Smithville Western Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview and review of the facility policy, the facility failed to store medications in a safe manner. This affected one (#79) resident, with the potential to affect nine additional residents (#14, #28, #41, #52, #54, #62, #89, #197, and #198) who were identified by the facility as being independently mobile and cognitively impaired residing on the memory care unit. The facility census was 90. Findings include: Record review for Resident #79 revealed an admission date of 01/02/24. Diagnoses included metabolic encephalopathy, altered mental status, depression, alcohol dependence and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 was severely cognitively impaired. Resident #79 had no impairment to the upper or lower extremities. Resident#79 used a walker/wheelchair for mobility. Observation on 06/25/24 at 11:26 A.M. of medication administration on the secured memory care unit with Registered Nurse…

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 staff interview, the facility failed to ensure residents rooms were maintained in a clean/sanitary manner and were in good repair. This affected 10 (#16, #17, #20, #21, #23, #33, #36, #39, #66, and #85) of 10 residents reviewed for physical environment. The facility census was 90. Findings include: Observation on 06/24/24 at 11:24 A.M. of Residents #33 and #66's room revealed the closet doors were hanging at a slant and off the track. Observation on 06/24/24 at 11:40 A.M. of Residents #17 and #39's room revealed several black markings and gashes across wall between the two residents' beds. Further observation of Resident #39's bed remote revealed the wiring was exposed and the bottom drawer of the resident's nightstand was off the track. Observation on 06/24/24 at 12:15 P.M. of Resident #85's room revealed several gashes and black marking along the wall that extended to bed two, which was unoccupied. Observation on 06/24/24 at 2:13 P.M. of Residents #16 and #23's room revealed the cover of the heating unit was missing, exposing the heating element. Continued…

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 resident fund records and staff interview, the facility failed to ensure resident funds were conveyed timely upon resident discharge from the facility. This affected one (#148) of one resident reviewed for funds conveyance. The facility census was 90. Findings include: Resident #148 was admitted to the facility on [DATE] with a readmission date of [DATE]. Resident #148 was discharged [DATE]. Review of a progress note dated [DATE] revealed Resident #148 was transferred to the hospital. Review of a progress note dated [DATE] revealed the hospital informed the facility that Resident #148 expired. Review of Resident #148's resident funds records revealed on [DATE], a check in the amount of $1193.46 was dispersed to the state and one for $527.18 was dispersed to the funeral home handling Resident #148's arrangements. Interview on [DATE] at 7:17 A.M. with Business Office Manager (BOM) #522 verified Resident #148's funds were not conveyed within the required timeframe of 30…

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 residents and/or resident representatives received written transfer notices when transferring to the hospital. This affected two residents (#11 and #51) of three residents reviewed for hospitalization. The facility census was 90. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 07/22/23. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, chronic diastolic (congestive) heart failure and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had impaired cognition and required substantial/maximum assistance from staff for bed mobility and was dependent on staff for transfers. Review of the Skilled Nursing Facility (SNF)/Nursing Facility (NF) to Hospital Transfer Forms dated 03/27/24, 05/13/24, and 06/04/24 revealed Resident #11 was transferred to the hospital on those dates. 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 medical record review, observation and staff interview, the facility failed to ensure dependent residents received nail care. This affected one resident (#89) of three residents reviewed for podiatry care. The facility census was 90. Findings include: Record review for Resident #89 revealed an admission date of 04/04/24. Diagnoses included unspecified dementia, muscle weakness and need for assistance with personal care. Review of the admission Medicare Five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #89 was severely cognitively impaired. Resident #89 had impairment to one side of the upper extremity and required substantial maximum assistants with personal hygiene. Further review of Resident #89's medical record revealed no evidence of an identified need for toenail care or that the resident received toenail care. Observation on 06/24/24 at 9:49 A.M. revealed Resident #89 was lying in bed. Resident #89's feet were sticking out from under the blanket at the end of the bed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, review of hospital records, staff interview and review of facility policy, the facility failed to ensure all fall interventions were implemented. This affected two (#41 and #45) of three residents reviewed for falls. In addition, the facility failed to follow procedures following a fall to prevent further injury. This affected one (#41) of three residents reviewed for falls. The facility census was 90. Findings include: 1. Record review for Resident #41 revealed an admission date of 03/18/21. Diagnoses included hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, subsequent encounter epilepsy, and epilepticus pseudobulbar affect vascular dementia. An additional diagnosis of displaced simple supracondylar fracture of right the humerus was added on 05/16/24. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was severely cognitively impaired. Resident #41 had no impairment to…

