Arbors At Woodsfield

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure interventions to prevent pressure ulcers were in place per orders. This affected one resident (#39) of two residents reviewed for pressure ulcers. The facility census was 55. Findings included: Record review revealed Resident #39 admitted to the facility on [DATE] with diagnoses including heart failure, type II diabetes, chronic obstructive pulmonary disease, atrial fibrillation, and dementia. Review of orders revealed Resident #39 had orders in place for an alternating air mattress (01/08/24) and zero gravity boots to bilateral feet while in bed (starting on 02/01/23 and discontinued on 04/08/24). Review of care plan dated 12/31/23 revealed Resident #39 is at risk for impaired skin integrity related to confined to a bed all or most of the time, dementia, diabetes, incontinent of bladder, incontinent of bowel, needs assistance with activities of daily living, palliative care, peripheral vascular disease diagnosis, and skin break…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interview, the facility failed to implement fall prevention interventions for a resident with a history of falls. This affected one resident (#27) of three residents reviewed for accidents. Findings include: Review of Resident #27's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a stroke with hemiplegia (paralysis) and hemiparesis (weakness) affecting her left non-dominant side, unspecified convulsions, Alzheimer's disease, vascular dementia, severe intellectual disabilities, muscle weakness, unsteadiness on her feet, and difficulty walking. Review of Resident #27's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was severely impaired. She had a functional limitation in her range of motion on one side of her upper and lower extremity. She had one fall since the prior assessment that was without injury. Review of Resident #27's plan of care revealed she had a care plan in place for…

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

Based on observation and interview, the facility failed to prepare pureed foods to meet the needs of residents requiring a pureed diet. This affected two residents (#5 and #19) of two residents who received a pureed diet. The facility census was 55. Findings included: Observation on 04/10/24 at 9:15 A.M. revealed [NAME] #420 washed her hands prior to beginning pureed foods. The first pureed food item to be prepared was a vegetable salad with Italian dressing. [NAME] #420 began by adding 12 ounces of vegetables with dressing already mixed in to the Robocoup machine. [NAME] #420 ran the machine for approximately 30 seconds, then paused to scrape the sides of the machine before continuing to blend again. She repeated this process 10 times. [NAME] #420 stated the food was not getting to the appropriate pureed texture and asked Dietary Manager (DM) #430 what to do; DM #430 stated she did not know what to do. [NAME] #420 stopped pureeing the mixture at 9:27 A.M. to taste, but said it was not ready to serve yet. She started to puree the mixture again for approximately 30 seconds, then…

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

Based on observations, record review, review of a food preference form, and interview, the facility failed to ensure a resident received food according to assessed food preferences/dislikes. This affected one resident (#58) of 24 residents reviewed for food/nutrition. Findings include: During an interview on 04/08/24 at 11:50 A.M., Resident #58 reported she did not like the facility's scrambled eggs so the facility generally prepared and served her fried eggs. Review of Resident #58's medical record revealed diagnoses including morbid obesity, anxiety disorder and depressive disorder. A care plan initiated 03/22/24 indicated Resident #58 was at risk for altered nutritional status related to a baseline care plan indicating obesity and medication diagnoses that included hyperlipidemia, depression, vitamin D deficiency, heart failure, and stage three chronic kidney disease. Interventions included providing meals/fluids based on resident food preferences and updating/honoring resident's food preferences on the tray ticket. On 04/09/24 at 8:19 A.M., Resident #58 was observed in bed with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility infection reports, review of inservice records, staff interview, and policy review, the facility failed to ensure antibiotics were not used unless criteria was met for the treatment of urinary tract infections. This affected one resident (#11) of five residents reviewed for unnecessary medications. Findings include: Review of Resident #11's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included neurogenic disorder withe Lewy bodies, Parkinson's disease, psychotic disorder with delusions, anxiety disorder and chronic kidney disease. Review of Resident #11's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had clear speech and was usually able to make herself understood. Her cognition was moderately impaired. Review of Resident #11's progress notes revealed the resident was straight catheterized on 03/07/24 at 5:05 A.M. for a urinalysis. Preliminary urine results were received on 03/07/24 at 10:33 P.M. and showed…

