Beeghly Oaks Center For Rehabilitation & Healing

Based on observation, interview, review of survey history from 12/16/22 through 06/05/24, review of approved plans of correction, and review of the State Operations Manual the facility failed to ensure concerns were addressed in a timely manner and failed to ensure their Quality Assurance and Performance Improvement (QAPI) program committee thoroughly evaluated, identified areas in need of improvement, and prior deficient practices were being monitored to determine if the plan of correction was being implemented as written and corrections were being sustained. This has the potential to affect all 102 residents residing in the facility. Findings include: Review of the facility's survey tracking history revealed the facility had an annual survey completed on 12/16/22 and complaint surveys on 05/02/23, 06/14/23, 04/24/24 and 06/05/24 which all resulted in citations related to the kitchen and dining services. Review of the facility's written plan of corrections (POCs) for the repeated dietary concerns for the annual survey completed on 12/16/22, the complaint survey completed 05/02/23,…

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

Based on observation, interview and review of facility work orders the facility failed to ensure the facility kitchen had a working garbage disposal. This had the potential to affect 100 residents who received meals from the kitchen. The facility identified Residents #25 and #197 as not receiving meals from the kitchen. The facility census was 102. Findings include: Observation on 09/09/24 at 7:48 A.M. of the facility kitchen dish room revealed the table sink that led into the dishwasher did not have a garbage disposal or pipes connected at the bottom to catch food and water. Instead, there was a hole that opened under the table sink and there was a basin on the floor that was filled with brown water, food scraps and a mug. Kitchen staff were rinsing off the dirty dishes in the sink and water and food scraps fell from the sink into the basin on the floor. Follow up tour of the kitchen on 09/09/24 at 9:00 A.M. with Dietary Manager (DM) #576 revealed staff continued to use the table sink next to the dishwasher that did not have a garbage disposal. Review of facility work orders from…

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, record review, and facility policy review, the facility failed to promote an environment that maintained each residents' dignity by serving meal trays with no knives. This affected Residents #20 and #82 and had the potential to affect the remaining 15 residents (#8, #40, #49, #50, #53, #54, #67, #70, #83, #89, #147, #148, #149, #150, and #151) who resided on the 1200 hallway. The facility identified no residents on the 1200 hallway that received nothing by mouth. The facility also failed to ensure Resident #254's urostomy bag was covered with a privacy cover. This affected one resident (#254) of one resident reviewed for catheter care. The facility census was 102. Findings include: 1. Review of the medical record for Resident #20 revealed an admission date of 01/23/24 with medical diagnoses including anemia, type two diabetes mellitus, anxiety disorder, obstructive sleep apnea, chronic pain, muscle weakness, and chronic kidney disease stage three. Review of the physician's orders…

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, interview, and facility policy review the facility failed to maintain a safe, clean, comfortable and homelike environment including clean and sanitary tube feed pumps and poles. This affected three residents (#60, #84, and #197) out of five residents reviewed for tube feed, additionally one resident (#13) was affected out of five residents reviewed for a clean and sanitary environment. The facility census was 102. Findings include: 1. Review of Resident #13's medical record revealed and admission date of 04/14/23. Diagnoses included colon cancer, history of urinary tract infections, congestive heart failure, and dementia. Review of Resident #13's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. She was dependent on staff for toileting hygiene, and personal hygiene. Resident #13 was always incontinent of both bowel and bladder. Observation made on 09/09/24 at 2:59 P.M. of Resident #13's room revealed State Tested Nurse Aide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to ensure care plans were updated to include new interventions and needs. This affected four residents (#22, #60, #81, and #197) of 35 residents reviewed for care plans, and had the potential to affect all 102 residents in the facility. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 08/16/24. Diagnoses included panic disorder, depression, alcohol dependence, respiratory failure, and osteoarthritis. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively intact. She was independent for eating, dressing, toileting, and personal hygiene, and required supervision for showering. Review of the care plan dated 08/16/24 revealed Resident #22 used antipsychotic medications. Interventions included administering medications as ordered, monitoring for side effects, consulting with the pharmacy to consider dosage reductions, and discussing…

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, interview, and facility policy review the facility failed to ensure oxygen was administered and cared for appropriately for Residents #2, #35, and #252. This affected three residents (#2, #35, and #252) of four residents reviewed for respiratory care. The facility identified 21 residents (#1, #2, #5, #14, #17, #20, #24, #26, #31, #34, #35, #55, #87, #88, #91, #149, #151, #152, #247, #252 and #253) who used oxygen. The facility census was 102. Findings include: 1. Review of the medical record for Resident #35 revealed an admission date of 07/31/24. Diagnoses included depression, chronic respiratory failure, diabetes, anemia, heart failure, and chronic obstructive pulmonary disease (COPD). Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively intact. He was independent in eating, required supervision for oral and personal hygiene and required partial assistance for toileting, showering, and dressing. He was on oxygen.…

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

Based on observation, interview, and facility policy review the facility failed to ensure medications were not kept past the recommended storage dates, failed to ensure medications were not loose in the medication cart, failed to ensure medications were dated when opened, and failed to ensure medications were not expired. This was observed on the three carts (1200, 1300, and 1400) of four medication carts in the facility. This affected one resident (#82) and had the potential to affect all 80 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #11, #12, #13, #14, #15, #17, #18, #19, #20, #21, #23, #24, #25, #26, #27, #28, #29, #32, #33, #34, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #49, #50, #52, #53, #54, #56, #57, #58, #60, #61, #62, #64, #65, #66, #67, #68, #69, #70, #73, #74, #76, #79, #80, #82, #83, #84, #85, #86, #87, #88, #89, #93, #147, #148, #149, #150, #151, #152, #197) residing on the 1200, 1300, and 1400 units. The facility census was 102. Findings include: Observation on 09/12/24 at 2:15 P.M. of the 1200-unit medication cart revealed a vial of Novolog…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure transmission-based precautions (TBP) were implemented appropriately, oxygen and urostomy was cared for appropriately, hand hygiene was performed and enhanced barrier precautions (EHB) were followed. This affected five residents (Residents #24, #62, #71, #252 and #254) of eight reviewed for infection control and had the potential to affect all residents in the facility. The facility census was 102. Findings include: 1. Review of the medical record for Resident #71 revealed an admission date of 07/01/24. Diagnoses included hydrocephalus, depression, obstructive uropathy, urine retention, dementia, diabetes and venous insufficiency. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was severely cognitively impaired. He required set up help for eating and oral hygiene, substantial assistance for showering and was dependent for toileting. Review of the physicians' orders for September 2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review the facility failed to ensure Resident #60's representative was timely notified after a fall. This affected one resident (#60) of four residents reviewed for falls. The facility census was 102. Findings include: Review of the medical record revealed Resident #60 was admitted on [DATE]. Medical diagnoses included cerebral infarction due to thrombosis of right posterior cerebral artery, type two diabetes mellitus with diabetic chronic kidney disease, Bell's palsy, essential primary hypertension, dysphagia, epilepsy, and adjustment disorder with mixed anxiety and depressed mood. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was moderately cognitively impaired. Resident #60 required setup or clean-up assistance with eating, partial to moderate assistance for oral hygiene and upper body dressing, and was dependent on staff for toileting, shower/bathing, lower body dressing, putting on and taking off footwear, 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 record review, staff interview, and facility policy review the facility failed to provide written notification of the facility's bed hold policy to the resident or the resident representative. This affected one resident (#197) of four residents reviewed for hospitalization. The facility census was 102. Findings include: Review of the medical record for Resident #197 revealed an admission date of 05/05/24 with subsequent hospitalizations from 06/17/24 to 06/19/24 and from 08/26/24 to 09/08/24. Diagnoses included Alzheimer's disease, chronic atrial fibrillation, muscle weakness, type two diabetes mellitus, hypertension, and major depressive disorder. Review of Resident #197's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of Resident #197's electronic medical record (EMR) profile revealed she had three emergency contacts listed with one designated as number one who was to be contacted with any changes in medical condition or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to ensure Resident #252's care plans were comprehensive to include all care needs. This affected one resident (#252) of 35residents reviewed for comprehensive care plans and had the potential to affect all 102 residents in the facility. Findings include: Review of the medical record for Resident #252 revealed an admission date of 07/31/24. Diagnoses included hypertension, kidney failure, muscle weakness, and chronic obstructive pulmonary disease (COPD). Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #252 was severely cognitively impaired. She required supervision for oral and personal hygiene, set up help for eating, and substantial assistance with toileting and showering. She was on oxygen. Review of the care plan dated 08/28/24 revealed no evidence Resident #252's care plan addressed the use of oxygen. Interview on 09/12/24 at 11:50 A.M. with the Director of Nursing (DON) confirmed…