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

Based on medical record review, resident interview and staff interview, the facility failed to ensure residents were free of unnecessary medication increases. This affected one (#74) of six residents reviewed for unnecessary medications. The facility census was 90. Findings include: Review of the medical record for Resident #74 revealed an admission date of 12/02/23. Diagnoses included end stage renal disease, depression, insomnia and anxiety disorder. Further review of census information revealed Resident #74 was moved to a new room on 03/19/24. Review of the plan of care revised 01/04/24 revealed Resident #74 had altered sleep pattern and difficulty falling asleep. Interventions included identifying regular sleep schedule, give measures of comfort including turn out lights, provide quiet and darkness and turn off television, give hypnotics per orders, and report complaints of sleeplessness to the charge nurse. Review of a physician's order dated 03/18/24 revealed Resident #74 had an order for Trazodone (an anti-depressant medication that can be used off-label for patients 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 2. Review of the medical record for Resident #79 revealed an admission date of 01/02/24. Diagnoses included, but not limited to, altered mental status, depression and anxiety disorder. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #79 had severe impaired cognition and required moderate assistance with activities of daily living (ADLs). Review of the care plan meeting documentation, completed by Social Services Designee (SSD) #900 with an effective date of 01/29/24 at 4:19 P.M., revealed a care conference meeting was held on 01/29/24 at 12:00 A.M. and the resident and resident representative attended. Review of the care plan meeting documentation, completed by Social Services Designee (SSD) #611 with an effective date of 04/29/24 at 10:32 P.M., revealed a care conference meeting was held on 01/29/24 at 12:00 A.M. and the resident and resident representative attended. Interview on 06/27/24 at 11:02 A.M. with Director of Nursing (DON) verified the care conferences dated 01/29/24 and…

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

Based on record review, staff interview, review of the Centers for Medicare and Medicaid Services (CMS) guidelines, and review of the Notice of Medicare Non-Coverage (NOMNC), the facility failed to ensure proper liability notices were received timely. This affected one resident (#104) of three residents reviewed for liability notices. The facility census was 101. Findings Include: Review of the closed medical record for Resident #104 revealed an admission date of 01/04/24 with diagnoses including Alzheimer's disease, dementia, and COVID-19. Review of the medical record revealed Resident #104 was discharged on 02/23/24. Review of the NOMNC revealed Resident #104 received notification that his skilled services would end effective 02/19/24 with the option to appeal no later than noon of the day before the effective date. Review of the NOMNC revealed Resident #104 signed and dated the NOMNC on 02/19/24 and was not given proper notice in order to appeal, if so wished. Review of the Centers for Medicare and Medicaid Services (CMS) guidelines found at www.cms.gov revealed the NOMNC must be…

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, interview, and facility policy review the facility failed to ensure Minimum Data Set (MDS) assessments were accurate regarding resident vaccination status. This affected three residents (#28, #38, and #99) out of five residents reviewed for vaccinations. The facility census was 107. Findings Include: 1. Medical record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, encephalopathy, anxiety disorder, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed Resident #28 was not offered the influenza vaccine. Further review of Resident #28's medical record revealed that she was offered and received the influenza vaccine on 10/17/23. Interview on 02/08/24 at 2:42 P.M. with MDS Licensed Practical Nurse (LPN) #313 verified that Resident #28's quarterly MDS was coded incorrectly. MDS/LPN #313 modified the MDS to reflect that Resident #28 was given the influenza vaccine as requested on 10/16/23. 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.

