Laurels Of Norworth The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to provide parameters for as needed pain medication. This affected one (Resident #62) of five residents reviewed for unnecessary medications. The facility census was 115. Findings include: Review of Resident #62's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included paraplegia and chronic pain syndrome. Review of the Minimum Data Set (MDS) assessment, dated 12/22/24, revealed Resident #62 was cognitively intact. Review of Resident #62's physician orders, dated December 2024 to February 2025, revealed an order for acetaminophen 650 milligrams (mg) every four hours as needed (PRN) for pain or fever. Also, there was an order for Oxycodone (narcotic pain medication) 15 mg every four hours as needed for pain. Neither medication had parameters as to which pain medication should be administered and what pain level each medication should be given at. Review of Resident #62's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to monitor behaviors and did not provide appropriate justification for a psychotropic medication for one (Resident #80) of five residents reviewed for unnecessary medications. The facility census was 115. Findings include: Review of the medical record for Resident #80 revealed an admission date of 10/03/24 with diagnoses including vascular dementia with behavioral disturbances. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #80 had severe cognitive impairment, and documentation of verbal behaviors. Review of the physician orders for Resident #80 revealed the following medication: Seroquel (Quetiapine Fumarate) 50 milligrams (mg) - Administered twice daily for vascular dementia behaviors, ordered on 10/31/24 with no stop date. Ativan (Lorazepam) 0.5 mg - Administered every four hours as needed for anxiety and agitation, with multiple renewal orders from 11/12/24 through 02/12/25. Trazodone HCl 50 mg -…

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, resident and staff interview, observation , review of policy, and review of the resident agreement, the facility failed to timely obtain routine dental services for residents. This affected two (Resident #60 and Resident #103) of two residents reviewed for dental services. The facility census was 115. Findings include: 1. Review of the medical record for Resident #103 revealed an admission date of 12/10/24 with diagnoses of epilepsy, type two diabetes mellitus, chronic kidney disease, mild cognitive impairment, and personal history of transient ischemic attack. Review of the Minimum Data Set (MDS) 3.0 assessment completed 12/17/24 revealed Resident #103 had moderate cognitive impairment and Resident #103 has no natural teeth or tooth fragments. Review of the care plan dated 12/12/24 revealed Resident #103 was at risk for infection, pain, or bleeding in the oral cavity. Resident #103 has no teeth present, and dentures were at home. Interventions included dental consult as needed,…

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 the facilities infection control log, staff interview, and facility policy review, the facility failed to to follow appropriate antibiotic stewardship protocols. This affected two (Residents #39 and #90) of five residents reviewed for unnecessary medications. The facility census was 115. Findings include: 1. Record review revealed Resident #39 was admitted to the facility on [DATE]. Diagnoses included osteomyelitis of vertebra, paraplegia, and neuromuscular dysfunction of bladder. Review of the Minimum Data Set (MDS) assessment, dated 01/27/25, revealed Resident #39 was cognitively intact. Review of Resident #39's physician orders, dated October and November 2024, revealed the following antibiotics were ordered and administered: Hiprex one gram (gm) for prophylaxis, Amoxicillin 875-125 milligrams (mg) twice daily for wound infection for seven days starting on 11/23/24, bactrim 800-160 mg twice daily for prevention for 10 days starting on 11/25/24, and Doxycycline 100 mg…

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, staff interview, medical record review and review of facility policy, the facility failed to ensure pureed foods were prepared in a manner to maintain nutritive value. This affected one (#46) of three residents reviewed for diet orders. The facility identified two residents with physician ordered pureed diets. The facility census was 112. Findings include: Review of the medical record for Resident #46 revealed an admission date of 08/02/24. Diagnoses included cerebral infarct (stroke), epilepsy, malnutrition, dementia and heart disease. Review of a physician order dated 08/02/24 revealed Resident #46 had an order for pureed diet. Review of the care plan dated 08/02/24 revealed Resident #46 had a nutritional risk related to mechanically altered diet and requiring assistance with meals. Interventions included to provide diet as ordered (regular diet, puree texture.) Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 was severely cognitively impaired 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, medical record review, review of a dietary meal ticket and staff interview, the facility failed to ensure diet textures were served per physician orders. This affected one (#77) of three residents reviewed for diet orders. The facility identified two residents with physician ordered pureed diets. The facility census was 112. Findings include Review of the medical record for Resident #77 revealed an admission date of 10/03/24. Diagnoses included respiratory failure with hypoxia, diabetes, chronic kidney disease, failure to thrive, vascular dementia, pneumonia muscle weakness and dysphasia. Review of the care plan dated 10/03/24 revealed Resident #77 had a nutritional risk related to mechanically altered/therapeutic diet and required assistance with meals. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 was severely cognitively impaired and required supervision/touching assistance with eating. The assessment also revealed the resident received a mechanically…

