Sienna Skilled Nursing & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure pharmacy recommendations were addressed by the physician for four (Residents #2, #5, #24, #54) of five residents reviewed for unnecessary medications. The facility census was 79. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 03/23/22 with diagnoses including diabetes mellitus, heart failure, depression and history of falling. Review of the physician ' s orders for Resident #2 revealed she had an order for Prozac 20 milligrams (mg) (an antidepressant) once daily dated 04/04/23 and Trazodone 50 mg (an antidepressant) at bedtime dated 11/24/22. The Trazodone was discontinued on 11/20/24. Review of the pharmacy recommendation titled Note To Attending Physician/Prescribed, dated 08/07/24 revealed the pharmacist recommended to consider a gradual taper of Resident 2 ' s antidepressant Prozac 20 milligrams (mg). The recommendation was left blank and was not signed or dated by the physician. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of facility policy, the facility failed to ensure infection control was maintained during medication administration for Resident #2 and #72, during incontinence care for Resident #61 and when caring for Resident #75 during contact isolation. This affected four residents (#2, #72, #61 and #75) of 24 residents observed for infection control. The facility census was 79. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 03/23/22. Diagnoses included but not limited to pulmonary hypertension and type 2 diabetes mellitus with diabetic chronic kidney disease. Review of the minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 had moderately impaired cognition. Observation on 08/06/25 at 8:39 A.M. with LPN #279 during medication administration revealed she had taken the medicine cup with medications into Resident #2 ' s room to administer. LPN #279 donned gloves without performing hand hygiene first.…

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 Resident #86's personal funds were forwarded to the resident's estate within 30 days. This affected one (Resident #86) of one resident reviewed for personal funds after death. The facility census was 79. Findings include:Review of the medical record for Resident #86 revealed an admission date of 01/09/24 with diagnoses including chronic obstructive pulmonary disease (COPD), dementia and heart disease. Resident #86 passed away at the facility on 06/09/25. Review of the Resident Funds Management Service Trial Balance, dated 08/06/25 revealed Resident #86 had a balance of $613.71.Interview on 08/06/25 at 10:58 A.M. with Business Office Manager (BOM) #273 verified Resident #86's personal funds of $613.71 were not dispersed to her estate within 30 days.

Number of residents sampled: Number of residents cited: Based on observation, staff interview and facility policy review the facility failed to maintain a clean homelike environment in resident's rooms by leaving visibly soiled privacy curtains hanging. This affected five residents (Residents #24, #45, #59, #66 and #78) out of 79 residents reviewed for environment. The facility's census was 79. Findings Include: Observation on 08/06/25 at 1:25 P.M. revealed Resident #24's privacy curtain was soiled with several large dark circular stains visible from the doorway and from the bed, where Resident #24 was lying.Interview on 08/06/25 at 1:30 P.M. with Certified Nursing Assistant (CNA) #235 confirmed the visibly soiled privacy curtain in Resident #24's room. CNA #235 stated housekeeping usually will change out the soiled privacy curtains for clean ones as needed.Observations on 08/06/25 from 2:05 P.M. to 2:25 P.M. revealed visibly soiled privacy curtains in the rooms of Residents #45, #59, #66 and #78. Each privacy curtain was observed with dark stains visible from the doorway.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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide showers per resident preference and shower schedule. This affected one (Resident #27) of four residents reviewed for activities of daily living (ADL's). The facility census was 79. Findings include:Review of the medical record for Resident #27 revealed an admission date of 06/25/25 with diagnoses including heart failure, chronic respiratory failure, diabetes mellitus, history of falling and difficulty walking. Review of the care plan dated 06/25/25 for Resident #27 revealed she required assistance with ADL's related to shortness of breath, weakness and history of falls. Interventions included for staff to assist her as needed daily with hygiene and showering her as per the facility policy weekly. Review of the document Shower Preference, dated 06/25/25, revealed Resident #27 preferred to have three showers weekly in the morning. Review of the document Shower Schedule, undated, revealed Resident #27 was scheduled to have showers on Monday 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 record review,staff interviews, and facility policy review, the facility failed to complete weekly skin assessments for Resident #39 who the facility identified as having surgical wounds upon admission. This affected one Resident (Resident #39) out of one resident reviewed for skin impairment. The facility census was 79.Findings Include: Review of the medical record for Resident #39 revealed admission date of 06/06/25 with diagnoses of aftercare for surgical repair of fracture to right ankle, atrial fibrillation (an irregular heartbeat), diabetes mellitus type two, chronic osteomyelitis, esophageal varices (bleeding of small blood vessels in the esophagus, liver cirrhosis (chronic liver damage), and congestive heart failure. Review of the Comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #39 was cognitively intact and required partial to moderate assistance with personal care and bathing. Resident #39 required a wheelchair or crutches for mobility and was non-weight…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility did not ensure appropriate treatment and equipment were provided to Resident #54 for bilateral hand contractures to prevent further decrease in range of motion. This affected one resident (#54) of one resident reviewed for range of motion/mobility. The facility census was 79. Findings Include:Review of the medical record for Resident #54 revealed admission to facility on 11/22/23 and reentry on 10/09/24. Pertinent diagnoses included bilateral hand contractures and Amyotrophic Lateral Sclerosis (ALS).Review of the physician orders from 11/22/23 to 08/07/25 for Resident #54 revealed there were no orders for bilateral hand splints. Further review revealed an order dated 04/14/2 for referral to a hand specialist for bilateral hand contractures. Review of the Occupational Therapy (OT) Discharge summary dated [DATE] for services 10/16/24 to 11/08/24 revealed Resident #54 was treated for bilateral hand contractures and bilateral hand splints were initiated…