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, record review, and review of the facility policy the facility failed to ensure Resident #84 received therapy and restorative services to help prevent a decline in activity of daily living (ADL). This affected one resident (#84) out of three residents reviewed for therapy services. The facility census was 102. Findings include: Review of Resident #84's medical record revealed an admission date of 10/27/23 with diagnoses including pneumonitis due to inhalation of food and vomit, dysphagia, pseudobulbar affect, and unspecified macular degeneration. Resident #84 was discharged from hospice services on 06/24/24. Review of Resident #84's care plan initiated on 10/30/23 and revised 11/21/23 included Resident #84 had contractures to bilateral wrists and ankles present on admission to the facility. Encourage participation in ADL. Refer to Physical Therapy (PT) and Occupational Therapy (OT) services for position aids, splints, hand rolls, etcetera (etc.). Assess joints for limitations,…

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, record review, and review of facility policy the facility failed to ensure Resident #54 was assisted into bed timely. This affected one resident (#54) out of three residents reviewed for dependent care. The facility census was 102. Findings include: Review of Resident #54's medical record revealed an admission date of 03/14/24 with diagnoses including acute respiratory failure with hypercapnia, type two diabetes mellitus with proliferative diabetic retinopathy without macular edema, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #54 was cognitively intact. Resident #54 was dependent for personal care including toileting hygiene, bathing dressing, sit to stand, and chair, bed-to-chair transfer. Review of the care plan dated 03/15/24 included Resident #54 required assistance with activities of daily living (ADL) related to bariatric diagnosis. Resident #54's ADL status would improve through the review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, record review, and facility policy review the facility failed to ensure timely incontinence care was provided for Resident #197. This affected one resident (#197) out of four residents reviewed for timely incontinence care. The facility census was 102. Findings include: Review of the medical record for Resident #197 revealed an initial admission date 05/05/24. Resident #197 was sent to the emergency room for increase in behaviors on 05/07/24 and returned to the facility on [DATE]. Diagnoses included chronic atrial fibrillation, muscle weakness, type two diabetes mellitus, unsteadiness on feet, osteoarthritis, hypertension, Alzheimer's disease, cognitive communication deficit, history of urinary tract infections, acute cystitis, dysphagia, and neuromuscular dysfunction of the bladder. Review of Resident #197's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Resident #197 required set up or clean up assistance 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 observation, record review, interview, and facility policy review the facility failed to provide adequate oversight of nutritional needs regarding weight loss, physician notification, and supplements for Residents #71, #75, #81. This affected three residents (#71, #75 and #81) of five residents reviewed for nutrition. The facility census was 102. Findings include: 1. Review of the medical record for Resident #71 revealed an admission date of 07/01/24. Diagnoses included hydrocephalus, depression, obstructive uropathy, urine retention, dementia, diabetes, and venous insufficiency. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was severely cognitively impaired. He required set up help for eating and oral hygiene, substantial assistance for showering and was dependent for toileting. He had no pressure ulcers but was at risk, had no unknown weight loss or gain and no swallowing issues. Review of the physicians' orders for September 2024 revealed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview the facility failed to ensure competent nursing staff as evidenced by a nurse leaving Resident #62, who was cognitively impaired with diagnoses of Alzheimer's disease, dysphagia (difficulty swallowing), flaccid hemiplegia, and a history of medication refusals, with a cup of pills to take to take independently. This affected one resident (#62) of 47 sampled residents. The facility census was 102. Findings include: Review of the medical record for Resident #62 revealed an admission date of 03/11/22. Diagnoses included urinary tract infection (UTI), chronic pain syndrome, cerebral infarction, essential primary hypertension, mixed hyperlipidemia, dysphagia, anxiety disorder, major depressive disorder, obsessive compulsive disorder, unspecified sequalae of cerebral infarction, flaccid hemiplegia affecting the left non-dominant size, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 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 record review, interview, and facility policy review the facility failed to ensure parameters were in place for the administration of pain medications for Resident #22. This affected one resident (Resident #22) of five reviewed for unnecessary medications. The facility census was 102. Findings include: Review of the medical record for Resident #22 revealed an admission date of 08/16/24. Diagnoses included panic disorder, depression, alcohol dependence, respiratory failure, and osteoarthritis. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively intact. She was independent in eating, dressing, toileting and personal hygiene, and required supervision for showering. Review of the physician's orders for September 2024 revealed an order for Tramadol 50 milligrams (mg) every 12 hours as needed for pain and an order for Acetaminophen 650 mg every six hours as needed for pain. Review of the care plan dated 08/16/24 revealed Resident #22 had pain…

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, record review, review of manufacturer instructions, and facility policy review the facility failed to prevent a significant medication error for Resident #60 and Resident #149. This affected one resident (#60) of five residents reviewed for unnecessary medications and one resident (#149) of four residents reviewed for medication administration. The facility census was 102. Findings include: 1. Review of the medical record for Resident #60 revealed an admission date of 09/23/23. Medical diagnoses included cerebral infarction due to thrombosis of right posterior cerebral artery, flaccid hemiplegia affecting right dominant side, type two diabetes mellitus, hyperlipidemia, Bell's palsy, essential primary hypertension, transient ischemic attack, dysphagia, acute respiratory failure with hypoxia, chronic kidney disease, and epilepsy. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was moderately cognitively impaired. Resident #60 required setup…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed timely notify the physician of lab results for Resident #81. This affected one resident (#81) of one resident reviewed for laboratory and diagnostic services. The facility census was 102. Findings include: Review of the medical record for Resident #81 revealed an admission date of 07/01/24. Diagnoses included compression fracture of the vertebrae, asthma, depression, osteoporosis, dementia, and muscle weakness. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #81 was severely cognitively impaired. She required supervision for personal hygiene, set up help for eating and oral hygiene, and substantial assistance for toileting, showering, and bathing. She had no pressure ulcers but was at risk, no oral issues, and no weight loss or gain. Review of the nursing progress note dated 09/04/24 at 5:01 P.M. revealed a pustule like rash was noted to Resident #81's bilateral gluteal folds. An order…