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, facility policy and procedure review and interview the facility failed to ensure residents had a monthly resident council meeting and failed to ensure adequate and timely responses to residents' concerns. This affected 13 residents (#1, #4, #5, #9, #14, #21, #23, #31, #32, #37, #44, #45 and #155) of 50 residents residing in the facility who had voiced concerns through resident council. Findings include: Review of facility resident council minutes for the past twelve months revealed there was no meeting conducted in April 2022. Review of facility resident council minutes, dated 08/09/21 revealed Residents #1, #4, #14, #21, #23, #32, #44 and #155 were informed that activities had started in that evening the month of August 2021. Review of facility resident council minutes, dated 01/21/22 revealed Residents #4, #9, #14, #44 and #155 were informed soup being added to the menu was discussed with the kitchen manager and administrator but there was no funding for soup. Review of facility resident council minutes, dated 03/13/22 revealed Residents #1, #4, #5, #9,…

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 resident personal fund account records, facility policy and procedure review and interview the facility failed to ensure quarterly bank statements were provided to residents/responsible parties and available for review. This affected 30 resident (#1, #2, #3, #4, #5, #6, #7, #8, #9, #16, #18, #19, #20, #21, #23, #24, #26, #27, #28, #29, #30, #34, #35, #36, #37, #38, #43, #44, #47 and #155) of 30 residents who had personal fund accounts maintained by the facility. The facility census was 50. Findings include: On 05/23/22 at 3:56 P.M. interview with Resident #1 revealed a concern she did not receive a quarterly statement related to her personal fund account. On 05/26/22 at 4:48 P.M. review of the resident personal account fund records with Business Office Manager #126 and Accounts Payable #152 revealed they had no written evidence of providing quarterly statements to all residents and/or the resident's responsible party for whom they managed personal fund accounts for. The staff members indicated they did receive quarterly resident trust fund (RTF) statements mailed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy and procedure review and interview the facility failed to develop and implement a comprehensive and individualized activity program to meet the total care needs and/or preferences of all residents. This affected four residents (#6, #7, #10 and #15) of four residents reviewed for activities and four additional residents (#4, #5, #9 and #23) present at a resident group meeting during the survey who voiced concerns related to activities. The facility census was 50. Findings include: 1. On 05/26/22 at 12:00 P.M. a group meeting interview with Resident #4, #5, #9, and #23 revealed they had previously requested more activities. All four residents revealed they have not received any response as to why they don't have more activities. During the meeting, the residents present reported there were not enough activities and they felt the facility needed to have more activities on the weekends. The residents indicated there were no activities on the weekends. On 05/26/22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to employ a qualified activity professional as required. This affected four residents (#10, #15, #7 and #6) of four residents reviewed for activities and four additional residents (#4, #5, #9 and #23) present at a resident group meeting who voiced concerns regarding activities. The facility census was 50. Findings include: 1. Record review revealed the facility former Activity Director (AD), AD #204 who was qualified to function as facility activity director last date worked in the facility on 09/02/21. Activity Director (AD) #203 was hired 09/08/21 and worked until 04/19/22. However, AD #203 was not certified or eligible as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body. AD #203 did not have two years of experience in a social or recreational program within the last five year nor was she a qualified occupational therapist or occupational therapy assistant. AD #203 had not completed a training course…