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, medical record review, review of Enhanced Barrier Precautions (EBP) signage, staff interview and review of facility policy, the facility failed to follow infection prevention guidelines for EBP when staff failed to wear appropriate personal protective equipment (PPE). This affected one (#28) of three residents reviewed for infection control. The facility census was 112. Findings include: Review of Resident #28's medical record revealed an admission date of 02/18/24 with pertinent diagnoses of: cerebral infarction, type two diabetes mellitus, chronic kidney disease and gastrostomy status. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/27/24, revealed Resident #28 was cognitively intact and used a wheelchair to aid in mobility. Further review revealed Resident #28 was always incontinent of bowel and bladder and used a feeding tube. Review of a physician order dated 08/01/24 revealed Resident #28 had an order to cleanse percutaneious endoscopic gastrostomy (PEG) tube (feeding tube placed through the stomach wall) site with wound cleanser and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interview, and policy review, the facility failed to obtain resident consent prior to searching a resident's personal possessions and removing personal items without resident knowledge. This affected one (#26) of three residents reviewed for personal property. The facility census was 108. Findings included: Review of the medical record review for Resident #26 revealed an admission date of 10/27/23. Medical diagnoses included traumatic spinal cord dysfunction, paraplegia, and neurogenic bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was assessed as cognitively intact. Resident #26 was independent for eating, independent for bed mobility, dependent for transfers, and substantial/maximal assistance for toileting. Review of Resident #26's medical record revealed a note dated 02/17/24 that the resident returned from a hospital visit. Interview with Resident #26 on 03/11/24 at 10:30 A.M. revealed, while he was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interview, and policy review, the facility failed to medications were maintained in a safe and secure manner. This affected one (#26) of one residents reviewed for medication storage. The facility census was 108. Findings included: Review of the medical record for Resident #26 revealed an admission date of 10/27/23. Medical diagnoses included traumatic spinal cord dysfunction, paraplegia, and neurogenic bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as cognitively intact. Resident #26 was independent for eating, independent for bed mobility, dependent for transfers, and required substantial/maximal assistance for toileting. Review of Resident #26's medical record revealed no assessment was completed for self-administration of medications. Observation on 03/11/24 at 10:43 A.M. revealed a medication cup with medications inside of it on Resident #26's bedside table in the resident's room. Interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of exterminator reports, resident and staff interviews, the facility failed to act upon exterminator recommendations and maintain the facility to control mice and ants. This affected 12 (#3, #18, #26, #27, #34, #42, #48, #60, #64, #83, #89, and #90) and had the potential to affect all the individuals in the home. The census was 112. Findings include: Interview on 08/18/23 at 4:05 P.M., with Resident #83 revealed he thought he saw a mouse in his room about a month ago. Interview on 08/18/23 at 4:08 P.M., with Resident #64 revealed he saw a mouse in his room around 3:00 A.M. about a month and a half ago. Interview on 08/18/23 at 4:10 P.M., with Resident #89 revealed he saw a mouse outside. Interview on 08/18/23 at 4:12 P.M., with Resident #3 revealed she saw mice in her room a few days ago around the trash can. She told the nurse and two were caught. Interview on 08/18/23 at 4:14 P.M., with Resident #90 revealed she saw some mice in her room about a week ago. They caught two on a…