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 interview, record review and review of the facility policy, the facility failed to ensure a thorough investigation was completed for a fall. This affected one (Resident #5) out of one resident reviewed for falls. Facility census was 79. Findings include:Review of the medical record for Resident #5 revealed an admission date of 05/14/20. Diagnoses included chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, morbid obesity, and asthma with exacerbation. Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 had moderately impaired cognition. Activities of daily living (ADL's) included substantial assistance for shower, dressing and hygiene and dependent for toileting assistance. Resident #5 was a Hoyer lift (mechanical lift) for transfers. Review of the physician orders for July 2025 revealed Resident #5 was a Hoyer lift for transfers, bilateral turning bars for bed mobility assist, bed in lowest position, mat to right side of bed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview and review of facility policy, the facility failed to provide respiratory care per physician order for Resident #77. This affected one resident (Resident #77) of three residents reviewed for Respiratory Care. The facility identified 23 additional residents (#8, #22, #2, #20, #36, #92, #88, #1, #58, #18, #27, #33, #28, #6, #5, #63, #21, #14, #54, #55, #70, #78 and #44) as receiving oxygen therapy. The facility census was 79.Findings include: Record review revealed Resident #77 was admitted on [DATE] with diagnoses including Atherosclerotic Heart Disease (AHD), Chronic Obstructive Pulmonary Disease (COPD), Emphysema, Acute Respiratory Failure with Hypoxia, Protein-Calorie Malnutrition, Dysphagia and Weakness. Review of Resident #77 ' s care plan dated 12/08/22 revealed she had alteration in health maintenance related to shortness of breath. Interventions included administering oxygen as ordered and as needed to relieve shortness of breath.Review of Resident #77 ' 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and facility policy review the facility failed to implement non-pharmacological interventions for pain management. This affected one resident (Resident #24) out of two residents reviewed for pain management. The facility census was 79. Findings Include: Review of the medical record for Resident #24 revealed an admission date 02/10/25 with diagnoses including osteomyelitis of vertebra, Multiple Sclerosis (MS), heart failure, sepsis, and depression. Resident #24 had intact cognition and was non-ambulatory. Review of Resident #24's physician orders revealed an order dated 07/18/25 for pain medication of Tramadol 50 milligram (mg) give one tablet by mouth every eight hours as needed for pain and an order dated 07/18/25 for pain medication of Tylenol 325 mg give two tablets (650 mg) by mouth every six hours as needed for pain. There were no non-pharmacological interventions (NPIs) implemented in the orders to be attempted prior to administering pain medications. 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 review of email communication, observation, and interview the facility failed to ensure the facility units for heating and cooling (packaged terminal air conditioner/PTAC) were maintained. This was observed in four rooms (Rooms 101, 215, 303, and 412) out of five heating and cooling units observed. Findings included: Observation on 04/22/25 at 7:42 A.M., with Maintenance Director (MD) of PTAC's in the resident rooms 101, 215, 303, and 412 revealed the filters and vents were covered