Glendora Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review, and interview, the facility failed to ensure psychotropic medications were only administered when needed, failed to ensure approval for gradual dose reductions were addressed in a timely manner, and failed to ensure monitoring of target symptoms were documented. This affected three (Residents #10, #21 and #27) of five residents whose records were reviewed for medication use. Findings include: 1. Review of Resident #10's medical record revealed diagnoses including schizoaffective disorder (bipolar type), affective mood disorder, mild cognitive impairment, anxiety disorder, dementia with mood disorder, and depression. A significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #10 was usually able to make herself understood and was usually able to understand others. The memory/cognitive skills were not assessed. The MDS indicated Resident #10 had exhibited behavioral symptoms not directed toward others one to three days. The behaviors pur…

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 review of the facility policy, the facility failed to ensure call lights were in place in three restrooms that were available for resident's use. This had the potential to affect seven residents, Resident #2, #3, #6, #15, #19, #28, and #30 who were identified by the facility as independent with mobility and transfers. The facility census was 36. Findings include: Observation on 09/15/24 at 9:11 A.M. revealed two restrooms located near the middle of the extended hall open to residents with a vending machine for Resident use at the end of the hall. A third restroom was located on the [NAME] residential hall. All three restrooms were identified as male or female restrooms and was wheelchair accessible, no further information was posted on the doors. Multiple observations from 09/15/24 through 09/19/24 revealed all three restrooms were unlocked at all times except when in use and none had a call system in place. Observation and interview on 09/19/24 at 8:32 A.M. with Maintenance Director #116 verified all three restrooms were kept unlocked at all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure a resident's code status was consistent amongst documents. This affected one (Resident #21) of 16 residents reviewed for advanced directives. Findings include: Review of Resident #21's medical record revealed diagnoses including vascular dementia, basal cell carcinoma of the skin, chronic kidney disease, hypertension, cerebrovascular disease and anxiety disorder. Review of a signed Do Not Resuscitate (DNR) form dated 10/06/23 revealed the option of Do Not Resuscitate Comfort Care (DNRCC) was chosen and was effective immediately. Review of Resident #21's electronic health record revealed a heading with a code status of Do Not Resuscitate Comfort Care Arrest (DNRCC-A) (allows for the use of life-saving measures before cardiac or respiratory arrest, but only comfort care after). Review of the facility's report sheet revealed code status was indicated on the report sheets. Resident #21's code status was listed as DNRCC-A. Review of 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 and interview, the facility failed to ensure residents and their representatives were provided a summary of the baseline care plan. This affected one (Resident #32) of four residents reviewed for baseline care plans. Findings include: Review of Resident #32's medical record revealed diagnoses including epilepsy, depression, delirium, dementia, and mood disorder. Resident #32 was admitted to the facility 05/10/24. No baseline care plan was located. On 09/18/24 at 11:48 A.M., the Administrator verified she was unable to find a baseline care plan or evidence a summary of a baseline care plan was provided to the resident/representative. The Administrator stated she would have the Director of Nursing search to determine if there was one located elsewhere. On 09/18/24 at 1:26 P.M., the Administrator provided Resident #32's baseline care plan but no evidence a summary was provided to Resident #32 and his representative.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure individualized care plans were developed for two (Residents #1 and #6) of 14 residents reviewed for comprehensive care plans. The facility census was 36. Findings include: Record review for Resident #1 revealed an admission date of 06/24/22. Diagnosis included pneumonitis due to inhalation of food and vomit. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was moderately cognitively impaired. Resident #1 required set up or clean up assistants with meals. Review of the physician orders for Resident #1 revealed an order dated 05/21/24 for Heart Healthy diet, pureed texture, nectar consistency, Resident may request thin water 30 minutes after oral (PO) intake. No thin water with PO intake for aspiration precaution. Review of the care plan updated 04/09/24 revealed Resident #1 was at nutritional risk. Interventions included to provide the diet as ordered. The care plan did not include nectar thickened…

