Alpine Nursing and Rehabilitation Center

Based on medical record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure resident rooms were free from pests. This affected one (Resident #23) of 17 residents reviewed for the physical environment. The facility census was 69 residents. Findings include: Review of the medical record for Resident #23 revealed an admission date of 01/17/25 with diagnoses including e muscular dystrophy, depression, and opioid dependence. Review of the Minimum Data Set (MDS) assessment for Resident #23 dated 04/23/25 revealed the resident #23 had intact cognition and required set up and supervision with activities of daily living (ADLs.) Observation on 05/18/25 at 2:46 P.M. of Resident #23's room revealed there were five ants on bedside table and four ants on windowsill and wall. Observation on 05/20/25 at 9:45 A.M. of Resident #23's room revealed there were 10 ants in total on the bedside table, wall, and windowsill. Interview on 05/20/25 at 9:46 A.M. with Resident #23 confirmed he had ants present in his room for weeks, he had reported it, but…

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, staff and resident interviews and policy review, the facility failed ensure meals were palatable. This affected three (Residents #31, #59 and #57) of three residents reviewed for food. The facility identified two residents who couldn't eat anything by mouth. The census was 73. Findings include: Review of the menu dated 04/07/25 revealed lunch consisted of a peppered hamburger patty, buttered noodles, green beans, and white cake. A test tray was obtained on 04/07/25 at 11:50 A.M. The meat was crispy around the edges and was tough. The noodles were over cooked and tasted mushy and the green beans were bland. During an interview on 04/07/25 at 11:55 A.M., Dietary Manager (DM) #171 stated if she cooks the noodles el [NAME], the residents complain they are too hard. This is the way the residents like the noodles. Se said to get the beef pepper patties done and up to temperature they had to be cooked this way. She admitted the foods were over cooked. During an interview on 04/07/25 at 12:55…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interviews, and policy / procedures the facility failed to perform incontinence care in a sanitary manner. This affected one (#19) out of three residents reviewed for incontinence care. The facility census was 67. Findings include: Review of the medical record for Resident #19 revealed an admission date of 04/11/28 with diagnoses of cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid artery, hypertensive heart disease with heart failure, and obesity. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate cognitive impairment. Resident #19 required setup assistance with eating, substantial assistance with personal hygiene, and was dependent on staff assistance with oral hygiene, toileting hygiene, bathing, dressing, bed mobility. Review of the care plan dated 06/24/22 revealed Resident #19 had bladder and bowel incontinence, with interventions to assist resident to the bathroom as needed and to provide…

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 and staff interviews, the facility failed to provide a safe environment for the residents when a window air-conditioning unit in the dining room had exposed wires and coils. This had the potential to affect 41 residents (#102, #107, #109, #110, #112, #116, #118, #119, #120, #122, #125, #126, #127, #128, #129,#130, #131, #134, #135, #136, #138, #139, #142, #143, #144, #145, #146, #147, #149, #151, #152, #153, #154, #156, #158, #159, #161, #162, #163, #164, and #167) who the facility identified who were cognitively impaired and mobile. The facility census was 71. Findings include: Observations on 05/15/24 at 10:20 A.M. in the dining room, was a window air conditioning unit plugged into electrical outlet. The air conditioning unit had exposed coils, wires, and a thick layer of dust with debris and cobwebs covering the exposed internal components of the unit. On the wall in the dining room was a thermostat with no dial with a typed note Do not change setting on the thermostat, and fan, doing so can cause the system to overheat and could cause a fire. For residents…

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, review of the facility policy, and resident and staff interview the facility failed to ensure the residents had access to their call light. This affected one (Resident #200) of two residents reviewed for call light accessibility and functioning. The facility census was 71. Findings include: Review of the medical record for Resident #200 revealed an admission date of 07/25/19. Diagnoses included right hip fracture, seizure disorder, left below the knee amputation, traumatic brain injury, and vascular dementia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 had intact cognition. Resident #200 required partial/moderate assistance from staff with oral hygiene and substantial/maximal assistance to dependent on staff for toileting, bathing/shower, upper body dressing, and lower body dressing. Review of the plan of care dated 06/14/22 revealed Resident #200 was at increased for risk for falls with interventions to have commonly used…