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, review of the facility menu, review of the National Dysphagia Diet Level documentation, completion of a test tray and interview the facility failed to ensure pureed diets were prepared at the appropriate consistency. This affected four residents (#8, #15, #26 and #39) of four residents identified to receive pureed diets. Findings include: Review of the Week-At-A-Glance menu for the dinner on 05/24/22 revealed the menu consisted of BBQ chicken thigh, capri vegetable blend, baked beans, cornbread and a blondie for dessert. On 05/24/22 at 4:02 P.M. observation of meal preparation revealed [NAME] #166 had already pureed the capri vegetables (zucchini, squash and carrots) and placed them in the steam table for service. [NAME] #166 was observed to place chicken thighs in the robo coupe (industrial blender) and pureed the chicken for the dinner meal. Once complete, [NAME] #166 placed the pureed chicken thighs into a metal pan and placed them in the steam table. [NAME] #166 verified the food was ready for service. Interview with [NAME] #166 at the time 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 and interview the facility failed to ensure food was prepared in a sanitary manner to prevent contamination. This affected four residents (#8, #15, #26 and #39) of four residents identified to receive pureed diets. Findings include: On 05/24/22 at 4:33 P.M. [NAME] #166 was observed to prepare puree rice for four residents, Resident #8, #15, #26 and #39 while wearing disposable gloves. Chicken broth was observed to be the liquid for puree and was in a plastic container near the robo coup. A metal tablespoon was observed submerged in the chicken broth. [NAME] #166 obtained a 1/3 cup plastic measuring cup with a handle and dipped the measuring cup into the broth and poured the chicken broth into the robo coupe with the rice. The cook returned the measuring cup to the container of broth and released the handle, causing the measuring cup to slide into the broth and become submerged along with the tablespoon. The cook continued to use the measuring cup by reaching into the broth, with her gloved hand to grab the handle until the rice was pureed to consistency. 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, record review, facility policy and procedure review and interview the facility failed to maintain adequate infection control practices, including the proper use of personal protective equipment (PPE) to prevent the spread of infection including COVID-19. This affected one resident (#248) who was in transmission based/droplet precautions and had the potential to affect 22 residents (#2, #3, #9, #11, #14, #15, #17, #19, #20, #21, #22, #25, #26, #27, #28, #29, #30, #35, #39, #41, #44, and #151) who resided on A Hall. The facility census was 50. Findings include: Review of Resident #248's medical record revealed an admission date of 05/14/22 with diagnoses including Parkinson's Disease, diabetes, contact with and (suspected) exposure to COVID-19 and neoplasm of the breast. Review of the physician's orders revealed an order, dated 05/14/22 for a point of care (POC) COVID-19 test to be obtained five days after admission The resident also had an order for transmission based precautions for ten days and if no symptoms (of COVID-19), may discontinue (precautions) after…

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, facility policy and procedure review and interview the facility failed to ensure Resident #20's physician was notified timely following weight loss and the resident's family request for an appetite stimulant. This affected one resident (#20) of six residents reviewed for nutrition. Findings include: Review of Resident #20's medical record revealed an admission date of 03/03/22 with diagnoses including unspecified injury of the head, metabolic encephalopathy, dementia without behavioral disturbance and rhabdomyolosis Review of the physician's orders revealed an order to obtain a monthly weight between the first and the tenth of each month. The resident also had an order (dated 04/01/22) for a regular diet with thin liquids. On 04/29/22 a new order for a sippy cup and divided plate with meals was ordered. Review of the resident's weights revealed the following: 03/05/22 194.8 pounds 03/08/22 188.6 pounds 03/15/22 173.8 pounds 03/29/22 162 pounds 04/02/22 166 pounds 05/06/22 153 pounds 05/09/22 160.9 pounds and 05/10/22 159 pounds No further weights 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 closed record review, facility policy and procedure review and interview the facility failed to ensure Resident #50 was provided a notice of the facility bed hold policy and ability to return to the facility upon admission and prior to a hospital transfer. This affected one resident (#50) of one resident reviewed for hospitalization. Findings include: Review of Resident #50's closed medical record revealed an admission date of 03/11/22 with diagnoses including COVID-19, malignant neoplasm of the uterus, malignant neoplasm of the brain, and malignant neoplasm of the lung. Review of the five day Minimum Data Set (MDS) 3.0 assessment, dated 03/15/22 revealed the resident was cognitively intact and required extensive assistance from two staff with bed mobility and extensive assistance of one staff member with dressing, toilet use and personal hygiene. A discharge, return not anticipated MDS 3.0 assessment was completed on 03/29/22. Further review of the closed medical record revealed no evidence the…

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

Based on medical record review, facility policy and procedure review and interview the facility failed to complete a new Preadmission Screening and Resident Review (PASARR) screening for residents with newly added mental health diagnoses. This affected two residents (#44 and #17) of two residents reviewed for PASARR reviews. Finding include: 1. Review of the medical record for Resident #44 revealed an admission date of 01/12/18. Review of Resident #44's most recent PASARR, dated 01/11/2018 revealed Resident #44 did not have any diagnoses of dementia, anxiety or delusions. Resident #44 had diagnoses added including dementia with Lewy bodies (dated 01/19/21), psychotic disorder with delusions due to known physiological conditions (dated 03/17/22), anxiety (dated 01/11/22) and major depressive disorder. Review of the plan of care, dated 01/15/2018 and revised 10/02/2019 revealed Resident #44 was at risk of exhibiting behaviors such as crying related to depression. Interventions included to administer medication as ordered and to monitor for behaviors. Review of the plan of care, dated…