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 ensure care plan revision for one resident, Resident #34 to reflect current functional abilities and weight bearing status. This affected one resident (Resident #34) of three residents reviewed for care plan revision. The facility census was 36. Findings include: Record review for Resident #34 revealed an admission date of 07/24/24. Diagnosis include fracture of the right femur, fracture of the shaft of the right tibia, fracture of shaft of right fibula, presence of right artificial wrist joint, displaced fracture of the shaft of first metacarpal bone, left hand. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #34 was cognitively intact. Resident #34 had impairment on both sides, upper and lower extremities. The resident used a wheelchair for mobility, was dependent for all activities of daily living (ADL) including eating, toileting, upper and lower body dressing, personal hygiene, sit to lying, lying to sit, and showers.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, and interview, the facility failed to implement fall interventions per resident care plans for one (Resident #12) of three residents reviewed for accidents. The facility also failed to ensure one resident, Resident #1 received thickened liquids as ordered. This affected one resident, Resident #1, of three residents reviewed for nutrition. The facility census was 36. Findings include: 1. Review of Resident #12's medical record revealed diagnoses including atherosclerotic heart disease, hypertension, history of falling, depression, visual loss in both eyes, mild dementia, generalized muscle weakness and abnormalities of gait and mobility. Review of a care plan initiated 08/05/24 revealed Resident #12 was at risk for falls related to confusion and lack of awareness of safety needs. An intervention was initiated for a fall mat to the exit side of the bed and to verify placement. On 08/23/24 an order was written for a fall mat to the exit side of bed and to verify…

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, review of pharmacy recommendations, policy review and interview, the facility failed to ensure all pharmacy recommendations were addressed by physicians. This affected one (Resident #27) of five residents reviewed for medication use. Findings include: Review of Resident #27's medical record revealed diagnoses including dementia with behavioral disturbance, hypertension, hyperlipidemia, heart disease, presence of coronary angioplasty implant and graft, anemia, anxiety disorder, restlessness and agitation. Review of a medication regimen review dated 09/22/23 revealed Resident #27 was receiving two antipsychotic medications, olanzapine and risperidone. The pharmacist asked for a diagnosis to support use. The pharmacist also indicated the medical record indicated the olanzapine and risperidone were used for psychosis and asked if the physician would consider discontinuing one of the medications to avoid duplicative therapy. The response dated 09/29/23 had a notation to change the diagnosis to dementia. The request regarding considering discontinuing one…

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 physician orders, policy review, and interview, the facility failed to ensure medications were administered in accordance with physician orders and policy. This affected two (Residents #15 and #138) of seven residents observed receiving medication. Two errors of 30 opportunities for error were identified resulting in a medication error rate of 6.6%. Findings include: 1. On 09/15/24 at 9:00 A.M., Registered Nurse (RN) #109 was observed administering medication to Resident #15. Among medication administered was colace (stool softener) 100 milligrams (mg). Review of Resident #15's physician orders revealed no order for colace 100 mg. There was an order dated 10/04/23 for two sennosides-docusate sodium 8.6-50 mg to be administered every morning for constipation that was not observed to be administered. On 09/15/24 at 12:40 P.M., RN #109 verified she had administered colace instead of sennosides-docusate as ordered. Review of the facility's Medication Administration policy (implementation date not recorded) revealed instructions to ensure the right drug…

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 infection surveillance records, policy review and interview, the facility failed to address use of a prophylactic antibiotic for a resident with recent use of multiple antibiotics. This affected one (Resident #27) of five residents revealed for medication use. Findings include: Review of Resident #27's medical record revealed diagnoses including dementia with behavioral disturbance, benign prostatic hypertrophy (BPH), neuromuscular dysfunction of the bladder and heart disease. Review of physician orders since admission on [DATE] revealed the following orders for antibiotics: 02/16/24: cipro 500 milligrams (mg) twice a day for ten days for a urinary tract infection (UTI) 04/07/24: bactrim DS 800-160 mg every 12 hours for benign prostatic hyperplasia (BPH) with lower urinary tract symptoms for seven days 04/10/24 nitrofurantoin 100 mg twice a day for seven days for infection in the urine 04/12/24 nitrofurantoin 100 mg twice a day for urinary tract infection for seven days…