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 interviews, and policy review, the facility failed to complete an assessment and implement a treatment for a newly developed pressure ulcer. This affected one (#43) out of three residents reviewed for pressure ulcers. The facility census was 65. Findings included: Review of the medical record Resident #43 revealed an admission date of 09/01/16 with medical diagnoses of chronic obstructive pulmonary disease, chronic respiratory failure, peripheral vascular disease, and hypertension. Review of the medical record for Resident #43 revealed an annual Minimum Data Set (MDS), dated [DATE], which indicated Resident #43 was cognitively intact and required substantial/maximum staff assistance for bed mobility, bathing, transfers, and toileting. The MDS indicated Resident #43 was always incontinence of bladder and frequently incontinent of bowel. The MDS indicated Resident #43 did not have any pressure ulcers. Review of the medical record for Resident #43 revealed a nurse's note dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and policy review, the facility failed to ensure personal protective equipment was worn in resident areas to prevent the potential spread of infection. In addition, the facility failed to ensure contaminated linens and trash were handled to prevent the potential spread of infection. This had the potential to affect all 63 residents at the facility. 1. Observation and interview on 08/22/22 at 8:52 A.M. State Tested Nurse Aide (STNA) #563 walked out of Resident #213 room. The STNA was wearing a N95 mask, eye protection, and an isolation gown. She walked down the walkway along the common area with no residents present and turned left out of view. The STNA returned within minutes carrying bath linens. The STNA #563 stated when she was given report at 6:00 A.M. she was told all residents on the corner were in isolation and believed she did not have to remove her gown if she was not entering another resident room or leave the isolated section of rooms. She then stated 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 medical record review, review of the Preadmission Screening and Resident Review, and staff interview, the facility failed to update a resident's Preadmission Screening and Resident Review (PASARR) when a new diagnosis of schizophrenia was added. This affected one resident (#28) out of three residents reviewed for PASARR. The facility census was 63. Review of Resident #28 medical record revealed he was admitted to the facility on [DATE]. Diagnoses included dizziness and giddiness, history of traumatic brain injury, vascular dementia with behavioral disturbance, type II diabetes, post traumatic stress disorder, depression, phobic anxiety disorder, acquired absence of right leg below knee, hypertension, and epilepsy. On 08/07/19 a new diagnosis of schizophrenia was added to his diagnosis. Review of the quarterly Minimal Data Set (MDS) dated [DATE] revealed Resident #28 was cognitively intact. His functional status was listed as limited to extensive one person assistance for all activities daily living. 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 medical record review, review of the Agency on Aging determinations, review of the hospital exemption form, and staff interview, the facility failed to complete the Preadmission Screening and Resident Review. This affected two residents (#19 and #42) out of three residents reviewed for Preadmission Screening and Resident Review. The census was 63. Findings include: 1. Medical Record Review for Resident #42 revealed admission date of admission date of 07/27/12. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, aphasia, dysphagia, major depressive disorder, dementia, post polio syndrome, contracture, unspecified joint, psychosis not due to a substance or known physiological condition, and anxiety disorder. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident had impaired cognition. Review of the Agency on Aging dated 11/08/12 revealed Pre-admission Screening (PAS) Determination was not applicable. Level of Care Determination effective date 09/08/12,…