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, review of work orders, review of facility map, resident and staff interview, the facility failed to maintain safe, clean, sanitary resident rooms. This affected 62 (#1, #2, #3, #4, #5, #7, #11, #12, #15, #17, #18, #22, #24, #25, #26, #27, #30, #31, #32, #33, #35, #36, #38, #39, #40, #42, #45, #46, #47, #50, #53, #54, #56, #57, #59, #65, #68, #69, #71, #75, #76, #78, #79, #83, #84, #85, #86, #87, #88, #89, #94, #97, #100, #101, #102, #104, #105, #109, #110, #113, #115, and #116) of 112 residents in the facility. The facility census was 112. Findings include: Observation on 08/18/23 between 4:37 P.M. and 6:15 P.M., of the resident rooms with the Administrator revealed the following: room [ROOM NUMBER]: the wall behind the beds needs patched and painted. room [ROOM NUMBER]: the wall by the air conditioner and below the picture to the right of the window needed painted. Both sides of the wall by bed A needed painted. room [ROOM NUMBER]: had a towel on the floor under the air conditioner 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview and facility policy review, the facility failed to ensure four residents ((#10, #31, #37 and #73), who were dependent on staff received care in the area of nail care and showers. This affected four of seven residents reviewed for activities of daily living (ADL). The facility census was 114. Findings Include: 1. Review of Resident #10's medical record revealed an initial admission date of 12/30/21 with diagnoses including atrial fibrillation, congestive heart failure, diabetes mellitus, adult failure to thrive, encephalopathy, chronic kidney disease, hypertension, anxiety disorder, dementia with behavioral disturbances and psychosis. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech, sometimes understands others, and has a severe cognitive deficit. The resident required extensive assistance of one for personal hygiene. Review of the plan of care dated 12/30/21 revealed the resident had a…

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, record review, facility policy review, and interview the facility failed to ensure residents smoking materials were stored in a safe and secure manner. This affected five residents (#74, #67, #16, #57, and #14) of five residents reviewed for smoking. The facility census was 114. Findings include: 1. Review of the medical record for Resident #74 revealed an admission date of 05/02/17. Diagnoses included schizophrenia, chronic obstructive pulmonary disease (COPD), abnormalities of gait and mobility, bipolar disorder, anxiety disorder, depression, schizoaffective disorder, tremor, and solitary pulmonary nodule. Review of the plan of care dated 12/01/21 revealed the resident had a potential risk of violating the smoking policy. Interventions included random checks of the resident's room as needed or indicated. Review of the Smoking assessment dated [DATE] revealed the resident was a safe smoker, followed smoking guidelines per facility policy, and returned smoking materials to the nursing…

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

Based on medical record review, observation, interview of facility staff, and facility policy, the facility failed to ensure medication was administered with a nurse at bed side and medications were stored in a safe and secure manner affecting two residents (#17, #74 ) out of four residents reviewed and failed to ensure that one medication cart was locked in patient care area. This had the potential to affect twelve residents ( #03, #06, #20, #21, #24, #35, #47,#50, #55, #59, #91, and #109) who were confused ,ambulatory, and wheelchair bound that propel independently. The facility census was 114. Findings Included: 1. Review of medical record revealed Resident #17 admission date of 10/06/21. Diagnoses included acute and chronic respiratory failure with hypoxia, type two diabetes mellitus, anxiety, obstructive sleep apnea, and psychoactive substance abuse. Review of quarterly Minimum Data Set (MDS) dated on 04/13/22 revealed a Brief Interview of Mental Status (BIMS) of 15 that indicated the resident was cognitively intact. Resident required for assistance supervision with one-person…

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, staff interview, and policy review, the facility failed to follow proper infection control and isolation precaution procedures regarding personal protective equipment (PPE) usage, incontinence care, and hand washing and did not disinfect the glucometer. This affected nine (Resident #365, #366, #367, #368, #73, #77, #88, #31, and #10) of 25 residents reviewed during the annual survey. In addition, the facility failed to cleanse a glucometer after use on one resident (#61) , which had the potential to affect five residents whom the facility identified as residing on unit three and utilizing the glucometer. The census was 114. Findings Include: 1. Observations on 07/11/22 from 11:51 A.M. to 11:57 A.M. revealed two State Tested Nursing Aides (STNA) walking into four separate rooms, who were on contact/droplet isolation precautions, without proper PPE. On 07/11/22 at 11:51 A.M., STNA #734 walked into Resident #365 room with only a mask and face shield on to provide a lunch…

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 staff interview, the facility failed to ensure contracted hospice documentation was available as part of the resident's medical record. This affected one (Resident #33) of one resident reviewed for hospice services. The facility census was 114. Findings Include: Review of Resident #33's medical record revealed an initial admission date 06/19/17 with the diagnoses of COPD, bipolar disorder, dementia with behavioral disturbances, CHF, hypertensive heart disease, anorexia, protein-calorie malnutrition, senile degeneration of brain, anemia, H/O COVID-19, thyrotoxicosis with diffuse goiter. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech, understood others, made herself understood and had a severe cognitive deficit. Review of the mood and behavior revealed the resident rejected care. The resident required extensive assistance of one with bed mobility and was independent with eating after set-up help. The assessment…

