarction without residual deficits, disorientation, type II diabetes, depression, dementia in other diseases classified elsewhere without behavioral disturbance, and anxiety. Review of Resident #29's significant change of condition Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was an extensive assist of one person for bed mobility, transfers and toilet use.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure one resident's (Resident #17) facility owned wheelchair was an appropriate size for safe transport to the dialysis center Additionally, the facility failed to ensure Resident #10 wore a smoking apron as assessed to need while smoking. This affected two of three residents reviewed for accidents. The facility census was 45. Findings include: 1. Review of Resident #17's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including diabetes type II, hypertension, anemia, gout, chronic kidney disease, Chronic Obstructive Pulmonary Disease (COPD), history of cerebral vascular accident (CVA), and paroxysmal atrial fibrillation. Resident #17 was transported to dialysis three times a week on Monday, Wednesday and Friday by the facility's transport van. Review of Resident #17's plan of care dated 08/16/18 revealed the resident had limited physical mobility. Interventions included an electric wheelchair for mobility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure nutritional oversight and monitoring of high risk residents. This affected two (Resident #10 and Resident #17) of three residents reviewed for nutrition. Findings include: 1. Review of Resident #10's medical record revealed an admission date of 04/20/17 and diagnoses including diabetes, end stage renal disease (ESRD), peripheral vascular disease and hypertension (high blood pressure). A minimum data set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact, needed supervision with eating, received a therapeutic diet and was on dialysis services. Review of May 2019 physician's orders revealed Resident #10 attended dialysis on Mondays, Wednesdays and Fridays. Resident #10's diet order was listed as a no added salt, potassium restricted diet with large meat portions and diet desserts/condiments. Resident #10's supplement orders were listed as a 1.5 liter fluid restriction per day and a no added sugar supplement drink twice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide individualized dementia care for a resident. This affected one (Resident #29) of two residents reviewed for dementia care. The facility census was 45. Findings include: Review of Resident #29's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of insomnia, transient ischemic attack, cerebral infarction without residual deficits, disorientation, type II diabetes, and dementia in other disease is classified elsewhere without behavioral disturbance, and anxiety. Review of Resident #29's significant change of condition Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was an extensive assist of one person for bed mobility, transfers and toilet use. Review of Resident #29's plan of care dated 04/13/19 revealed the resident had chronic/progressive impaired thought processes characterized by: deficit in memory, judgement, decision making related to Anxiety and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to accurately document a transfer to the emergency room. This affect one (Resident #28) of one reviewed for hospitalizations. The census was 45. Findings include: Record review for Resident #28 revealed an admission date of 05/14/19 with diagnoses including anxiety, bipolar disorder and right shoulder pain. The quarterly Minimum Data (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact and had pain. Review of hospital Discharge summary dated [DATE] revealed resident came to emergency room for concerns of a possible urinary tact infection and the physician at the facility would not repeat the labs. Results for the urinalysis were negative indicating no infection. Discharge instructions recommended following up with primary care physician. Review of progress note dated 12/21/19 revealed resident returned from the emergency room and had urinalysis and laboratory blood work. The medical record contained no documentation or information 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.