with dirt, dust, and the filters were in despair (ripped). room [ROOM NUMBER] was missing one of the two filters. The MD reported the PTAC systems were about [AGE] years old, and it was difficult to find parts. The MD confirmed each PTAC had two filter, and the filters were to prevent the coils from getting dirty and dusty. The MD confirmed findings during observation and reported the cleaning of the filters was housekeeping responsibility. Interview on 04/22/25 at 7:57 A.M., with Housekeeping Supervisor # 177 revealed 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 closed medical record review, review of photos, and interview the facility failed to ensure podiatry services and foot care were provided. This affected two residents (#81 and #82) of three closed records reviewed. Findings included: 1. Closed medical record review revealed Resident #82 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, end stage renal disease, restless leg syndrome, and anemia. Review of Resident #82's ancillary service consent dated 01/16/24 revealed the resident's son had signed a consent for podiatry services. Review of Resident #82's closed paper and electronic medical record revealed no evidence the resident had been seen by podiatry. Review of photos of Resident #82's feet (provided by the resident's family) revealed the resident's left great, second, third, and forth toenails were long and extended out past the end of the toe. There was old nail polish on the toenails that extended to the end of the toe. There was dry, thick scaly skin noted 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, review of fall investigation, observation, and interview the facility failed to ensure fall interventions were in-place per the resident's plan of care. This affected one (Resident #66) of three records reviewed for falls. Findings included: Medical record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including history of falls, cerebrovascular disease, diabetes, seizures, and absent of right great toe. Review of Resident #66's census sheet revealed Resident #66 was moved to room [ROOM NUMBER] on 03/20/25. Review of the fall investigations dated 12/2024 to 04/2025 with the Director of Nursing (DON) revealed Resident #66 had sustained three falls. On 12/20/24 the resident had fallen out of bed because she felt like she had to get out of bed. The new intervention was to hang a sign to ask for help and to use call light. On 12/27/24 the resident had fallen out of bed reaching for her phone. The new intervention was to move items within reach. 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 closed medical record review, review of drug information, and interview the facility failed to ensure a resident's drug regimen was free from unnecessary medication when the resident was administered morphine not in accordance with hospice orders. This affected one resident (#81) of three resident records reviewed for death. Findings included: Based on closed medical record revealed Resident #81 was admitted to the facility on [DATE] and expired on [DATE]. Diagnoses included tracheostomy, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, type 2 diabetes, history of malignant neoplasm of tongue and breast, malignant neoplasm of tonsils, disease of intestine, neuromuscular dysfunction of bladder (urinary catheter), gastrostomy, heart failure, gastro-esophageal reflux disease, constipation, depression, adjustment disorder with depressed mood, abdominal aortic aneurysm, anxiety, and anemia. Review of Resident #81's orders dated 01/2025 revealed Lorazepam…