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, interviews and facility policy review, the facility failed to ensure one resident (#31) received incontinence care in a timely manner. This affected one of one resident reviewed for bowel and bladder incontinence. Additionally, the facility failed to ensure one resident's (#42) indwelling urinary catheter collection bag was positioned to promote optimal draining. This affected one of one resident reviewed for catheter care. The facility census was 114. Findings Include: 1. Review of Resident #31's medical record revealed an initial admission date of 11/01/21 with the diagnoses of anemia, orthostatic hypotension, chronic kidney disease, dementia, hypothyroidism, depression, protein-calorie malnutrition, cardiomegaly, chronic pain, osteoporosis, gastro-esophageal reflux disease, osteoarthritis, abnormal weight loss, irritable bowel syndrome (IBS), anxiety disorder, tremor and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE]…

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, observation, interview of staff, and policy, the facility failed to ensure that tracheostomy residents had the correct supplies. This affected one resident (#17) out of three tracheostomy residents reviewed. The facility census was 114. Findings Included: Review of medical record revealed Resident #17 revealed an admission date of 10/06/21. Diagnoses included acute and chronic respiratory failure with hypoxia, type two diabetes mellitus, anxiety, obstructive sleep apnea, and psychoactive substance abuse. Review of quarterly Minimum Data Set (MDS) dated on 04/13/22 revealed resident was cognitively intact. Resident required for assistance supervision with one-person physical assist with bed mobility, toilet use, and personal hygiene. Resident required supervision setup help only for dressing, and transfers. Resident required setup help for all meals. Resident plan of care dated on 07/14/22 revealed resident was at risk for difficulty in breathing and risk for respiratory complications related to acute on chronic respiratory failure with hypoxia. Interventions…

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, staff interview, and policy review, the facility failed provide appropriate parameters to ensure as needed pain medication was given in a consistent manner. This affected one (Resident #35) of five residents reviewed for unnecessary medications. The census was 114. Findings Include: Resident #35 was admitted to the facility on [DATE]. His diagnoses were encephalopathy, chronic respiratory failure, unspecified protein calorie malnutrition, type II diabetes, hypertensive heart disease, esophagitis, tracheostomy status, hyperlipidemia, insomnia, depression, cognitive communication deficit, and schizoaffective disorder. Review of his Minimum Data Set (MDS) assessment, dated 05/06/22, revealed he had a significant cognitive impairment. Review of Resident #35 medical records revealed he had a physician order for Morphine 15 milligrams (mg), 0.5 tablet every four hours as needed for moderate pain. Also, he had a physician order for Morphine 15 mg, one table every four hours as needed 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, record review, facility staff interview, policy review and manufacture administration directions, the facility failed to administer medication according to physicians order for one resident (#61) of five residents observed during medication pass, and failed to properly administer medication using an insulin pen for one resident (#61) of one resident observed receiving insulin. This resulted in a medication error rate of nine percent. The total facility census was 114. Findings Include: Observation of Resident #61 receiving medication on 07/13/22 at 8:31 A.M. revealed Licensed Practical Nurse (LPN) #500 administered the following medications to Resident #61: Aricept (acetylcholinesterase inhibitor) 10 milligram (mg), escitalopram (antidepressant)10 mg, Pepcid (H2 Blocker) 20 mg, Lantus (Antidiabetic) 10 units via insulin pen, and Humalog (Antidiabetic) 2 units via insulin pen. During the observation of the medication preparation for the insulin administration the LPN verified the correct resident insulin pens were obtained, and then dialed the pen to the dose…