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

Based on record review, observation and interview, the facility failed to ensure appealing and palatable food was served to Resident #45 and #152. This affected two residents (#45 and #152) out of nine residents reviewed for food and nutrition, and had the potential to affect 100 residents who received meals in the facility. The facility identified Resident #25 and #197 did not receive meals from the kitchen. The facility census was 102. Findings include: Review of the facility menu for 09/09/24 revealed residents were to have ham and hash brown skillet with a blueberry muffin for breakfast. Review of the recipe Homemade Blueberry Muffin dated 09/09/24 revealed once ingredients were mixed to then portion batter with a number 20 dipper into greased muffin pans about two thirds full. The recipe further stated that a regular portion was one whole muffin. Observation on 09/09/24 at 7:48 A.M. of breakfast meal service revealed Dietary Manager (DM) #576 was placing a scooper full of a grayish-blue food item on plates for resident breakfast tray line. Interview on 09/09/24 at 8:18 A.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure residents had the required assistive devices to aid in maintaining independence while eating. This affected one resident (Resident #81) of nine residents reviewed for food/nutrition. The facility identified two residents (#46 and #81) who required assistive devices while eating. The facility census was 102. Findings include: Review of the medical record for Resident #81 revealed an admission date of 07/01/24. Diagnoses included compression fracture of the vertebrae, asthma, depression, osteoporosis, dementia and muscle weakness. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #81 was severely cognitively impaired. She required supervision for personal hygiene, set up help for eating and oral hygiene and substantial assistance for toileting, showering and bathing. She had no weight loss or gain. Review of the care plan dated 07/01/24 revealed Resident #81 had a nutritional problem due…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of facility policy the facility failed to ensure resident records reflected Resident #61 leaving and returning from the hospital. This affected one resident (#61) of 36 residents reviewed for accurate documentation. The facility census was 102. Findings include: Review of the medical record revealed Resident #61 was most recently admitted to the facility on [DATE]. Medical diagnoses included hypothyroidism, essential primary hypertension, hyperlipidemia, vitamin D deficiency, major depressive disorder, adjustment disorder, anxiety disorder, dementia, fracture of unspecified part of left shoulder scapula, multiple fractures of ribs, stress fractures of ulna and radius, and laceration without foreign body of scalp. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 was severely cognitively impaired. Resident #61 was independent with eating and personal hygiene, required supervision or touching assistance with oral hygiene, lower…

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

Based on record review and interview the facility failed to ensure all residents were offered and received the influenza vaccine. This affected two residents (Residents #7 and #255) of five reviewed for vaccinations. The facility census was 102. Findings include: Review of the medical record for Resident #7 revealed an admission date of 02/09/21. Diagnoses included heart disease, head injury, diabetes, hypertension, anxiety, kidney disease and overactive bladder. There was no documentation Resident #7 had been offered or refused the influenza vaccine. Review of Resident #7's immunization history revealed he last received an influenza vaccine on 10/28/22. Review of the influenza vaccine log for 2023 revealed Resident #7 consented to the influenza vaccine on 10/23/23 but never received it. Review of the medical record for Resident #255 revealed an admission date of 01/11/23 and a discharge date of 03/25/24. Diagnoses included heart disease, hypertension, depression, diabetes, hyperlipidemia, vitamin D deficiency and muscle weakness. There was no evidence Resident #255 had been offered…

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

Based on record review and interview the facility failed to ensure all residents were offered the COVID-19 vaccine. This affected two residents (Residents #7 and #255) of five residents reviewed for vaccinations. The facility census was 102. Findings include: Review of the medical record for Resident #7 revealed an admission date of 02/09/21. Diagnoses included heart disease, head injury, diabetes, hypertension, anxiety, kidney disease and overactive bladder. Review of Resident #7's immunization history revealed no evidence she had been offered a COVID-19 vaccine. Review of the medical record for Resident #255 revealed an admission date of 01/11/23 and a discharge date of 03/25/24. Diagnoses included heart disease, hypertension, depression, diabetes, hyperlipidemia, vitamin D deficiency and muscle weakness. Review of resident #255's immunization history revealed no evidence she had been offered a COVID-19 vaccine. Interview on 09/12/24 at 12:56 P.M. with the Director of Nursing (DON) revealed the facility had been asking residents if they wanted the COVID-19 vaccination but most…

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

Based on observation, interview, record review, and facility policy review the facility failed to ensure food was stored and prepared in a sanitary manner and failed to ensure a sanitary environment. This had the potential to affect all 98 residents in the facility who receive food from the kitchen. The facility identified one resident (#16) who received nothing by mouth. The facility census was 99. Findings include: Tour of the kitchen on 06/05/25 at 9:10 A.M. with Dietary Manager #602 revealed the dishwasher was not reaching appropriate temperatures for the rinse cycle. It had not reached the appropriate temperature since the end of March 2024. Dietary Manager #602 reported that a repair man was there in March 2024, and he reported the dishwasher needed a bolster that was on backorder. The maintenance man was aware of it, and it had not come in. She reported that the staff was running dishes through the dishwasher twice and rinsing them in the sanitizer in the three sinks. She confirmed that no formal in-service was completed regarding the emergency dishwasher procedures, but the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review the facility failed to maintain privacy for the medical records of Residents #26 and #46. This affected two residents (#26 and #46) of three residents reviewed for confidentiality of records. This had the potential to affect all 99 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 12/12/23. Diagnoses included obstructive and reflux uropathy, secondary malignant neoplasm of the bone, malignant neoplasm of the prostrate, and paraplegia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had intact cognition. Resident #26 required extensive/substantial assistance for all activities of daily living. Resident #26 had an indwelling catheter for urine and was frequently incontinent of bowel. Review of the care plan dated 03/29/24 for Resident #26 revealed he would receive personalized care. Interventions included allowing…

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 facility menus and spreadsheets, observation and interview, the facility failed to follow menus as written and failed to offer appropriate portion sizes of foods on the menu to ensure residents received adequate nutrition. This had the potential to affect all residents receiving meals from the kitchen excluding one resident (Resident #16) the facility identified as eating nothing by mouth. The facility census was 97. Findings include: Review of the facility menu dated 04/17/24 revealed the lunch meal would consist of barbeque pork loin, cowboy baked beans, and buttered spinach. Review of the facility menu and spreadsheets for the dinner meal on 04/17/24 revealed tuna salad sandwiches with four ounces of tuna per sandwich would be served for dinner. Interview was conducted on 04/17/24 at 12:30 P.M. with Ombudsman #900 and #901 who were present in the facility at the time of the interview. Ombudsman #900 and #901 revealed there were many food complaints from the residents including hot foods being served cold, the foods not being palatable and the dietary staff…