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, taste tray, food temperature, policy review, and interview, the facility failed to prepare food to enhance texture and serve at an appetizing temperature. This affected all 83 of 83 residents in the facility. The facility census was 83. Findings include: Observation of the lunch tray line took place on 03/20/25 at 11:41 A.M. [NAME] #94 was wearing gloves and had hair and beard coverings. When asked if temperatures were obtained he stated he already took the temperatures and motioned toward a binder. Observation revealed the lids were off the chaffing dishes on the steam table. Dietary #94 plated the dining room trays. They were sent to the dining room in an open to air cart. Interview on 03/20/25 at 12:10 P.M. until 12:20 P.M. of anonymous residents dining in the dining room revealed: - The food is hot in the dining room, not for the hall trays (reported by three residents). - They repeat the same vegetables a lot (reported by four residents). - There serve carrots too often. - It is hard…

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 food was stored, prepared and held under sanitary conditions. This affected all 83 of 83 the residents in the facility The facility census was 83. Findings include: Observation of the kitchen on 03/20/25 at 11:29 A.M. revealed the shelf above the cooking surface of the cooktop and top of the steamer were dirty with brown debris, dusty and a greasy, sticky film. The fronts of the silver refrigerators, freezers, ovens, oven handles were sticky, smeared with dried food and fingerprinted. The Ansel system above the cooktop was dusty. The linoleum type squares on the floor were soiled, dull, dirty with stains, yellowed, and cracked. There was food debris around the appliances on the floor. The steam table had a thick amount of hard whitish lyme build up. There were chaffing tins turned upside down on top of the lyme build up. The wood block holding the knife set was covered with dust around the slits the knives slide into. Two of the metal prep tables had an electric box in the bottom shelf. Both looked damaged with darken…

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 clearly identify rooms of residents on isolation precautions to prevent the spread of infection. This had the potential to affect all 86 residents. Findings include: Observations during the tour on 02/20/24 between 9:15 A.M. and 9:45 A.M. revealed there was an isolation cart in the hallway past Resident #69's room with a sign posted above the isolation cart to stop and see the nurse. During an interview with State Tested Nursing Assistant (STNA) #140, at the time of the observation, verified the sign was posted beyond the door and anybody going straight to the room would not observe the sign alerting them to stop and see the nurse. An isolation cart was also observed past Resident #26 and Resident #44's room door with a sign posted above it to see the nurse before entering. At 9:30 A.M., STNA #150 verified the signage for Resident #26 and #44's room was past the entrance to the room and if a visitor did not understand the purpose of the isolation cart and went straight to the room, they would not know to see…

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 interviews, and facility policy review, the facility failed to ensure staff members were properly washing their hands in the kitchen to prevent contamination. This had the potential to affect all 81 residents who received food from the kitchen. The facility identified all residents as receiving food from the kitchen. The facility census was 81. Findings include: Observation on 11/29/23 from 11:40 A.M. to 12:40 P.M. with Dietary Manager #122 of the lunch tray line revealed the following concerns: a. At 12:01 P.M. Dietary Aide #168 was observed taking a food cart to the main dining room and came back into the kitchen at 12:02 P.M. and immediately grabbed another cart without washing her hands and proceeded to the tray line where she placed drinks on tray, placed dome lid on plate, and placing trays in cart. b. At 12:07 P.M. Dietary Aide #168 was observed taking a food cart out of the kitchen and came back into the kitchen at 12:09 P.M. and immediately grabbed another cart without washing her hands and proceeded to the tray line where she placed drinks on…