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

Based on medical record review, observation, resident interview, staff interview, and policy review, the facility failed provide the appropriate diet to meet a residents needs. This affected one (Resident #73) of five residents reviewed for food. The census was 114. Findings include: Review of the medical record for Resident #73 revealed an admission date of 08/17/21. Diagnoses included type II Diabetes (DM2), hypertensive chronic kidney disease with stage I through stage IV chronic kidney disease (CKD), CKD stage III, thoracic region spondylosis with myelopathy, dementia, wedge compression fracture of the first lumbar vertebra, encephalopathy, personal history of COVID-19. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/21/22, revealed the resident had intact cognition with a Brief Interview of Mental Status (BIMS) score of 13 out of 15 (no impairment). The resident required extensive assistance of one to two or more staff members for all Activities of daily Living (ADL's) except eating which she required set up and was independent. Review of 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, resident interview, staff interview, and policy review, the facility failed to ensure all call lights were functioning appropriately. This affected one (Resident #27) of one call lights attempted for functionality. The census was 114. Findings Include: Observations on 07/11/22 from 2:55 P.M. to 3:05 P.M. revealed surveyor pushing Resident #27 call light button five times; the call light did not activate the light above her entry door to her room, and it did not activate the light inside the room as well. The call light was plugged into the wall appropriately; the call light was simply not activating the signal to let others know she needed assistance. Director of Nursing and Plant and Maintenance Director #791 walked into Resident #27 room at approximately 3:05 P.M., both attempted to activate the call light, and it did not work for them either. Plant and Maintenance Director #791 left the room to get a new call light cord. Resident #27 was admitted to the facility on [DATE]. Her diagnoses…

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

Based on observation, staff interview, and review of facility policy, the facility failed to ensure food was stored correctly and not expired. This affected 111 of 113 residents who receive food from the kitchen (Residents #15 and #54 receive nothing by mouth). The facility census was 113. Findings Include: 1. Observation on of the dry storage area in the kitchen on 12/09/19 at 9:33 A.M. revealed a bag of flour open, uncovered, and exposed to the air. Interview with Dietary Manager (DM) #172 on 12/09/19 at 9:33 A.M. verified the bag of flour was open, uncovered, and exposed to the air. 2. Observation of the reach in refrigerator on 12/09/19 at 9:36 A.M. revealed an undated container of applesauce. Interview with DM #172 on 12/09/19 at 9:36 A.M. verified the container of applesauce was undated. 3. Observation of the kitchen on 12/11/19 at 11:22 A.M. revealed an unopened bag of white bread with a best by date of 12/03/19 next to the tray line. The observation further revealed an opened bag of white bread with a best by date of 12/03/19 on the wooden prep table next to the stove.…

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, staff interview, review of manufactures instructions for cleaning glucometers, review of Centers for Disease Control and prevention (CDC) recommendations, and review of facility policy, the facility failed to properly cleanse a glucometer device. This had the potential to affect 24 Residents (#4, #9, #10, #27, #29, #33, #37, #40, #44, #47, #50, #56, #65, #75, #80, #82, #83, #100, #102, #103, #104, #105, #260 and #309) of 113 residents the facility identified as using the glucometer device. The facility also failed to wear appropriate personal protection equipment (PPE) when providing wound care to a resident on contact isolation. This affected one Resident (#259) of three residents the facility identified as being on contact isolation. Lastly, the facility failed to post a sign outside one Resident's (#100) of three the facility identified who was n contact isolation. The facility census was 113. Findings include: 1. Observation of medication administration on…

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

Based on observation, staff interview and review of facility policy, the facility failed to properly prepare pureed consistency vegetables. This had a potential to affect all eight residents (Resident #8, #24, #28, #65, #73, #91, #208 and #310) on a pureed diet. The facility census was 113. Findings Include: Observation in the kitchen on 12/11/19 at 11:28 A.M. revealed [NAME] #170 remove pureed vegetables from the oven. The pureed vegetables were observed to be semi-solid and brownish around the bottom and edges of the container. [NAME] #170 proceeded to transfer the pureed vegetables and brownish semi-solid pieces into a new container. [NAME] #170 then proceeded to stir the pureed vegetables and brownish semi-solid pieces together until surveyor intervened and showed [NAME] #170 the semi-solid brownish pieces that were not of a pureed consistency. Interview with [NAME] #170 on 12/11/19 at 11:28 A.M. verified the semi-solid brownish pieces stirred within the pureed vegetables were not of pureed consistency. The interview further revealed [NAME] #170 had not noticed the semi-solid…