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, review of the facility incidents, and policy review, the facility failed to ensure a fall investigation was completed and root cause was identified post resident fall. This affected one resident (#15) out of 20 sampled residents. The facility census was 63. Review of the medical record for Resident #15 revealed an admission date of 11/03/21. Diagnosis included obstructive and reflux uropathy, pseudobulbar affect, personal history of Covid-19, dementia, and adult failure to thrive. Review of the quarterly minimum data set (MDS) assessment dated on 06/23/22 revealed Resident #15 had severe cognitive impairment. Resident #15 required total dependence for bed mobility, dressing, bathing, and personal hygiene. Resident was setup assistance for all meals. Resident #15 required extensive one-person assistance for toilet use, and transfers. The resident used a wheelchair for ambulation. Review of the plan of care dated on 07/11/22 revealed Resident #15 was at risk 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure weights were monitored per recommendation. This affected one resident (#42) out of seven residents reviewed for nutrition. The census was 63. Findings include: Review of the medical record for Resident #42 revealed admission date of 07/27/12. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, aphasia, dysphagia, major depressive disorder, dementia, post polio syndrome, contracture, unspecified joint, psychosis not due to a substance or known physiological condition, and anxiety disorder. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #42 had impaired cognition. The resident required total assistance of two persons for bed mobility and transfers. The resident had a functional limitation in Range of Motion (ROM) on one side of the upper extremity and impairment on both sides of the lower extremities. The resident required supervision with setup help only for eating.…

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 comprehensively document care provided for residents. This affected two residents (#54 and #61) of 24 resident record reviews. The census was 63. Findings include: 1. Medical Record Review for Resident #54 revealed admission date of [DATE]. Diagnoses included neoplasm of uncertain behavior of spinal cord, pressure ulcer unspecified site, stage III, pressure ulcer of sacral region, unspecified stage, and severe protein calorie malnutrition. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had intact cognition. The resident required extensive one person assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident required supervision set up help only for eating. The resident had a pressure ulcer/injury. The resident had one stage three pressure ulcer and two stage four pressure ulcers, one upon admission/entry or reentry.…

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, staff interview and review of medication storage policy, the facility failed to properly label drugs and biological's used in the facility and the facility failed to ensure medication carts were secure. This directly affected two Residents (#70 and #62) of two whose medication were observed opened and undated. This had the potential to affect all residents. The facility also failed to ensure medication carts on the memory impaired unit were locked. Facility census was 67. Findings include: 1. Review of the medical record for Resident #70, revealed an admission date of 08/31/12. Diagnoses included acute angle-closure glaucoma, mood disorder, hemiplegia and heart failure. Review of the most recent Minimum Data Set (MDS) 3.0 assessment, dated 08/01/19, revealed the resident had moderately impaired cognition. Resident #70 had no behaviors, did not reject care, and did not wander. Resident was dependent or required extensive assistance for activities of daily living…

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 on cleaning glucometers and facility policy the facility failed to maintain an infection program. The facility failed to ensure a glucometer was cleaned between resident use. This directly affected three Residents (#15, #48 and #54) of three observed. The facility also failed to follow their Legionella plan. This had the the potential to affect all residents that resided in the facility. Facility census was 67. Findings include: 1. During observation on 08/28/19 at 8:25 A.M. revealed Licensed Practical Nurse (LPN) #5 completed a finger stick blood sugar (FSBG) on Resident #48 and returned the glucometer to the top of the medication cart. At 8:33 A.M., LPN #5 used the same glucometer and completed a FSBG on Resident #54. At 8:50 A.M., LPN #5 used the same glucometer and completed a FSBG on Resident #15. LPN #5 did not clean the glucometer in between residents use of the glucometer. Interview with LPN #5 on 08/28/18 at 8:55 A.M. verified she did not clean the glucometer between resident use when checked the residents…

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

Based on review of the infection control book, staff interview and review of facility policy the facility failed to ensure they had an infection prevention and control program (IPCP) that included antibiotic use and a system to monitor antibiotic use. This had the potential to affect all the residents that resided in the facility. Facility census was 65. Findings include: Review of the infection control book with infection control designee/Assistant Director of Nursing (ADON) #63 on 08/28/19 at 3:25 P.M. revealed the infection control book only contained surveillance, tracking and resident information that include infections and possible communicable disease for July and August 2019. The infection control book contained no evidence that included antibiotic use nor a system to monitor antibiotic use prior to July 2019. Interview with ADON #63 at the time of the review verified the facility had no evidence of an IPCP that included antibiotic use and a system to monitor antibiotic use. ADON #63 also verified the facility only had surveillance, tracking and resident information that…