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

Based on observation and interview, the facility failed to ensure palatable foods were served at meals. This had the potential to affect all residents receiving meals from the kitchen excluding one resident (Resident #16) who the facility identified as eating nothing by mouth. The facility census was 97. Findings include: Interview was conducted on 04/17/24 at 12:30 P.M. with Ombudsman #900 and #901 who were present in the facility at the time of the interview. Ombudsman #900 and #901 revealed there were many food complaints from the residents including hot foods being served cold, the foods not being palatable and the dietary staff not serving what was on the menu. Interviews conducted intermittently throughout the survey from 04/17/24 to 04/24/24 with Residents #1, #15, #17, #20. #21, #42, and #58 revealed they were unhappy with the food. They stated the food did not always taste good and at times hot foods were served cold. Observation was conducted on 04/18/24 at 11:15 A.M. of the kitchen tray line and revealed all food being served for lunch from the trayline met minimum…

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 and interview, the facility failed to ensure timely assistance was provided with incontinence care for one (Resident #25) of three residents reviewed for incontinence. The facility census was 96. Findings include: Review of Resident #25's medical record revealed diagnoses including weakness and paralysis of one side of the body following a stroke. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #25 was cognitively intact and was always continent of bowel. On 11/07/23 at 9:19 A.M., Resident #25's call light was observed to be activated when the surveyor entered the hallway. At 9:20 A.M., Licensed Practical Nurse (LPN) #102 entered Resident #25's room and inquired if Resident #25 needed something to which he replied he had a bowel movement and needed cleaned. LPN #102 responded she would get Resident #25 some assistance and left the room. At 9:28 A.M., a staff member the resident identified as working in the therapy department responded to…

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

Based on observation, medical record review and interview, the facility failed to identify and address an area of skin impairment in a timely manner. This affected one (Resident #25) of ten residents reviewed for quality of care. The facility census was 96. Findings include: Review of Resident #25's open medical record revealed diagnoses including type two diabetes mellitus, hypertension, heart disease and one sided weakness and paralysis following a stroke affecting the right dominant side. Resident #25 was admitted to the facility 11/01/23. There was no documentation of injuries or orders for dressing changes to the right lower arm. On 11/07/23 at 10:10 A.M., Resident #25 nodded toward a bandage on his right lower arm toward the wrist stating he wished somebody would check his arm. The bandage had been on his arm since he was in the hospital when he bumped his arm and it started bleeding. There was no date on the bandage. The bandage had some yellowish discoloration in some areas near the wrist and a dark discoloration in one area. Upon leaving the room, Licensed Practical Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to timely assess a resident with a history of falls for continued fall risk or need for interventions and failed to ensure another resident's fall interventions were implemented in accordance with physician orders. This affected two (Residents #63 and #98) of four residents reviewed for falls. The facility census was 96. Findings include: 1. Review of Resident #98's medical record revealed diagnoses including displaced fracture of the surgical neck of the right humerus, epilepsy, acquired hemolytic anemia, type two diabetes mellitus, rhabdomyolysis, hypertension (HTN), hyperlipidemia, anxiety disorder, depression, sleep apnea, and alcohol abuse. A nursing note dated 10/19/23 at 6:15 P.M. indicated Resident #98 was admitted into the facility. A medication list was sent to the physician and verified. A nursing note dated 10/19/23 at 9:51 P.M. indicated the nurse was notified Resident #98 was in the bathroom on the floor. Resident #98 was alert…

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, medical record review, policy review and interview, the facility failed to monitor and ensure a resident's catheter bag was positioned appropriately to decrease risks associated with urinary tract infections. This affected one (Resident #12) of three residents reviewed for urinary tract infections. Findings include: Review of Resident #12's medical record revealed diagnoses including type two diabetes mellitus, acute kidney failure, and obstructive and reflux uropathy. Resident #12 was sent to the hospital after falling on 09/30/23 and was admitted with a urinary tract infection (UTI). A Nurse Practitioner note dated 10/11/23 indicated Resident #12 had an indwelling foley which was draining a milky, light yellow urine and had just completed treatment for a UTI. A nurse practitioner note dated 11/04/23 indicated Resident #12's urine was clear yellow. On 11/02/23 at 11:30 A.M. when Licensed Practical Nurse (LPN) #102 entered Resident #12's room to administer medication, observations revealed Resident #12's urinary catheter bag was on the floor under the bed. LPN…

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, review of physician orders, policy review and interview, the facility failed to ensure medications were administered in accordance with physician orders and failed to ensure medications were not expired while preparing them for administration. This affected one (Resident #72) of eight residents observed for medication administration. Three errors were identified out of 33 opportunities resulting in a 9.09% medication error rate. The facility census was 96. Findings include: On [DATE] between 8:45 A.M. and 9:03 A.M., Licensed Practical Nurse (LPN) #102 was observed preparing and administering medication to Resident #72. The following errors were identified: 1. LPN #102 placed a stool softener in the medication cup along with other medication without checking the expiration date. The expiration date on the bottle was February 2023. After this was directed to the attention of LPN #102 she removed the stool softener from the medication cup. 2. Prior to LPN #102 placing a catapres patch 0.2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure a resident's medical record was complete in regard to a fall and unaccompanied exit of the facility and to ensure a resident's orders were transcribed timely. This affected two (Residents #12 and #62) of 14 residents whose medical records were reviewed. The facility census was 96. Findings include: 1. Review of Resident #62's medical record revealed diagnoses including end stage renal disease, anxiety disorder, hypertension, depression, insomnia, bipolar disorder, chronic viral hepatitis B, hepatitis A, and cognitive communication deficit. An elopement risk assessment dated [DATE] indicated Resident #62 was disoriented occasionally or orientation was not determined. Resident #62 was independently mobile. Resident #62 had exit seeking behaviors. On 10/27/23, Resident #62 was assessed as severely cognitively impaired. On 11/01/23, an order was written for a wanderguard to the left ankle at all times. Check the placement and function every…

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, record review, and facility policy, the facility failed to promote an environment that maintained each residents' dignity by serving meal trays with disposable spoons and no knives. This affected Resident #4 but had the potential to affect 82 residents who received meals from the kitchen. The facility identified Resident #142 as not receiving meals from the kitchen. The facility census was 83. Findings include: Review of medical record for Resident #4 revealed an admission date of 11/28/22 and diagnoses included acute respiratory failure, end stage renal (kidney) disease, unspecified angina pectoris (chest discomfort), and gastro-esophageal reflux disease (acid reflux) without esophagitis (inflammation of the esophagus). Review of the most recent five day Minimum Data Set assessment dated [DATE] revealed Resident #4 was cognitively intact, required extensive assist of two persons for bed mobility, total dependence of two persons physical assist for transfer, total dependence 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.