Based on observations, interviews, record review, and policy review the facility failed to ensure the dishwasher provided sufficient sanitizer, all food was labeled, dated, and stored properly and food was prepared in a sanitary manner. This had the potential to affect all residents of the facility. The facility also failed to ensure all food in each of the three-unit resident refrigerators was covered and dated. This had the potential to affect all residents. The census was 93. Findings include: 1. Observation on 03/22/21 at 11:05 A.M. of the facility kitchen low-temperature dishwasher revealed the wash temperature of 120 Fahrenheit (F), rinse temperature of 130 F. The sanitizer revealed a level of 50 parts per million (ppm). Interview on 03/22/21 at 11:06 A.M. with Dietary Services Director (DSD) #628 verified the sanitizer was not at a sufficient level. He reported it had been low and a call was placed on 03/21/22 for service to adjust the level. Review of the dishwasher temperature logs from 01/01/22 to 03/22/22 revealed wash temperatures ranged from 125 F to 140 F. There 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 observation, interviews, and record review the facility failed to maintain the air temperature above 71 degrees in Resident #49's room. This affected one (Resident #49) of 31 residents on the 500-hall. Facility census was 93. Findings include: Review of the medical record revealed Resident #49 was admitted on [DATE] with diagnoses including chronic kidney disease, atherosclerotic heart disease, chronic kidney disease, and severe protein-calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 had mild cognitive impairment. Interview on 03/21/22 at 9:08 A.M. Resident #49 stated she was cold, and it was always cold in her room. The resident stated if the sun was shining and the blind to the window was raised, her room would warm up. Observation and interview on 03/22/22 at 2:21 P.M. revealed Resident #49 was sitting in a chair with long sleeves and a jacket on. Resident #49 stated she was cold. Interview on 03/22/22 at 3:43 P.M. with State…

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's #28 and #34 had a comprehensive care plan for smoking. This affected two of 21 residents reviewed for care plans. The facility census was 93. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 12/01/20. Diagnoses included anemia, hypokalemia, right eye blindness, unsteadiness on feet, need for assistance with personal care, history of falling, abnormalities of gait and mobility, muscle weakness, and nicotine dependence. The annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 had moderately impaired cognition and impaired vision. Review of Resident #28's current care plan revealed it was silent to smoking. Review of the smoking assessment dated [DATE] revealed Resident #28 was identified as a smoker and was assessed as not at risk for injury related to smoking. Resident #28 has no history of burns or smoking problems. Resident #28 was able to identify locations…

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, taste test, and recipe review the facility failed to prepare pureed foods at a consistency appropriate for safe swallowing. This had the potential to affect eight residents (Resident's #6, #12, #20, #31, #47, #72, #74 and #386) who were prescribed a pureed diet and consumed meals from the facility's kitchen. The facility census was 93. Findings include: Observation on 03/22/22 at 3:05 P.M. of the puree preparation revealed Dietary Services Director (DSD) #628 was preparing pureed corn chowder for the dinner meal. DSD #628 was noted preparing one half gallon of corn chowder with 35 packages (two per pack) crackers. He confirmed the recipe was cut in half from 25 servings to 12. The recipe called for one gallon and three cups with 75 two-per-pack crackers. Confirmed he was looking for mashed potato-like consistency. Taste test of finished product revealed final product was smooth, however extremely thick. Regional Dietary Services Director #681 confirmed the consistency of the corn chowder upon tasting as being extremely thick. Interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure fortified soup was of honey thick consistency for Resident #6. This affected one (Resident #6) of two residents (Resident's #6 and #30) who received honey thick liquids and fortified foods. The facility census was 93. Findings include: Review of the medical record revealed Resident #6 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis, chronic obstructive pulmonary disease (COPD), and diabetes type II. Review of the physician's order dated 12/08/21 revealed Resident #6 received a pureed texture diet with honey consistency liquids. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had significant cognitive impairment, required supervision and set-up for eating. Review of the care plan dated 12/13/21 revealed Resident #6 received a pureed diet with honey thick liquids and fortified foods and a care area for eating/nutrition that included honey thickened liquids, no straws,…

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 Resident #40 received assistive devices for meals. This affected one of three residents (Residents #15, #40 and #72) reviewed for nutrition. The facility census was 93. Findings include: Review of the medical record revealed Resident #40 was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disorder (COPD), adult failure to thrive, hypertension, dementia with unspecified psychosis, and high blood pressure. Review of the physician's orders revealed an order dated 04/28/21 for a sippy cup at all meals. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 had severe cognitive impairment requiring supervision/assist of one staff for meals. Review of the care plan dated 01/12/19 revealed a care area for nutrition which included an intervention dated 07/08/21 for a sipper cup with meals. Review of the dietary progress note dated 03/09/22 written by Dietary Technician (DT) #690…