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, gradual dose reductions (GDR) were made and responded to and acted upon timely. This affected three Residents (#2, #41, and #67) of five reviewed for unnecessary medication use. The facility census was 67. Findings include: 1. Medical record review for Resident #2 revealed an admission date of 11/30/15. Medical diagnoses included dementia without behavioral disturbance, encephalopathy, hypothyroidism, occlusion and stenosis of unspecified carotid artery, vitamin B deficiency, heart disease, hyperlipidemia, spinal stenosis, psychosis, depression. Review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the residents cognition was severely impaired. Resident #2 was noted as being totally dependent for activities of daily living (ADLs) and was noted as always being incontinent of both bladder and bowel. Further review of Resident #2's medical record revealed a pharmacy GDR request dated 04/24/19 which…

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 and safely store food items. This had the potential to affect all residents who consumed meals from the facility kitchen. The facility identified one resident (Resident #11) who did not consume food prepared by the kitchen staff. The facility census was 67. Findings include: Observation on 08/25/19 at 8:40 A.M. of the kitchen revealed an open-undated carton of potato salad, open-undated bags of shredded cheese, open-undated thickened juice, open-undated slices of pie and multiple miscellaneous leftovers without dates. There were also multiple open-undated cereals and pretzels in the dry storage area. The walk-in freezer had boxes of frozen meats sitting on the floor in the freezer that had not been placed on the shelves. Interview on 08/25/19 at 8:55 A.M. with Dietary [NAME] (DC) #35 confirmed the open and undated products in the walk-in cooler and in the dry storage. DC #35 also confirmed the boxes of frozen meat in the walk-in freezer that were sitting directly on the floor. 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 medial record review, observation and staff interview the facility failed to provide meals to all of the residents at a table at the same time. This affected one Resident (#24) of 17 residents observed eating in the dining area on the secured unit. The facility census was 67. Findings include: Review of Resident #24's medical record revealed the resident was admitted [DATE] with diagnoses including a left femur fracture and dementia. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive deficit. The MDS also identified the resident required extensive one-person assistance for bed mobility, transfer, dressing, toileting and personal hygiene. The resident required only supervision for eating. Review of care plan dated 06/14/19 revealed the resident had a potential nutritional risk related to her femur fracture and dementia. Observation of dining on 08/25/19 from 11:50 A.M. to 12:25 P.M. revealed two State Tested Nursing Assistants (STNAs) #15 and #62 were assisting…

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, personal funds statement review, staff interview and review of facility policy the facility failed to provide a spend down letter to residents and/or the resident's representative when the resident's personal trust fund account was $200 less than Social Security Income (SSI) resource limit. This affected one Resident (#11) of five reviewed for personal funds accounts. The facility census was 67. Findings include: Review of the medical record revealed Resident #11 was admitted to the facility on [DATE]. Diagnoses included heart disease, tracheostomy, gastrostomy, atrial fibrillation, chronic respiratory failure, epilepsy, type two diabetes, and major depressive disorder. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #11 was severely cognitively impaired with delirium, inattention and altered level of consciousness noted. The MDS also revealed the resident was totally dependent with one person assistance for bed mobility, locomotion, dressing, eating,…