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 with residents and staff, medical record review and review of facility policies, the facility failed to maintain dignity for two residents. This affected two (Resident #2 and #54) of 23 residents reviewed for dignity. The facility census was 113. Findings include: 1. Review of Resident #54's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dementia, recurrent depressive disorder, anxiety, and contracture of the left knee. Review of the Minimum Data Set (MDS) assessment, dated 10/26/19, revealed she had a severe cognitive impairment and required extensive assistance with dressing. The resident did not reject care. Observation on 12/09/19 at 11:40 A.M. revealed Resident #54 was in a hospital gown watching television in her wheelchair in her room. Interview on 12/09/19 at 11:41 A.M. with State-Tested Nursing Assistant (STNA) #80…

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 review of the facility policy, the facility failed to ensure Resident #72's advance directive (code status) was accurately reflected in the medical record. This affected one (#72) of 23 residents reviewed for advanced directives. The facility census was 113. Findings include: Review of Resident #72's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included spinal stenosis, acute respiratory failure with hypoxia, morbid obesity and type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment revealed the resident was cognitively intact. Review of the physician orders, dated [DATE], revealed an order for a code status of Do Not Resuscitate(DNR)/Comfort Care (CC). (A DNR order indicates that a person will not receive cardiopulmonary resuscitation (CPR) in the event his or her heart stops beating. A DNRCC requires that only comfort measures be administered before, during, or after a person's heart or breathing stops).…

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 with residents, legal representatives and staff, and review of the facility policy, the facility failed to ensure care conferences occurred quarterly for two residents. This affected two (Resident #54 and #100) of 23 residents reviewed for timely care conferences. The facility census was 113. Findings include: 1. Review of Resident #54's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dementia, dysphagia, recurrent depressive disorder, anxiety, and contracture of the left knee. Review of the Minimum Data Set (MDS) assessment, dated 10/26/19, revealed she had a severe cognitive impairment. The last documented care conference in the resident's medical record was 06/13/19. Telephone interview on 12/10/19 at 12:49 P.M. with Resident #54's court-appointed Guardian revealed he had not been invited to nor attended a 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 medical record review, observation, interview with facility staff, review of the facility's activity calendar and review of the facility's policy, the facility failed to ensure the activity needs were met for one (Resident #4) of one resident reviewed for activity needs. The facility census was 113. Findings include: Review of Resident #4's medical record revealed she admitted to the facility 09/10/14. Diagnoses included dementia without behavioral disturbance and major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 12/02/19, revealed she had a severe cognitive impairment and required extensive assistance from staff with all activities of daily living except eating. Review of the comprehensive annual MDS assessment, dated 02/15/19, revealed it was important for her to do things with groups of people and participating in her favorite activities. Review of the care plan, last revised 08/01/19, revealed she had potential for impaired social interaction or social isolation related to depression and impaired cognition. The care plan stated her…

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, resident and staff interview and review of facility policy, the facility failed to administer oxygen per physician orders, date and label oxygen administration tubing and humidification bottle to prevent contamination, and failed to obtain a physician order for a resident to receive oxygen. This affected three (Resident #72, #82 and #103) of nineteen residents the facility identified as being on oxygen. The facility census was 113. Findings include: 1. Review of Resident #72's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included spinal stenosis, acute respiratory failure with hypoxia, morbid obesity and weakness. Review of the Minimum Data Set (MDS) assessment revealed the resident was cognitively intact. Review of the physician order, dated 11/04/19, revealed an order for oxygen (O2) at four liters per minute (LPM) via nasal cannula (NC) every shift. Review of the care plan, dated 11/05/19, revealed the resident had a potential 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, staff interview, medical record review and review of the facility policy, the facility failed to provide timely physician-ordered dental arrangements and services for one (Resident #4) of one resident reviewed for dental concerns. The facility census was 113. Findings include: Review of Resident #4's medical record revealed she was admitted to the facility 09/10/14. Diagnoses included dementia without behavioral disturbance, type two diabetes, and dysphagia. Review of the Minimum Data Set (MDS) assessment, dated 12/01/19, revealed she had a severe cognitive impairment and required extensive assistance from staff with personal hygiene. Review of a physician progress note, dated 03/21/19, revealed Resident #4 had bleeding gums, likely secondary to dental caries, gingivitis. The physician stated she would likely require multiple tooth extractions. Review of Resident #4's in-facility dental consult note, dated 03/21/19 and a physician order dated 03/21/19, revealed she was to have three teeth extracted by a dentist in the community. Review of a physician telephone…

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.