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, policy review, and interview, the facility failed to ensure a resident exhibiting symptoms of new onset shortness of breath, cough, and decreased oxygen saturation levels was tested to rule out COVID-19. This affected one (Resident #69) of 24 residents reviewed for infections. The facility census was 93. Findings include: Review of Resident #69's medical record revealed diagnoses including acute or chronic congestive heart failure (CHF), atrial fibrillation, and malignant neoplasm of the prostate, acute cholecystitis, chronic myeloproliferative disease, diverticulitis of intestine, acute respiratory failure with hypoxia, acute kidney failure, and obesity. Upon admission, an order was written for oxygen at two to five liters per minute via nasal cannula to maintain an oxygen saturation level above 92% if Resident #69 had shortness of breath as needed. A physician's progress note dated 02/11/22 indicated Resident #69 had new onset of atrial fibrillation. Breath sounds…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews the facility failed to provide a safe and homelike environment. This affected three (Resident's #35, #66, and #77) of 24 residents reviewed for environment. The facility census was 93. Findings include: Review of medical record revealed Resident #77 was admitted on [DATE] with diagnoses including syncope and collapse, encephalopathy, and dementia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #77 had mildly impaired cognition. The resident required extensive assistance of two staff for transfers and toileting. Review of medical record revealed Resident #66 was admitted [DATE] with diagnoses including end stage renal disease, respiratory failure, dependence on renal dialysis, and history of transient ischemic attack. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #66 had mildly impaired cognition. The resident required limited assistance of one staff for transfers and toilet use. Review of medical record…

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

Based on observation, interview and record review the facility failed to ensure the operation of the kitchen was maintained in a sanitary manner related to the dish machine, cleaning of the thermometers and monitoring appropriate food temperatures prior to service in the north dining room. This had the potential to affect the 102 residents who received meals from the facility and the 15 residents (Residents #40, #55, #94, #3, #104, #102, #15, #67, #71, #69, #97, #41, #75, #43 and #7) who received meals from the north dining room. Findings included: 1. Review of the dish washer temperature/sanitation logs policy, not dated, revealed the logs would be maintained for wash/rinse temperatures daily. Test strips for chlorine would be used weekly for testing of the final rinse sanitation level for low temperature dish machines. The required chlorine levels were 50 parts per million (ppm). Review of the in-service dated 11/27/18 revealed the staff were educated on dish machine soap and reading the temperature (not the chemical levels). Further review of the sign in revealed dietary aids…

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 residents were afforded dignified dining experiences in the north dining room including receiving timely meals, adequate supplies of service ware such as silverware, plates, cups, bowls, and ordered/requested food items. This had the potential to affect the 15 residents (Residents #40, #55, #94, #3, #104, #102, #15, #67, #71, #69, #97, #41, #75, #43 and #7) who received meals from the north dining room and one of one resident reviewed for food concerns (Resident #3). Findings include: Review of the meal service times for the north dining room revealed breakfast was to be served at 8:15 A.M. and dinner at 5:15 P.M. Review of the monthly food committee meetings dated 12/26/18, 01/23/19, 02/27/19 and 03/27/19 revealed various, vague concerns but there was no evidence of any resolution to any of the concerns. Review of the care conference meeting, dated 03/27/19, revealed Resident #3 and family had concerns that were not written out and were very vague. Further review revealed there was no evidence 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 and record review the facility failed to ensure resident's code status were clearly and/or easily identified. This affected two of two residents reviewed for accuracy of code status (Residents #57 and #71). Findings include: 1. Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease required hemodialysis, atrial fibrillation and respiratory failure. On admission the resident had an order for a full code. The resident was admitted to the hospital 10/30/17 and Do Not Resuscitate Comfort Care Arrest (DNR CCA) paperwork was signed. When the resident returned to the facility on [DATE] an order for a full code was written. Review of the physician's order dated 10/29/18 revealed to change from full code to DNR CCA. Review of the occupational therapy evaluation dated 02/21/19 revealed the resident was a full code status. Review of the quarterly minimum data set (MDS) 3.0 dated 02/27/19 revealed the resident 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 observation, interview and record review the facility failed to ensure a resident was comprehensively assessed, care planned and had a physicians order for the use of a seatbelt while in his electric wheelchair. This affected one of one residents reviewed for restraints (Resident #57). Findings include: Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease that required hemodialysis, atrial fibrillation and respiratory failure. The resident was morbidly obese and required the use of an electric wheelchair for mobility. Review of the occupational therapy evaluation dated 02/21/19 revealed the resident was referred to therapy to instruct the resident on the use of the new electric wheelchair. There was no mention of a seatbelt with the wheelchair. Further review of the therapy re-evaluation from 04/12/19 through 05/10/19 revealed the resident needed additional education on use of the electric wheelchair because he have having…