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, facility record review and staff interview, the facility failed to provide the required Beneficiary Protection Notifications (BPN) when Medicare Part A residents were discharged from services with skilled days remaining. This affected three Residents (#16, #323 and #324) of four residents reviewed for BPN during the annual survey. The facility census was 67. Findings include: 1. Review of the facility BPN and medical record review revealed Resident #16 was admitted to the facility on [DATE], and discharged from Medicare Part A Services on 03/22/19 with skilled days remaining. The resident remained in the facility. Further review of the BPN revealed Resident #16 was only provided the Notice of Medicare Non-Coverage (NOMNC) form and was not provided the required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN). Interview conducted on 08/27/19 at 11:38 A.M., Social Services (SS) #75 stated he was only able to find verification Resident #16 was provided 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 medical record review, staff and resident interviews, review of concern forms, review of facility self-reported incidents (SRI), and review of facility policy, the facility failed to implement their abuse and misappropriation policy when they failed to report to the state agency. This affected one Resident (#10) of 24 residents reviewed. The facility census was 67. Findings include: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, hypertension, orthostatic hypotension, type two diabetes, schizoaffective disorder, absence of left leg above the knee, falls, and chronic obstructive pulmonary disease. Review of the five day Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact with no behaviors. Review of the Resident/Family/Staff Concern form dated 05/17/19 revealed Resident #10 reported his laptop missing. Social Service (SS) #75 noted both resident rooms (previous and current) 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 medical record review, staff and resident interviews, review of concern forms, review of facility self-reported incidents (SRI), and review of facility policy, the facility failed to ensure allegations of misappropriation of property were reported to the state agency. This affected one Resident (#10) of 24 residents reviewed. The facility census was 67. Findings include: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, hypertension, orthostatic hypotension, type two diabetes, schizoaffective disorder, absence of left leg above the knee, falls, and chronic obstructive pulmonary disease. Review of the five day Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact with no behaviors. Review of the Resident/Family/Staff Concern form dated 05/17/19 revealed Resident #10 reported his laptop missing. Social Service (SS) #75 noted both resident rooms (previous and current) were searched,…

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 interviews, review of concern forms, review of facility self-reported incidents (SRI), and review of facility policy, the facility failed to thoroughly investigate allegations of misappropriation of property. This affected one Resident (#10) of 24 residents reviewed. The facility census was 67. Findings include: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, hypertension, orthostatic hypotension, type two diabetes, schizoaffective disorder, absence of left leg above the knee, falls, and chronic obstructive pulmonary disease. Review of the five day Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact with no behaviors. Review of the Resident/Family/Staff Concern form dated 05/17/19 revealed Resident #10 reported his laptop missing. Social Service (SS) #75 noted both resident rooms (previous and current) were searched, staff and residents…

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 provide a notice of transfer/discharge to the resident's representative upon being transferred to the hospital. This affected two Residents (#10 and #48) of four reviewed for hospitalization. The facility census was 67. Findings include: 1. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, hypertension, orthostatic hypotension, type two diabetes, schizoaffective disorder, absence of left leg above the knee, falls, and chronic obstructive pulmonary disease. Review of the five day Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact with no behaviors. Review of Section E-Behaviors revealed no behaviors were noted. Review of Section G-Functional Status revealed the resident required extensive one-person assistance with bed mobility, toileting, personal hygiene, dressing, transfer, supervision with setup assistance with eating,…

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 provide a bed hold notice to the resident's representative upon being transferred to the hospital. This affected two residents (#10 and #48) of four reviewed for hospitalization. The facility census was 67. Findings include: 1. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, hypertension, orthostatic hypotension, type two diabetes, schizoaffective disorder, absence of left leg above the knee, falls, and chronic obstructive pulmonary disease. Review of the five day Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact with no behaviors. Review of Section E-Behaviors revealed no behaviors were noted. Review of Section G-Functional Status revealed the resident required extensive one-person assistance with bed mobility, toileting, personal hygiene, dressing, transfer, supervision with setup assistance with eating, limited…

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 complete a significant change Minimum Data Set as(MDS) with the required 14 days for residents with a significant change in status. This affected two Residents (#35 and #48) of 20 residents reviewed for MDS assessments during the investigation stage of the annual survey. The facility census was 67. Findings include: 1. Review of Resident #35's medical record revealed being originally admitted on [DATE] and readmitted on [DATE]. Medical diagnosis included cerebral infarction, need for assistance with personal care, hemiplegia and hemiparesis, malignant neoplasm of unspecified part of bronchus or lung, acute or chronic respiratory failure, muscle wasting or or atrophy, muscle weakness, cognitive communication deficit, dysphagia, hyperlipidemia, chronic kidney disease, anemia, arteriosclerotic heart disease, hypertension and peripheral vascular disease. Review of the quarterly MDS assessment dated [DATE] revealed Resident #35 was cognitively…