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

Based on observation, staff interview, and review of facility spreadsheets and recipes, the facility failed to ensure the recipe for puree chicken and dumplings was followed and the correct portion size of chicken and dumplings was served to those residents on a regular and puree diet. This had the potential to affect 60 residents who were on either a regular or puree consistency diet. The facility identified 21 residents as being on a mechanical soft diet, and there were no residents who didn't receive food from the kitchen. The facility census was 81. Findings include: Review of the facility recipe for pureed chicken and dumplings revealed for ten servings, the chicken and dumpling recipe should be prepared as directed; ten eight-ounce ladles of prepared chicken and dumplings should be added to the food processor and processed until fine in consistency. Two and one half teaspoons of low sodium chicken base should be gradually added to the mixture (All liquid may not be required). Observation and interview on 11/30/23 at 10:47 A.M. with Dietary [NAME] (DC) #160 revealed she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to adequately inform/specify in writing, services that would be discontinued. This affected three residents (#22, #234, and #235) of three residents reviewed for beneficiary notices. The census was 81. Findings Include: 1. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including respiratory failure, chronic kidney disease, pneumonia, and muscle weakness. Review of Resident #22's Notice of Medicare Non-Coverage (NOMNC) form, dated 11/17/23, revealed services would discontinue on 11/20/23. The NOMNC form did not specify which services would be discontinued. The form stated, the effective date coverage of your current skilled nursing facility will end: 11/20/23. During interview on 11/30/23 at 11:10 A.M., Social Services Director (SSD) #165 confirmed that the NOMNC form for Resident #22 did not specify which type of skilled services would be ending and only indicated the ending date 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 record review, staff interview and facility policy review, the facility failed to send a written transfer/discharge notice for Resident #57 and #76 reviewed for hospitalization and failed to notify the ombudsman of discharge for Resident #26, #57 and #76. This affected three residents (#26, #57, and #76) of three residents reviewed for transfer/discharges. The facility census was 81. Findings include: 1. Review of medical record review for Resident #76 revealed when the resident was sent to the hospital on [DATE] the reason for the transfer/discharge was reviewed with the Emergency Contact Number One for the resident and when the resident was sent to the hospital on [DATE] the reason was reviewed with Resident #76. There was no indication that a written transfer/discharge notice had been sent to the resident/resident representative for the 10/18/23 and 10/26/23 hospitalizations as required. Interview on 11/29/23 at 2:31 P.M. with Licensed Social Worker#165 revealed she verbally went over 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 record review, staff interview, and facility policy review, the facility failed to ensure written bed hold notices were provided for Resident #57 and Resident #76 at the time of transfer. This affected two residents (#57 and #76) of three residents reviewed for hospitalizations. The facility census was 81. Findings include: 1. Review of medical record for Resident #76 revealed the resident was sent to the hospital on [DATE] and again on 10/26/23. Review of the facility documentation for the bed hold notices revealed there was no bed hold notification sent to Resident #76 or the Resident Representative when the resident was sent to the hospital on [DATE] and 10/26/23. Interview on 11/29/23 at 2:51 P.M. with Business Office Manager #176 revealed she only sent bed hold notices to the residents sent to the hospital who were under Medicaid payor source. Since Resident #76 was under a managed care payor source, she had not sent bed hold notices for when Resident #76 was sent out to the hospital on [DATE] 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 and staff interview, the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASARR) documents were accurate to reflect resident current conditions and diagnoses. This affected three residents (#52, #54, and #66) of four residents reviewed for PASARR documents. The census was 81. Findings Include: 1. Medical record review revealed Resident #52 was admitted to the facility on [DATE] with diagnoses including heart failure, emphysema, protein calorie malnutrition, psychotic disorder with hallucinations, depressive disorder, and anxiety disorder. Review of Resident #52's PASARR document, dated 10/29/21, revealed under Section E, there were no diagnoses listed. During interview on 11/30/23 at 8:42 A.M., Social Services Director (SSD) #165 confirmed the resident's PASARR document did not indicate any mood disorders and should have been updated with the diagnoses of psychotic disorder with hallucinations, depressive disorder, and anxiety disorder. 2.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy review, and interview, the facility failed to ensure residents were free from accident hazards and received adequate assistance to prevent accidents. This affected two residents (#29 and #58) of five residents reviewed for accidents. The facility census was 81. Findings include: 1. Review of the medical record for Resident #29 revealed an admission date of 02/09/21 with diagnoses including chronic obstructive pulmonary disease, peripheral vascular disease, diabetes mellitus, dementia, and osteoarthritis. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #29 was dependent for bed to chair and chair to bed transfers and required the use of a Hoyer lift (manual hydraulic lift). Review of the care plan dated 10/28/23 revealed Resident #29 was totally dependent for completion of activities of daily living (ADLs) and unable to participate in any aspect of transfers. The care plan further revealed he required the use of a Hoyer…