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 interviews, the facility failed to re-evaluate a resident via a Pre-admission Screening and Resident Review (PASARR) after being newly diagnosed with psychosis. This affected one (Resident #6) of one resident reviewed for PASARR assessments. Findings include: A record review of the medical record of Resident #6 revealed he was admitted on [DATE] with diagnoses of delusional disorders, hallucinations, bipolar disorder, psychosis and mild cognitive impairment. His diagnosis of bipolar disorder was entered on 12/29/16 and diagnosis of unspecified psychosis entered on 05/21/18. Record review of the PASARR assessment dated [DATE] revealed there were no indications of serious mental illness. There were no other PASARR assessments completed since 06/28/16. The care plan of Resident #6 dated 07/05/18 revealed this resident had psychotic symptoms and staff were to monitor his behaviors. He had the potential for altered behavior patterns, disruptive interactions, disruptive verbal behaviors,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a comprehensive care conference for a resident to ensure all concerns were addressed. This affected one of one residents reviewed for care conferences (Resident #3). Findings include: Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses which included Traumatic Brain Injury and Cerebral Vascular Accident with right sided hemiparesis. Review of the care conference meeting, dated 03/27/19, revealed Resident #3 and family had concerns with dietary and nursing that were not written out and were very vague. Review of the sign in sheet revealed there were only three staff involved in the meeting including Social Service Designee (SSD) #117, activities aid (AA) #122 and wound nurse, Licensed Practical Nurse, (LPN ) #123. Further review revealed there was no evidence of the facility addressing the concerns. Review of the communication from Social Service Designee (SSD) # 117 to Dietary Manager (DM) #118…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident had a comprehensive bladder program in place when the resident needed assistance of staff for toileting to ensure the resident was able to maintain as much continence as possible. This affected one of one residents reviewed for bladder incontinence (Resident #12). Findings include: Record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease requiring continuous oxygen and respiratory failure with hypoxia. Review of the three day tracker revealed it was only completed one day on 07/06/18 which indicated the resident was continent of bladder. Further review revealed no comprehensive assessment or care plan were completed and implemented. Review of the admission minimum data set (MDS) 3.0 dated 07/11/18 revealed the resident was cognitively intact but needed extensive assistance of two staff for activities of daily living (ADL) including…

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 provide timely and effective pain management for Resident #60's continued pain following a fall. This affected one (Resident #60) of three residents reviewed for falls. The facility census was 102 residents. Findings include: Review of Resident #60's medical record revealed an admission date of 03/30/18 with diagnoses that included dementia and unsteadiness on feet. An annual Minimum Data Set 3.0 (MDS) assessment revealed Resident #60 had severely impaired cognition and required extensive assist with transfers and ambulation. The resident had a physician's order dated 03/30/18 for acetaminophen 650 milligrams (mg) every four hours for pain as needed (PRN). Review of the medication administration record (MAR) since January, 2019 indicated Resident #60 used the PRN acetaminophen one time prior to 02/07/19. Review of the progress notes revealed on 02/07/19 at 8:00 A.M. Resident #60 was found on the floor next to her bed by staff members. The resident complained of pain to the shoulder at that time. 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 observation, interview and record review the facility failed to ensure coordination of care for a resident who received hemodialysis from an outside facility. This affected one of one residents reviewed for dialysis (Resident #57) and affected four of four residents on fluid restrictions (Resident's #96, #2, #10 and #57) . Findings include: Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease requiring hemodialysis (HD). The resident had physician ordered medications to be given daily in the morning as well as a physician's order to monitor fluid intake. Review of the quarterly minimum data set (MDS) 3.0 dated 02/27/19 revealed the resident was cognitively intact. a) Review of the facility's Intake and Output Recoding Tool Guidelines, revised May 2014, revealed measurements of fluid would be initiated with a physicians order. Review of the physicians order dated 08/13/18 revealed the resident was to be on an 1800 cubic…

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.