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 Minimum Data Set (MDS) assessment data, and staff and resident interviews, the facility failed to accurately code data on the resident MDS assessment. This affected one (Resident #26) of 24 residents reviewed during the investigation stage of the annual survey. The facility census was 67. Findings include: Review of the medical record revealed Resident #26 was admitted to the facility 06/27/18 with diagnoses including hemiplegia and hemiparesis following a cerebrovascular disease, type two diabetes, major depressive disorder, and gastro-esophageal reflux disease. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was cognitively intact, with no behaviors noted. Review of Section G-Functional Status revealed the resident required total one-person dependence with bed mobility, extensive one-person assistance with transfers, toileting, extensive two-person assistance with personal hygiene, supervision and setup with locomotion, 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 record review and staff interview the facility failed to ensure residents had complete and accurate care plans. This affected one Resident (#48) of 20 residents care plans reviewed during the investigation phase of the annual survey. The facility census was 67. Findings include: Review of Resident #48's medical record revealed being admitted on [DATE] with diagnoses including fracture of the left tibia, heart failure and altered mental status. Review of the minimum data set (MDS) dated [DATE] revealed the resident had severe cognitive decline. The resident required total dependence for bed mobility, transfers, toileting, dressing and personal hygiene. The resident required only supervision for eating. The resident received medications including anticoagulants, antipsychotics and antidepressants. Review of Resident #48's physician order dated 05/24/19 revealed Eliquis (anticoagulant) five milligrams, give one tablet by mouth two times a day. Review of Resident #48's plan of care dated 07/19/19 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interview, and review of facility policy, the facility failed to complete and revise resident care plans. This affected four Residents (#26, #34, #35 and #57) of 24 reviewed during the investigation stage of the annual survey. The facility census was 67. Findings include: 1. Review of the medical record revealed Resident #26 was admitted to the facility 06/27/18 with diagnoses including hemiplegia and hemiparesis following a cerebrovascular disease, type two diabetes, major depressive disorder, and gastro-esophageal reflux disease. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was cognitively intact, with no behaviors noted. Review of Section G-Functional Status revealed the resident required total one-person dependence with bed mobility, extensive one-person assistance with transfers, toileting, extensive two-person assistance with personal hygiene, supervision and setup with locomotion, one person assistance with dressing,…

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, family and staff interview, review of After Visit Summary, review of Medication Error log and review of facility policy the facility failed provide medications with professional standard of quality when a nurse hid medications in food and left the food unattended. This affected two residents (#27 and #60) of 17 residents who received medications on the memory care unit. The facility census was 67. Findings include: 1. Review of Resident #60's medical record revealed the resident was admitted on [DATE] with diagnoses including dementia without behavioral disturbance, history of falling and malignant neoplasm of the large intestine. Review of Resident #60's Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive deficit. The resident required extensive one-person physical assistance for bed mobility, transfers, eating, dressing and toileting. The resident required total dependence for personal hygiene. Review of Resident #60's plan of care dated 03/25/19…

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, observation, and staff interview, the facility failed to provide mouth care for a dependent resident. This affected one Resident (#11) of one reviewed for activities of daily living (ADL's). The facility census was 67. Findings include: Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including heart disease, tracheostomy, gastrostomy, atrial fibrillation, chronic respiratory failure, epilepsy, type two diabetes, and major depressive disorder. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #11 was severely cognitively impaired with delirium inattention and altered level of consciousness noted. Review of Section E-Behaviors revealed the resident had rejection of care and physical behavioral symptoms directed towards others was noted one to three days during the lookback period. Review of Section G-Functional Assessment revealed the resident was totally dependent with one-person assistance with 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 medical record review, observations and staff interview, the facility failed to ensure a resident was provided with activities per the plan of care. This affected one Resident (#17) of two reviewed for activities. The facility census was 67. Findings include: Medical record review for Resident #17 revealed an admission date of 02/28/15. Medical diagnoses included encounter for attention to gastrostomy, dysphasia oropharyngeal phase, feeding difficulties, dementia, hypotension, anemia, hyperlipidemia, Alzheimer's, chronic kidney disease, type two diabetes mellitus, anemia, adult failure to thrive, depression, and hypertension. Review of Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed, the resident's cognition was severely impaired and the resident required extensive assistance with activities of daily living (ADL's). Review of Resident #17's care plan revealed Resident #17 would participate in activities of her choice two times per week to promote socialization 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, family interview, staff interview and review of hospital records, the facility failed to provide timely care for one resident and failed to provide proper positioning for one resident. This affected Resident (#61) reviewed for delay of care and Resident (#40) reviewed for positioning. The facility census was 67. Findings include: 1. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, myocardial infarction, heart disease, encephalopathy, stage four chronic kidney disease, and hallucinations. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired with delirium inattention and disorganized thinking behaviors continuously present. Review of Section G-Functional Status revealed the resident required total one-person assistance with bed mobility, locomotion, total two-person assistance with transfer, and walking…