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

Based on record review, facility policy and procedure review and interview the facility failed to develop comprehensive and individual care plans for Resident #44 related to psychoactive medication, Resident #12 related to restorative nursing services and Resident #6 related to activities. This affected three residents (#6, #12 and #44) of 25 residents whose care plans were reviewed. Findings include: 1. Review of the medical record for Resident #44 revealed an admission date of 01/12/18. Resident #44 had diagnoses including dementia with Lewy bodies (dated 01/19/21), psychotic disorder with delusions due to known physiological conditions (dated 03/17/22), anxiety (dated 01/11/22) and major depressive disorder. Review of the plan of care, initiated on 01/12/18 and most recently revised on 01/12/22 revealed the resident had no care plan related to the use of an antipsychotic medication. Review of Resident #44's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/29/22 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition for daily decision…

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, facility policy and procedure review and interview the facility failed to ensure comprehensive and individualized care plans were revised for Resident #19 related to advance directives and Resident #43 related to medication administration. This affected two residents (#19 and #43) of 25 residents reviewed for care planning. Findings include: 1. Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including essential hypertension, unspecified mononeuropathy of the right and left lower limb, hypothyroidism, unspecified asthma, age-related osteoporosis without current pathological fracture, and glaucoma. On 09/20/19 the diagnosis of repeated falls was added, on 12/12/20 the diagnosis of generalized muscle weakness was added, on 02/01/22 the diagnoses of difficulty walking, not elsewhere classified was added, and on 03/26/22 encounter for palliative care was added. Record review revealed Resident 19 had advance directive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review, facility policy and procedure review and interview the facility failed to ensure a comprehensive discharge summary was completed for Resident #49 as required. This affected one resident (#49) of two residents reviewed for transfer/discharge. Findings include: Review of Resident #49's closed medical record revealed the resident was admitted on [DATE] with diagnoses including diabetes with neuropathy, pressure ulcers to the left buttock, right buttock and sacrum, a deep tissue injury to the right heel, congestive heart failure and colostomy due to cancer. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 04/14/22 revealed the resident was cognitively intact and required extensive assistance of two staff for bed mobility and total dependence of two staff members with transfers. The resident also required extensive assistance of one staff member with personal hygiene and total dependence of one staff member with toilet use. The resident had three Stage II pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #15, who required staff assistance for activities of daily living care received adequate and timely assistance with nail care to maintain proper hygiene. This affected one resident (#15) of two residents reviewed for activities of daily living. Findings include: Review of Resident #15's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including osteomyelitis of vertebra, sacral and sacrococcygeal region, pressure ulcer of sacral region Stage IV (full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer), type 2 diabetes, atrial fibrillation, dementia, Alzheimer's, abnormal posture, heart failure and dysphagia. A 03/07/22 activity of daily living plan of care revealed an intervention (dated 03/15/22) to check nail length and trim and clean on bath day and as necessary. Review of the 03/08/22…

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, record review and interview the facility failed to assess and timely notify the physician of an identified skin alteration for Resident #17. This affected one resident (#17) of one resident reviewed for non-pressure skin alterations. Findings include: Review of Resident #17's medical record revealed an admission date of 11/06/09 with a diagnosis including major depression. Review of the physician's orders revealed an order (dated 09/10/19) for showers every Tuesday and Friday during the 7:00 A.M. to 3:00 P.M. shift and as needed and Nystatin cream twice a day for itching under the resident's breasts. Review of annual Minimum Data Set (MDS) 3.0 assessment, dated 03/01/22 revealed the resident was cognitively intact, independent for activities of daily living and required supervision and set up help for bathing. Review of the weekly skin assessments revealed the last skin assessment completed was dated 05/20/22 and no skin alterations were noted. On 05/23/22 at 1:16 P.M. interview with Resident #17 revealed she had an area on her upper back that itched and 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, record review, manufacturer guidelines review, facility policy and procedure review and interview the facility failed to ensure pressure ulcer interventions were provided in accordance with manufacturer guidelines and to meet the needs of Resident #15. This affected one resident (#15) of two residents reviewed for pressure ulcers. The facility identified three residents who had pressure ulcers. Findings include: Review of Resident #15's medical record revealed a 03/02/22 admission with diagnoses including osteomyelitis of vertebra, sacral and sacrococcygeal region, pressure ulcer of sacral region Stage IV (full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer), type 2 diabetes, atrial fibrillation, dementia, Alzheimer's disease, abnormal posture, heart failure and dysphagia. Record review revealed Resident #15 was admitted to the facility with a Stage IV pressure ulcer to the sacrum measuring 8.52 centimeter (cm) in length by 6.56 cm width with 0.7 cm depth and 0.7 cm tunneling at 3:00. A plan of care…