Based on observation, interview, and facility policy, the facility failed to ensure the residents had the right to secure and confidential medical records by allowing state tested nursing assistants (STNAs) to use their own personal computers to chart in the electronic medical record (EMR). This had the potential to affect all 83 residents. Findings include: Interview on 12/07/22 at 1:22 P.M. with STNA #917 revealed she had a difficult time finding a facility computer for charting. She stated there were two laptop computers on top of the medication carts along with two desktop computers for the 1100 and 1200 hall for charting. STNA #917 expressed some nurses would not let the STNAs use the laptops, or the nurses would sit in front of the desktop computer while using a laptop, which left the STNAs no computers for charting. STNA #917 stated she would bring in her own computer for easier access to charting. Interview on 12/07/22 at 1:55 P.M. with Director of Nursing (DON) confirmed the STNAs should use the desktop computers at the nursing station, or the laptop computers used 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 observation, interview, and record review, the facility failed to ensure sufficient staffing to provide timely incontinence care to Resident #191, provide sufficient restorative services to Resident #48, #50, #62 and #191, provide pain medications timely to Resident #2, and timely answer resident call lights. This had the potential to affect all 83 residents residing in the facility. Findings include: 1. Record review for Resident #191 revealed an admission date of 06/14/22 with diagnoses including type II diabetes mellitus, hypertension, osteomyelitis, chronic kidney disease, gastroesophageal reflux, major depressive disorder, and atrial fibrillation. Review of quarterly MDS dated [DATE] revealed the resident had impaired cognition, she needed assistance by one staff member for bed mobility, transfers, dressing, toileting, bathing, and personal hygiene. Review of Resident #191's care plan dated 10/22/22 revealed she was at risk for impaired skin integrity due to incontinence of bowel and bladder. The…

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

Based on interview, observation, and facility policy review, the facility failed to ensure residents were provided well balanced meals and failed to honor the residents' food and beverage preferences. This affected Residents #4,#6, #26, #48, #61, #66, #77, and #80 and had the potential to affect 82 residents who received meals from the kitchen. The facility identified Resident #142 as not receiving meals from the kitchen. The facility census was 83. Findings include: Interview and observation on 11/28/22 at 1:02 P.M. and on 11/30/22 at 12:07 P.M. revealed Resident #4 felt he was getting items on his meal tray that he should not be getting on a renal diet, such as tomato and potato items. He stated he had told the facility staff his preferences; however, there were no preferences listed on his diet card. Resident #4 stated he told the facility staff he did not like the lemon diet iced tea; however, they kept sending the diet iced tea on his tray. Resident #4 stated he had voiced his preferences more than once, and he thought it fell on deaf ears. Observation of Resident #4's dietary…

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

Based on observation, interview ,review of dietary schedules, and review of the Facility Wide Assessment, the facility failed to consistently provide adequate number of dietary staff to ensure a clean kitchen and dumpster area. This had the potential to affect all 83 residents who resided in the facility, excluding Residents #142 who did not receive nutrition by mouth. Findings include: Observation of the kitchen and interview on 11/28/22 from 11:00 A.M. to 12:02 P.M. revealed the perimeter of the floor revealed a build up of dirt. Dietary Supervisor (DS) #806 stated the dietary aides were to mop it at night. Observation of the three-compartment sink revealed all three compartments had food debris on the bottom and sides. DS #806 confirmed the three-compartment sink had not been cleaned the previous night. DS #806 stated the tasks were not being completed since the facility did not have enough staff at night. DS #806 revealed the facility had hired some new staff, but they had not started yet. Interview and observation of the dumpster area on 11/20/22 with DS #806 revealed debris 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, interview, policy review, and record review, the facility failed to ensure a standardized menu was followed and failed to ensure menus were distributed or posted for residents to make food choices. This had the potential to after all 82 residents receiving meals from the facility, specifically affected Residents #2, #4, #61, and #80. The facility identified Resident #142 as not receiving meals from the facility. The census was 83. Findings include: Interview and observation during the kitchen tour on 11/28/22 from 11:00 A.M. to 12:02 P.M. with Dietary Supervisor (DS) #806 revealed there were no facility menus. DS #806 at the time of observation confirmed the facility does not have planned menus or spread sheets at this time, and the facility staff would go off their knowledge of what scoop size to use. Interview on 11/28/22 at 1:02 P.M. revealed Resident #4 had no idea what the menu was and felt there was a lot of repetition. Interview on 11/28/22 at 2:15 P.M. and on 11/29/22 at 11:26 PM with DS #806 revealed staff members go off memory what each diet was…

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

Based on observation, interview, and record review, the facility failed to ensure food was served at an appetizing temperature and an acceptable palatability. This had the potential to affect 82 residents who received meals in the facility. The facility identified Resident #142 as receiving no food from the kitchen. The facility census was 83. Findings include: An interview on 11/28/22 at 10:03 A.M. with Resident #61 revealed every time the food was delivered it was cold or lukewarm and the meat was often dry. An interview conducted on 11/28/22 at 1:02 P.M. with Resident #4 revealed the food was the worst, and the food was cold almost every time it was delivered. An interview conducted on 11/28/22 03:24 PM with Resident #24 revealed the food was nasty and cold. An interview conducted on 11/29/22 at 8:35 A.M. with Resident #80 revealed food was cold and not good. An interview conducted on 11/29/22 at 4:41 P.M. with Resident #77 revealed the meals were frequently cold. Review of facility temperature logs from August 2022 through November 2022 revealed no tray line temperatures were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to obtain or accommodate food and beverage preferences and failed to provide options of similar nutritive value to residents who chose not to eat the food that was initially served or who requested a different meal choice. This affected three (Resident #4, #61 and #80) but had the potential to affect all 82 residents receiving a meal from the kitchen. The facility identified Resident # 143 as not receiving food from the kitchen. The facility census was 83. Findings include: 1. Review of medical record for Resident #80 revealed an admission date of 08/11/22 and diagnoses included end stage renal (kidney) disease, essential (primary) hypertension (high blood pressure), acute on chronic diastolic (congestive) heart failure, and type 2 diabetes with hyperglycemia (excessive amount of glucose circulating in the blood) Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #80 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and facility policy review, the facility failed to provide drinks consistent with residents' preferences. This affected three (Residents #4, #61 and #80) but had the potential to affect all 82 residents who received beverages. The facility identified Resident # 142 as not receiving any beverages by mouth. The facility census was 83. Findings include: 1. Review of medical record for Resident #4 revealed an admission date of 11/28/22 and diagnoses included acute respiratory failure, end stage renal (kidney) disease, unspecified angina pectoris (chest discomfort), and gastro-esophageal reflux disease (acid reflux) without esophagitis (inflammation of the esophagus). Review of the most recent five day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact, required extensive assist of two persons for bed mobility, total dependence of two persons physical assist for transfer, total dependence of one person assist for locomotion, toilet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to provide a substantial snack when there was greater than a 14-hour lapse between the evening meal and breakfast. This had the potential to affect 82 residents who received meals from the kitchen. The facility identified Resident #142 as not receiving meals from the kitchen. Facility census was 83. Findings include: Observation of facility posted mealtimes revealed the start of breakfast service began at 7:15 A.M., lunch service began at 11:15 A.M., and dinner service began at 4:15 P.M., which was a 15-hour lapse between the evening meal and breakfast meal. Observation on 11/28/22 from 6:25 P.M. to 6:28 P.M. of the snack containers delivered by dietary staff to each of the three nurses stations revealed each nursing station received one metal square pan filled with three wrapped peanut butter and jelly sandwiches, three bananas, three snack sizes bags of pretzels, one snack size bag of potato chips, two eight-ounce containers of diet lemonade, two…