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 failed to maintain sufficient levels of staff on the secured care unit to meet the supervisory and total care needs of all residents. This affected two residents (#1 and #2) and had the potential to affect the 11 residents residing on the facility secured memory care unit. Findings include: On 07/01/24 at 8:11 A.M. the surveyor entered the facility to conduct the complaint investigation. There were two licensed nurses and three State Tested Nursing Assistants (STNA) on duty to provide care for 33 residents currently residing in the facility. Eleven of the resident's resided on the memory care unit. Staffing on the memory care unit included one Registered Nurse (RN) and one STNA. Review of the facility staffing schedules and assignment sheets from May and June, through 06/27/24 revealed the facility only staffed one nurse on the secured memory care unit, with no other assigned/dedicated staff. Interview on 07/01/24 at 8:31 A.M. with STNA #120 revealed…

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

Based on observation, interview and policy review, the facility failed that kitchen staff wore hair restraints while serving food and in the kitchen. This had the potential to affect all 30 residents who received food from the facility. No residents were identified as receiving nothing by mouth (NPO). The facility census was 30. Findings include: Observation on 11/06/23 at 8:02 A.M. revealed that [NAME] #114 was serving food without a hair restraint or beard net on and Dietary Manager #112 was walking in front of the steamtable with her hair not in a hair restraint. DM #112 and [NAME] #114 stated that they should have been wearing hair nets. Interview on 11/07/23 at 8:17 A.M. with Dietary Manager revealed that staff forgets to wear hairnets because they have so much to do in the morning like roll silverware. Review of the undated facility policy titled, Maintaining a Sanitary Tray Line, revealed that staff should wear hair restraints.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy, the facility failed to ensure that Resident #33 was free from verbal abuse. This affected one resident (Resident #33) out of five residents reviewed for abuse. This had the potential to affect all 30 residents that resided in the facility. The facility census was 30. Findings include: Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] and discharged on 11/02/23. Review of the admission Minimum Data Set (MDS) 3.0 assessment was not completed. Review of the admission assessment dated [DATE] revealed Resident #33 was oriented to person, place, time, and orientation. Review of the concern form dated 11/02/23 revealed family of Resident #33 alleged that on 11/01/23 State Tested Nursing Assistant (STNA) #108 was a kind of rough and rude. The investigation portion of concern on the form revealed Director of Nursing (DON) met with STNA #108 and discussed the incident. STNA #108 confirmed that she had a bad day, didn't perform…

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, the facility failed to implement its abuse policy to appropriately protect Resident #33 from verbal abuse. This affected one resident (Resident #33) out of five residents reviewed for abuse. The facility census was 30. Findings include: Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] and discharged on 11/02/23. Review of the admission Minimum Data Set (MDS) 3.0 assessment was not completed. Review of the admission assessment dated [DATE] revealed Resident #33 was oriented to person, place, time, and orientation. Review of the concern form dated 11/02/23 revealed family of Resident #33 alleged that on 11/01/23 State Tested Nursing Assistant (STNA) #108 was a kind of rough and rude. The investigation portion of concern on the form revealed Director of Nursing (DON) met with STNA #108 and discussed the incident. STNA #108 confirmed that she had a bad day, didn't perform her best and admitted to being rude to staff…

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, interview and facility policy, the facility failed to complete an investigation of an allegation of verbal abuse. This affected one resident (Resident #33) out of five residents reviewed for abuse. The facility census was 30. Findings include: Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] and discharged on 11/02/23. Review of the admission Minimum Data Set (MDS) 3.0 assessment was not completed. Review of the admission assessment dated [DATE] revealed Resident #33 was oriented to person, place, time, and orientation. Review of the concern form dated 11/02/23 revealed family of Resident #33 alleged that on 11/01/23 State Tested Nursing Assistant (STNA) #108 was kind of rough and rude. The investigation portion of concern on the form revealed Director of Nursing (DON) met with STNA #108 and discussed the incident. STNA #108 confirmed that she had a bad day, didn't perform her best and admitted to being rude to staff and residents. Further review…