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

Based on medical record review and staff interview the facility failed to ensure staff members documented resident care provided appropriately. This affected one resident (#74) of one resident reviewed for nephrostomy tubes. The facility census was 81. Findings include: Review of Resident #74's medical record revealed an admission date of 11/13/23 with diagnoses that included cervical cancer with metastasis to the liver and hydronephrosis with the use of bilateral nephrostomy tubes (tubing inserted through the abdomen into the kidney to drain urine). Physician's orders on 11/14/23 revealed orders for nephrostomy tube care to be completed every shift. Additional orders on 11/16/23 indicated to flush nephrostomy tubing every three days. Review of the Treatment Administration Record (TAR) on 11/28/23 at 1:50 P.M. revealed the resident's bilateral nephrostomy tubes were already flush for 11/28/23 dayshift by Registered Nurse (RN) #121. On 11/28/23 at 1:55 P.M., interview with RN #121 revealed she had documented on the TAR she had completed the bilateral nephrostomy tube flush, but had…

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 provide a skilled nursing facility advanced beneficiary notice form to Resident #19 and #40 when they were cut from skilled nursing care and remained in the building. The facility also failed to ensure Resident #177 received notification of medicare non-coverage prior to being cut from skilled therapy services and discharged to the community. This affected three residents (Resident #19, #40 and #177) of three residents reviewed for beneficiary protection notification (cut letters). Findings include: 1. Review of Resident #19's medical record revealed an admission date of 11/13/19 with diagnoses including heart disease, malnutrition and chronic kidney disease. Review of the physician orders revealed the resident received skilled nursing services from 12/10/21 through 01/07/22. Further record review revealed the facility provided the resident a notice of medicare non-coverage (NOMNC) on 01/05/22 and there was no appeal for the decision to end the resident's services. The resident remained in the facility for long term care.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Resident #40 received an accurate Preadmission Screening and Resident Review (PASRR) screen upon admission to the facility. This affected one resident (Resident #40) out of one resident reviewed for PASRR to the facility. Findings include: Review of Resident #40's medical record revealed an admission date of 09/21/21 with diagnose including anxiety disorder and schizoaffective disorder bipolar type. Review of Resident #40's quarterly Minimum Data Set assessment dated [DATE], revealed the resident was cognitively intact. Review of Resident #40's PASRR completed by the facility, on the day the resident was admitted to the facility, revealed the facility marked the resident did not have a diagnosis of a mental disorder. Review Resident #40's February 2022 physician orders revealed the resident had been receiving Abilify 5 milligrams (antipsychotic) by mouth daily, since her admission, for schizoaffective disorder bipolar type. Interview on 02/23/22…

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

Based on observation, interview, and record review, the facility failed to ensure therapy recommendations for a functional maintenance ambulation program and a Range of Motion (ROM) restorative nursing program were implemented for Resident #39. This affected one resident (Resident #39) of two residents reviewed for therapy. Findings include: Review of the medical record for Resident #39 revealed an admission date of 03/01/21 with diagnoses including hypertensive heart, diabetes mellitus, and primary generalized osteoarthritis. Review of the 06/03/21 Occupational Therapy (OT) discharge summary revealed Resident #39 was discharged from OT on 06/03/21 with a restorative program for bilateral hand ROM exercises. It stated restorative nursing program education was completed with the facility. Review of the 11/16/21 Physical Therapy (PT) discharge summary revealed that the resident had recommendations for functional maintenance ambulation program to ambulate with a front wheeled walker with contact guard assist. Review of the 01/13/22 annual Minimum Data Set assessment, revealed Resident…

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, policy review, and staff interview, the facility failed to ensure appropriate indication for use of an indwelling urinary catheter and catheter care was documented as completed. This affected one (Resident #15) of two residents reviewed for indwelling urinary catheters. Findings include: Review of Resident #15's medical record revealed an admission date of 12/08/20 with diagnoses including neuromuscular dysfunction of bladder and cerebrovascular accident. Further review of Resident #15's medical record found no evidence of any urology consultation which indicated a diagnosis of neuromuscular dysfunction of the bladder. Review of Resident #15's indwelling urinary (Foley) catheter assessment completed on 11/12/21 revealed a trial removal was completed with a post void urinary residual of over 200 milliliters (ml) of urine. Review of Resident #15's progress notes found no evidence of a trial removal of the indwelling urinary catheter or evidence of a post void residual of over 200 ml. Review of Resident #15's care plans revealed a current care plan in…

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.