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

Based on observation, record review and staff interview the facility failed to ensure the kitchen area was maintained in a clean and sanitary manner and food was labeled and dated in a manner to prevent contamination and/or spoilage. This had the potential to affect all 82 residents who received meals from the kitchen. The facility identified Resident # 142 as not receiving meals from the kitchen. The facility census was 83. Findings include: Observation of the kitchen area on 11/28/22 from 8:14 A.M. to 8:45 A.M. revealed the following findings which were verified by Dietary Supervisor (DS) #806: In the walk in cooler was one half bag of shredded cheddar cheese opened and not dated, one gallon storage bag of nine single serve unopened tubes of sour cream with a use by date of 11/08/2, one full bag of pepper jack cubes opened and not dated, one half bag of mild cheddar cheese cubes opened and not dated, one square metal pan of diced ham with a lid not labeled or dated, one large tube of raw hamburger with plastic wrap wrapped around the open end observed sitting directly on the…

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

Based on observation, interview, and facility policy review, the facility did not maintain garbage and refuse properly in an area free of surrounding litter. This had the potential to affect all 83 residents residing in the facility. Findings include: Interview and observation with Maintenance Staff #806 of the dumpster area on 11/30/22 at 8:45 A.M. revealed on the cement pad, where two blue dumpsters sat, were observed to be two clear gloves, four blue gloves, one empty eight ounce container of fruit punch, one fruit and grain bar in the package unopened, one cookie snack bag unopened, one white plastic spoon, one empty eight-ounce container of milk, one candy wrapper, one unopened pepper packet, one empty clear sleeve bag for foam cups, one half of a white Styrofoam plate, two empty clear plastic bags, one straw, one wet napkin, one unopened salt packet, one chocolate frozen supplement lid, a second candy wrapper, one green eight by eleven inch sheet of paper, one empty plastic medicine cup, and one empty pill packet. At the time of the observation, Maintenance Staff #806 verified…

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 interviews, observation and record reviews, the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This affected all residents of the facility. The census was 83. Findings include: During the annual recertification and extended survey completed from 11/28/22 through 12/16/22 the following concerns were identified through observation, record review, facility policy and procedure review and interview: a. The facility failed to promote an environment that maintained dignity and respect, failed to honor Resident #36's choices in bathing, and failed to ensure the safeguard of medical records. See findings at F550, F561, and F583. b. The facility failed to ensure Resident #10 was free from abuse and that all allegations of abuse were thoroughly investigated. See findings at F600 and F610. c. The facility failed to ensure resident minimum data set assessments were accurate for Resident #4 and Resident #36, and comprehensive care plans addressed the needs 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 interviews, observation and record reviews, the facility failed to ensure to ensure the medical director coordinated medical care and helped to implement and evaluate resident care policies that reflect current professional standards of practice. This affected all residents of the facility. The census was 83. Findings include: 1. Resident #24 was admitted [DATE] with diagnoses including metabolic encephalopathy, diabetes type II,heart disease and end stage renal disease with anemia. The resident received off-site dialysis three days a week. Review of Resident #24's physician orders revealed orders for a renal/controlled carbohydrate diet with regular texture and thin liquids. Review of Resident #24's Quarterly MDS 3.0 assessment of 10/20/22 revealed the resident was cognitively intact, required extensive assist of two for activities of daily living, and received dialysis. Review of the care plan of 09/05/22 revealed care areas for anemia related to diabetes and at risk of complications. 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.

Based on observation, interview, and record review, the facility failed to ensure accurate and complete medical records related to dialysis treatment for 14 residents (Resident #8, #24, #35, #38, #53, #57, #62, #66, #67, #74, #79, #80, #83, #294) and oxygen tube changes for Resident #2, and failed to ensure resident medical records were maintained in a confidential and secure manner. This had the potential to affect all residents. The census was 83. Findings include: 1. Review of all 14 residents (Resident #8, #24, #35, #38, #53, #57, #62, #66, #67, #74, #79, #80, #83, #294) of 14 resident medical records of those who receive dialysis in the facility, revealed the medical record did not contain dialysis communication regarding each resident's medical care and status before and after receiving dialysis treatment. Interview on 12/06/22 at 4:45 P.M. with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #837 revealed the document titled Dialysis Hand Off Communication Report was not being filled out by the facility nurses prior to the residents going to dialysis. 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 observation, interview, record review and review of facility policy, the facility failed to ensure Resident's #29 and #30 were placed on contact isolation related to urine culture results, failed to ensure Resident #29's antibiotics were ordered timely, failed to ensure Resident #2's oxygen tubing was changed as ordered, failed to ensure appropriate hand hygiene during medication administration, failed to ensure Resident #22's catheter was maintained in a sanitary manner to prevent infection, and failed to ensure appropriate personal protective equipment (PPE) was used when care was provided for a resident on contact precautions (Resident #33) to potentially prevent the spread of Clostridium Difficile infections. This had the potential to affect all 83 residents residing in the facility. Findings include: 1. Review of Resident #29's medical record revealed an admission date of 04/21/19, a re-entry date of 10/03/22 and diagnoses included pulmonary embolism without acute cor pulmonale, heart failure,…

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, record review and review of facility policy, the facility failed to ensure Resident's #2, #15, #16, #25, #58 and #81 were administered oxygen per physician orders. This affected six residents (Resident's #2, #15, #16, #25, #58 and #81) out of seven reviewed for oxygen administration. Findings include: 1. Review of Resident #81's medical record revealed an admission date of 08/25/22 and diagnoses included asthma, muscle weakness, and non-[NAME] lymphoma. Review of Resident #81's physician orders dated, 08/29/22, revealed administer oxygen at five liters per minute via nasal cannula, every shift. Review of Resident #81's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #81 was cognitively intact and required extensive assistance of two staff for bed mobility and toilet use, and total dependence of two staff for transfers. Resident #81 used oxygen. Observation on 11/28/22 at 2:23 P.M. of Resident #81 revealed he was lying in bed and had oxygen…

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, record review, and facility policy, the facility failed to ensure ongoing communication and collaboration with the dialysis facility for residents who required dialysis. This affected all 14 residents (Resident #8, #24, #35, #38, #53, #57, #62, #66, #67, #74, #79, #80, #83, #294) of 14 residents reviewed for dialysis at the facility. Findings include: 1. Review of medical record for Resident #80 revealed an admission date of 08/11/22 and diagnoses included end stage renal (kidney) disease, essential (primary) hypertension (high blood pressure), acute on chronic diastolic (congestive) heart failure, and type 2 diabetes with hyperglycemia (excessive amount of glucose circulating in the blood) Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #80 was cognitively impaired, required limited assistance with one-person physical assist for bed mobility, walk in room, walk in corridor, dressing, and toilet use, was independent with…