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 resident and staff interview, the facility failed to ensure a resident was sent for an ophthalmology referral in a timely manner. This affected one Resident (#70) of one reviewed for vision. The facility census was 67. Findings include: Review of Resident #70's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dysarthria following unspecified cerebrovascular disease, mood disorder, generalized osteoarthritis, hypertension, peripheral autonomic neuropathy, anxiety, diaphragmatic hernia without obstruction or gangrene, psoriasis, benign prostatic hyperplasia without lower urinary tract symptoms, major depressive disorder, type 2 diabetes mellitus with hyperglycemia, kidney failure, anemia, and insomnia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had moderately impaired cognition with no delusions, hallucinations or behaviors. Resident #70 required extensive assistance for activities 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, resident and staff interview, and review of facility Smoking Policy, the facility failed to ensure a resident assessed to require supervision with smoking was not permitted to possess their own smoking materials. This affected one Resident (#26) of six observed for smoking. The facility census was 67. Findings include: Review of Resident #26's medical record revealed an admit date of 06/27/19 with diagnoses including hemiplegia, hemiparesis, cerebral infarction, encephalopathy, anemia, type 2 diabetes mellitus without complications, depression, insomnia, atrial fibrillation, cerebral atherosclerosis, gastro-esophageal reflux disease without esophagitis, vascular disease, anxiety, traumatic amputation of one unspecified lesser toe, subsequent encounter, hypertension, heart disease and aphasia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had no cognitive impairment with no delusions, hallucinations or behaviors. Resident #26…

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 monthly Medication Regimen Reviews (MRR) were performed. This affected three Residents (#2, #41, and #67) of five residents reviewed for unnecessary medications. The facility census was 67. Findings include: 1. Medical record review for Resident #2 revealed an admission date of 11/30/15. Medical diagnoses included dementia without behavioral disturbance, encephalopathy, hypothyroidism, occlusion and stenosis of unspecified carotid artery, vitamin B deficiency, heart disease, hyperlipidemia, spinal stenosis, psychosis, depression. Review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2's cognition was severely impaired. Resident #2 was noted as being totally dependent for Activities of Daily Living (ADLs) and was noted as always incontinent of both bladder and bowel. 2. Review of Resident #41's medical record revealed an admission date of 03/08/18. Diagnosis included difficulty 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 closed and open medical record review and staff interview, the facility failed to maintain residents medical records in a complete and accurate manor. This affected two Resident's #21 and #35) of six reviewed. The facility census was 67. Findings include: 1. Review of the closed medical record revealed Resident #21 was admitted to the facility [DATE]. The resident expired on [DATE]. Further review of the medical record revealed no documentation of the resident expiring and of the release of her body. Review of the last progress note dated [DATE] at 11:43 A.M. revealed hospice was with the resident full time. The resident was resting comfortably in her bed with no verbal vocalization, only moans and groans noted. The resident was able to take her medication orally. The daughter called to check on the resident and spoke with her briefly. Interview conducted on [DATE] at 8:55 A.M., Licensed Practical Nurse (LPN) #18 verified the medical record did not contain documentation of Resident #21's death. LPN #18…

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.