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

Based on record review, facility policy and procedure review and interview the facility failed to provide a restorative program as scheduled for Resident #12. This affected one resident (#12) of four residents reviewed for restorative programs. Findings include: Review of the medical record for Resident #12 revealed an initial admission date of 06/11/21 and a re-admission date of 02/15/22. Resident #12 had diagnoses including cerebral infarction due to occlusion or stenosis of right middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affect left non-dominant side, facial weakness and difficulty walking. Review of Resident #12's admission Minimum Data Set (MDS) 3.0 assessment, dated 02/22/22 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating an intact cognition for daily decision making abilities. Resident #12 was assessed to require extensive assistance from one staff member for bed mobility, transfers, mobility, dressing, toilet use and personal hygiene. The MDS assessment revealed Resident #12 had impairments to one upper 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, record review, facility policy and procedure review and interview the facility failed to ensure Resident #5, who had a history of falls in the facility had fall interventions in place as planned and education to prevent additional falls. This affected one resident (#5) of four residents reviewed for accidents. Findings include: Review of Resident #5's record revealed the resident was admitted to the facility on [DATE] with diagnoses of degenerative disease of the nervous system, ataxia, type two diabetes mellitus, essential hypertension, hyperlipidemia, generalized muscle weakness and repeated falls. Review of Resident #5's care plan, dated 02/06/22 revealed a goal for the resident to be free of falls. Interventions included to apply grip liner to the recliner and wheelchair and educate resident to leave lift chair in the seated position when not in use. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 02/18/22 revealed the resident was cognitively intact and had no…

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

Based on observation, record review, meal ticket review and interview the facility failed to ensure Resident #32 received a dysphagia diet as ordered. This affected one resident (#32) of ten residents reviewed for dining. Findings include: Review of Resident #32's medical record revealed a 05/26/19 admission and a 12/03/20 readmission with diagnoses including cerebral infarction, anemia, hypothyroidism and diverticulosis. Review of the 05/14/21 potential for decline in nutritional status related to advanced age, significant weight loss and mechanically altered diet plan of care revealed a goal for the resident to maintain adequate nutritional status as evidenced by maintaining weight with no significant changes, no signs or symptoms of malnutrition and consuming at least 75 percent of at least three meals daily through review date. A 05/14/21 intervention included to weigh per facility policy, monitor, record, report to physician as needed signs and symptoms of malnutrition (emaciation, muscle wasting, significant weight loss of greater than five percent in one month, 7.5 percent 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.

Based on record review, facility policy and procedure review and interview the facility failed to ensure residents received timely COVID-19 vaccination after receiving consent for administration. This affected one resident (#248) of one resident reviewed for transmission based precautions. Findings include: Review of Resident #248's medical record revealed an admission date of 05/14/22 with diagnoses including Parkinson's Disease, diabetes and neoplasm of the breast. Review of the physician's orders, dated 05/14/22 revealed the resident was placed in transmission based precautions (TBP) for ten days (related to COVID-19) and if no symptoms, the facility may discontinue the precautions. The resident also had an order for a point of care test (COVID-19 rapid test) five days after admission. Review of the Vaccination Administration Record Informed Consent for Vaccination in Long Term Care Facility revealed I want to receive the following vaccination: COVID-19 Vaccination. The form was signed by the resident on 05/14/22. Review of the Immunization Documentation revealed no evidence 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.