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

Based on observation and interview the facility failed to properly maintain comfortable temperatures throughout the facility. This affected eleven residents (Residents #16, #19, #20, #23, #26, #31, #34, #37, #40, #95 and #96) residing on the memory care as well as ten (Residents #2, #10, #18, #21, #32, #35, #38, #93 #94, and #193) outside of the memory care unit. The facility census was 39. Findings include: 1. Observation of the memory care unit on 11/14/22 beginning at 9:11 A.M. revealed Residents #16 and #19's room was cold. State Tested Nursing Assistant (STNA) #654 confirmed the room was cold and stated the unit had been cold for a few days when she was present. Observation of thermostat outside of the resident's room revealed a reading of 65 degrees Fahrenheit (F). Residents #16 and #19 were not interviewable. Further interview with STNA #654 revealed the shower room was also cold and she was running the hot water in an attempt to heat it up prior to giving Resident #96 a shower. Observation at time of interview revealed the shower room was cold and there was hot water…

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 failed to ensure resident records were accurate. This affected four residents (Resident #6, Resident #11, Resident #39, and Resident #144) of 20 residents whose medical records were reviewed for accuracy. The facility census was 39. Findings include: 1. Review of the medical record revealed Resident #6 had an admission date of 09/04/20 with diagnoses including schizophrenia, type II diabetes, heart failure and metabolic encephalopathy. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderate cognitive impairment. Functionally, she required extensive assistance of two staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of the fall risk assessment dated [DATE] stated Resident #6's last fall occurred on 04/03/33. This was inaccurate as the resident had a fall on 06/11/22. Interview with the Director of Nursing (DON) on 11/16/22 1:30 P.M. verified the above finding. 2. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure resident assessments were accurate. This affected one resident (Resident #144) of 16 residents (Resident #1, Resident #4, Resident #6, Resident #11, Resident #12, Resident #16, Resident #19, Resident #29, Resident #32, Resident #33, Resident #34, Resident #38, Resident #39, Resident #40, Resident #96 and Resident #97) reviewed for accuracy of assessments. The facility census was 39. Findings include: Medical Record review for Resident #144 revealed an admission date of 10/26/22 with diagnoses including osteomyelitis of the left ankle and foot, Type II diabetes, depression, and chronic respiratory failure. The comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #144 had impaired cognition and required extensive assistance for mobility and total assistance with transfers. Resident #144 had no falls in the past 90 days. Review of the nurses note dated 10/26/22 at 3:10 P.M. revealed Resident #144 was admitted to 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 and interview, the facility failed to ensure resident care plans were comprehensive. This affected two residents (Resident #6, and Resident#11) of 16 residents (Resident #1, Resident #4, Resident #12, Resident #16, Resident #19, Resident #29, Resident #32, Resident #33, Resident #34, Resident #38, Resident #39, Resident #40, Resident #96, and Resident #97) whose care plans were reviewed. The facility census was 39. Findings Include: 1. Review of the medical record revealed Resident #6 had an admission date of 09/04/20 with diagnoses including schizophrenia, type II diabetes, heart failure, bipolar disorder, and metabolic encephalopathy. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had moderate cognitive impairment. Resident #6 required extensive assistance of two staff for most activities of daily living including, bed mobility, dressing, toilet use, and personal hygiene. Review of Resident #6's physician orders revealed on 10/27/22 the physician…

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 antibiotic treatment was administered in a timely manner and failed to ensure a physician's order was updated and canceled timely when it no longer pertained to the resident. This affected one resident (Resident #40) of three reviewed for antibiotic treatment and one resident, (Resident #11) of 19 residents reviewed for accuracy of physician orders. The facility census was 39. Findings include: 1. Review of Resident #40's medical records revealed an admission date of 08/19/22 with diagnoses including dementia and schizophrenia. Review of laboratory results dated [DATE] revealed Resident #40 had a urine specimen collected on 09/25/22 and the results were reported on 09/28/22. Further review revealed the results were faxed to the physician on 09/30/22 at 2:29 P.M. Urine results were reported Resident #40 was positive for a Escherichia coli (E-coli) (bacterial infection). Review of the progress note dated 09/30/22 at 2:41 P.M. authored by Licensed…

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 fall risk assessments were accurate, failed to ensure fall investigations were complete and thorough, and failed to ensure fall mats were in place. This affected three residents (Resident #6, Resident #19, and Resident #144) of four resident's reviewed for accidents. The facility census was 39. Findings include: 1. Review of the medical record revealed Resident #6 had an admission date of 09/04/20 with diagnoses including schizophrenia, type II diabetes, heart failure, bipolar disorder, and metabolic encephalopathy. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had moderate cognitive impairment. Resident #6 required extensive assistance of two staff for bed mobility, dressing, toilet use, and personal hygiene. Review of the fall risk scores dated 04/03/22 and 08/14/22 state Resident #6 had no falls; however, the resident had falls on 04/03/22 and 06/11/22. Review of Resident #6's fall…

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 failed to ensure State Tested Nursing Assistant (STNA) #657 was adequately trained to apply a resident's splint. This affected one resident (Resident #11) of three residents who were ordered a splint. The facility census was 39. Findings include: Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, type II diabetes, depression, hemiplegia, and dysphagia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had severe cognitive impairment. She was totally dependent on two staff members for toileting and personal hygiene. For bed mobility, dressing, and eating Resident #11 required extensive assistance of two staff. Observation on 11/15/22 at 7:30 A.M. revealed STNA #657 got Resident #11 changed and dressed for the day. When STNA #657 was asked about her arm splint, STNA #657 stated she did not know if Resident #11 wore an arm splint.…

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 the rationale for why a gradual dose reduction was not approved was documented in the physician's notes. This affected one resident (Resident #6) of five residents (Resident #1, Resident #34, Resident #40, and Resident #144) reviewed for unnecessary medications. The facility census was 39. Findings include: Review of the medical record revealed Resident #6 had an admission date of 09/04/20 with diagnoses including schizophrenia, type II diabetes, heart failure, bipolar disorder, and metabolic encephalopathy. Review of this resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had moderate cognitive impairment. She required extensive assistance of two staff for bed mobility, dressing, toilet use, and personal hygiene. Review of the physician orders revealed on 08/15/21 Resident #6 was ordered trazodone 50 milligrams (mg) (antidepressant and sedative) at bedtime for insomnia. This order was still in effect today. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure psychotropic medications were only ordered with an appropriate diagnosis. This effected one (Resident #144) of five residents reviewed for psychotropic medications. The facility census was 39. Finding include: Medical record review for Resident #144 revealed an admission date of 10/26/22 with diagnoses including osteomyelitis of the left ankle and foot, type II diabetes, depression, chronic respiratory failure, heart failure, and anemia. There was no diagnoses for anxiety or insomnia. The comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #144 had intact cognition and behaviors. The resident rejected evaluations and had wandering behaviors that had gotten worse. Review of the physician orders for November 2022 revealed orders for scheduled lorazepam one milligram (mg) for anxiety at bedtime. Trazodone 100 mg was scheduled at bedtime for insomnia. Interview on 11/17/22 at 2:30 P.M. with the Director of Nursing (DON)…

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 failed to ensure proper hand hygiene was maintained during a wound dressing change. This affected one resident (Resident #144) of two residents reviewed for wound care. The facility census was 39. Findings include: Review of the medical record revealed Resident #144 was admitted to the facility on [DATE] with diagnoses included osteomyelitis, type II diabetes, chronic respiratory failure, and atherosclerotic heart disease. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #144 was cognitively intact. The resident rejected evaluations and had wandering behaviors that had gotten worse. Review of the plan of care dated 11/16/22 revealed Resident #144 had potential for skin impairment related to osteomyelitis, diabetes, and incontinence of bowel and bladder. Interventions included: educate the resident on causative factors and measures to promote and maintain skin integrity; observe the resident's skin and keep clean 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 and interview the facility failed to provide a clean, comfortable and homelike environment for all residents. This affected three residents (#12, #32 and #136) of 16 residents whose rooms were observed. The facility census was 35. Findings include: 1. Review of Resident #136's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of morbid obesity, high blood pressure, major depression and subdural hemorrhage. An admission assessment dated [DATE] revealed the resident was alert and oriented, and required two staff assistance for transfers and was continent of bowel and bladder. An interview and observation on 10/06/19 at 9:32 A.M. with Resident #136 and her family member revealed concerns that the bathroom was not clean and it did not feel homelike in their opinion. An observation with the family member revealed black particles floating in the commode water, a black caked substance inside the commode tank, yellow discolored floor/tiles, 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.