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

Based on observation, interview and record review, the facility failed to prepare food in a form to meet the individual needs of residents. This affected Residents (#9, #10,#20, #27, #35, and #81) who were on a mechanically altered diet and Residents (#9 and #35) who were on nectar thick liquids. The facility census was 83. Findings include: Observation and interview on 11/28/22 from 11:00 A.M. to 12:02 P.M. with Dietary Supervisor #806 revealed the sweet and sour chicken was made with diced chicken and was being served to both the regular and mechanical soft diets. DS #806 confirmed the sweet and sour was made with diced chicken, and it was appropriate for the mechanical soft ground diets. DS #806 stated the facility would chop up items in the food processor, but she did not feel the food items were getting to the proper food consistency, which was why she would like to see the facility purchase a new commercial combination food processor. Interview on 11/30/22 at 9:00 A.M. with Speech Therapy (ST) #909 revealed a mechanical soft consistency should consist of all meat ground, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, policy review, and record review, the facility failed to assure the residents received the appropriate therapeutic diet as prescribed. This affected Resident #80, and had the potential to affect all 74 residents on a therapeutic diet. The facility identified 82 residents as receiving a meal from the kitchen. The facility identified Resident #142 as not receiving a meal from the kitchen. The facility census was 83. Findings include: Review of medical record for Resident #80 revealed an admission date of 08/11/22 and diagnoses included end stage renal (kidney) disease, essential (primary) hypertension (high blood pressure), acute on chronic diastolic (congestive) heart failure, and type 2 diabetes with hyperglycemia (excessive amount of glucose circulating in the blood) Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #80 was cognitively impaired, required limited assistance with one-person physical assist for bed mobility,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to ensure residents received restorative nursing services as recommended by the therapy department. This affected four residents (Resident #48, #50, #62 and #191) of four residents reviewed for restorative nursing services. Findings include: 1. Resident #48 was admitted [DATE] with diagnoses including injury to the spinal cord in the cervical region, spinal stenosis: cervical, and quadriplegia from a motor vehicle accident. Review of physician orders revealed orders for bilateral dynamic hand splints at all times while in bed for contractures. A physician order dated 08/30/22 revealed the resident was discharged from occupational therapy (OT) and referred to restorative nursing. An order dated 09/06/22 revealed the resident was discharged from physical therapy (PT) and referred to restorative nursing. Review of the quarterly MDS 3.0 of 11/15/22 revealed the resident was cognitively intact, and required total dependence of two for Activities…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to ensure Resident #56's preferences regarding bathing were honored. This affected one resident (Residents #36) out of three residents reviewed for choices. Findings include: Review of Resident #36's medical record on 12/05/22 2:23 P.M. revealed an admission date of 11/01/22. Diagnosis included hypertension, type II diabetes mellitus, adult failure to thrive, urinary tract infection (UTI), diarrhea, hyperlipidemia, major depressive disorder, dysphagia, epilepsy, guillian-barre syndrome, and amyotrophic lateral sclerosis (ALS). Review of Resident #36's Minimum Data Set, dated [DATE] revealed the resident had intact cognition, she needed an extensive assist by two staff members for bed mobility, transfers via hoyer lift, dressing, toileting, personal hygiene and bathing. Review of Resident #36's care plan dated 11/01/22 revealed Resident #36 needed assistance with activities of daily living including showers related to limited mobility,…

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, record review, and facility policy review, the facility failed to ensure Resident #10 was free from physical and mental abuse. This affected one resident (Resident #10) of three residents reviewed for abuse. Findings include: Review of Resident #10's medical record revealed an admission date of 10/18/18 and diagnoses included hyperlipidemia, type two diabetes mellitus without complications and moderate protein-calorie malnutrition. Review of Resident #10's care plan dated, 08/07/22, included Resident #10 had bladder incontinence related to impaired mobility. Resident #10 would remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included check Resident #10 for incontinence with rounds and as required for incontinence. Wash, rinse and dry perineum and change clothing as needed after incontinence episodes. Review of Resident #1's Annual Minimum Data Set (MDS) 3.0 assessment dated , 09/26/22, revealed Resident #1 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 observation, interview, record review and review of the facility policy, the facility failed to ensure a thorough investigation was completed for allegations of physical, emotional and verbal abuse towards Resident #10 by a staff member. This affected one resident (Resident #10) out of three residents reviewed for abuse. The facility census was 83. Findings include: Review of Resident #10's medical record revealed an admission date of 10/18/18 and diagnoses included hyperlipidemia, type two diabetes mellitus without complications and moderate protein-calorie malnutrition. Review of Resident #10's care plan dated, 08/07/22, included Resident #10 had bladder incontinence related to impaired mobility. Resident #10 would remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included check Resident #10 for incontinence with rounds and as required for incontinence. Wash, rinse and dry perineum and change clothing as needed after incontinence episodes. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy, the facility failed to ensure an accurate Minimum Data Set (MDS) assessment was completed for a Resident #4 and #36. This affected two residents (Resident #4 and Resident #36) out of 45 residents reviewed for MDS assessment accuracy. Findings include: 1. Record review revealed Resident #4 was admitted to the facility on [DATE] with acute respiratory failure, end stage renal disease, angina pectoris, encounter for aftercare following kidney transplant. Review of Resident #4's physician orders revealed an order dated 10/25/22 for the discontinuation of Nepro 60 milliliters (ml) for 10 hours from 8:00 P.M. to 6 A.M. with a free water flush from 8:00 P.M. to 6:00 P.M., an order dated 10/26/22 for the discontinuation of a 240 ml Nepro bolus after meals if less than 50% of meal eaten and 60 ml free water fluids (FWF) if Nepro bolus was given, an order dated 10/26/22 for the discontinuation of 30 ml/hour free water flush from 9:00 P.M. to 5:00 A.M., an order 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 interview and record review, the facility failed to ensure care plans were comprehensive to address the needs of Residents #24, #83 and #294. This affected three residents (Residents #24, #83 and #294) of three residents reviewed for care plans. Findings include: 1. Resident #24 was admitted [DATE] with diagnoses including metabolic encephalopathy, type II diabetes, morbid obesity due to excess calories, end stage renal disease with anemia (ESRD). Review of Resident #24's physician orders revealed orders for a renal/controlled carbohydrate diet, regular texture with thin liquids. Review of weights for Resident #24 revealed a 16.75 percent (%) (37.3 pounds) increase from 08/27/22 to 11/26/22. Review of care plan of 09/05/22 revealed care areas for anemia related to ESRD and a risk of complications. Interventions included encourage intake of foods high in iron, and vitamin C, review diet and make recommendations as required, and a dietary consult to regulate protein, sodium and potassium. There was no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #44), who was Spanish speaking and had impaired vision, was provided a functional communication system. This affected one resident (Resident #44) of two residents reviewed for communication difficulty and/or sensory problems. Findings include: Medical Record review revealed Resident #44 had an admission date of 09/13/22 and diagnoses included neuromuscular dysfunction of bladder, unspecified convulsions, unspecified cerebral infarction (stroke), traumatic hemorrhage of cerebrum (acute loss of blood in the brain), altered mental status, and aphasia following cerebral infarction (inability to comprehend of formulate language because of damage to the brain from the stroke). Review of the care plan for Resident #44 dated 09/15/22 revealed a communication problem related to language barrier with a goal of being able to make basic needs known daily using a communication board and a facility provided translator as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Resident #36 and Resident #191 received timely incontinence care. This affected two residents (Resident #36 and Resident #191) of three residents reviewed for incontinence. Findings include: 1. Review of Resident #36's medical record on 12/05/22 2:23 P.M. revealed an admission date of 11/01/22. Resident #36's diagnoses included hypertension, type II diabetes mellitus, adult failure to thrive, urinary tract infection (UTI), diarrhea, hyperlipidemia, major depressive disorder, dysphagia, epilepsy, Guillian-barre syndrome, and amyotrophic lateral sclerosis (ALS). Review of Resident #36's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition, she needed an extensive assist by two staff members for bed mobility, transfers via hoyer lift, dressing, toileting, personal hygiene ad bathing. She was independent with eating. Review of Resident #36's care plan dated 11/01/22 revealed Resident #36 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.

Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #2 received her pain medication per physician orders. This affected one resident (Resident #2) out of three residents reviewed for pain management. The facility census was 83. Findings include: Review of Resident #2's medical record revealed an admission date of 05/19/21 and diagnoses included cerebral infarction, acute kidney failure, fibromyalgia, and multiple sclerosis. Review of Resident #2's physician orders dated 05/26/22, revealed oxycodone-acetaminophen tablet 7.5 -325 milligrams (mg), give one tablet by mouth every six hours for pain. Review of Resident #2's Quarterly Minimum Data Set (MDS) 3.0 assessment dated , 11/19/22, revealed Resident #2 was cognitively intact and was independent for bed mobility, transfers, and toilet use. Resident #2 used oxygen. Review of Resident #2's Medication Administration Record (MAR) from 11/22/22 at 6:00 P.M. through 11/24/22 at 12:00 P.M. revealed Resident #2 was not administered oxycodone. Review of Resident #2'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 interview, record review and review of facility policy, the facility failed to ensure Resident #24's physician was able to be contacted for Resident #24's change in condition. This affected one resident (Resident #24) out of three reviewed for emergency physician services. Findings include:Resident #24 was admitted [DATE] with diagnoses including metabolic encephalopathy, diabetes type II,heart disease and end stage renal disease with anemia. The resident received off-site dialysis three days a week. Review of Resident #24's physician orders revealed orders for a renal/controlled carbohydrate diet with regular texture and thin liquids. Review of Resident #24's Quarterly MDS 3.0 assessment of 10/20/22 revealed the resident was cognitively intact, required extensive assist of two for activities of daily living, and received dialysis. Review of the care plan of 09/05/22 revealed care areas for anemia related to diabetes and at risk of complications. Interventions included dietary consults to regulate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for five (Residents #8, #17, #53, #65 and #74) of 20 residents whose records were reviewed for accuracy of assessments. Findings include: 1. Review of Resident #53's medical record revealed an initial admission date of 11/13/19. Diagnoses included altered mental status and hypertension. Wound grids dated 11/13/19 indicated Resident #53 had deep tissue injuries to the right and left heels. Skin grids were completed weekly with the wound grids dated 12/12/19 indicating Resident #53 continued to have deep tissue injuries to both heels. Resident #53 was discharged to the hospital on [DATE] with a sacral wound infection. Resident #53 returned from the hospital 12/23/19. Skin grids completed 12/26/19 indicated the pressure ulcers on both heels were unstageable with 100% eschar (dead tissue). A five day Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #53 had two unstageable…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure advance directives (code status) were accurate throughout Resident #79's medical record. This affected one resident of 24 residents reviewed for advance directives. Findings include: Review of the medical record revealed Resident #79 was admitted to the facility on [DATE] and diagnoses included arteriosclerotic heart disease, hypertension, and atrial fibrillation. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #79 was alert, oriented and cognitively intact. Review of Resident #79's electronic physician orders dated 07/11/19 revealed an advance directive for Do Not Resuscitate Comfort Care-Arrest (DNRCC-Arrest) (emergency/resuscitative therapies before a cardiac arrest, but not during or after an arrest). Review of the medical record hard copy for Resident #79 revealed a signed advance directive dated 01/01/18 for Do Not Resuscitate Comfort Care (DNRCC) (provision of care for comfort and that eases pain and…

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

Based on medical record review and interview, the facility failed to provide discharge instructions to a resident which were easy to understand. This affected one (Resident #83) of one resident reviewed for discharge. Findings include: Review of Resident #83's closed medical record revealed diagnoses including sepsis, type 2 diabetes mellitus, moderate protein-calorie malnutrition, atrial fibrillation, anemia, abnormal uterine and vaginal bleeding, history of pulmonary embolism, atrial flutter and depression. A social service note dated 10/30/19 at 12:52 P.M. indicated Resident #83 voiced a desire to discharge home with home health and durable medical equipment. A nursing note dated 11/26/19 at 1:30 P.M. indicated Resident #83 discharged home. Resident #83 was given medications and discharge instructions. The discharge instructions included, Diet is as follows: CCHO/NAS diet regular texture, thin liquids. Labs-CBC w/diff and CMP 1 x a month on the 2nd of the month Continue w/Psych meds, check blood sugars Zinc oxide barrier cream to peri area and a PRN, clean area of coccyx w NSS,…

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 and interview, the facility failed to implement physician orders to prevent falls for Resident #4. This affected one of two residents reviewed for accidents. Findings include: Review of Resident #4's medical record revealed diagnoses including apraxia (a neurological disorder that affects a person's ability to perform everyday movements), generalized muscle weakness, Alzheimer's disease, anemia, hypertension (high blood pressure), and psychotic disorder with delusions. A care plan initiated 06/10/17 indicated Resident #4 was at an increased risk of falls related to joint pain and a history of falls. Resident #4 had a physician's order dated 06/13/17 for a low bed with mats to the floor, an order dated 06/29/17 for anti-tippers to the wheelchair at all times, and an order dated 04/13/18 for dycem (a nonskid material) to the wheel chair seat. The care plan for Resident #4 was updated indicating automatic locking breaks were to be applied to the wheelchair at all times. 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, record review and interview, the facility failed to ensure Resident #8 received the necessary treatment and services after identification of psychosocial adjustment difficulty. This affected one resident of 19 residents reviewed for identification of needs. Findings include: Resident #8 was initially admitted to the facility on [DATE] with diagnoses including compression fracture of thoracic vertebra, type two diabetes mellitus, and dementia. Review of Resident #8's quarterly Minimum Data Set (MDS) assessment, dated 10/18/19, indicated Resident #8 had severe cognitive impairment scoring a 5 out of 15 on the Brief Interview for Mental Status (BIMS). Scores of zero to seven indicate severe cognitive impairment. The 10/18/19 MDS assessment also indicated Resident #8 had severe depression, scoring 20 out of 30 on the Patient Health Questionnaire-9 (PHQ-9) (a scale to monitor depression for the previous 14 days). One specific question on the PHQ-9 asked if Resident #8 had thoughts of being…

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

Based on observation, record review and interview, the facility failed to ensure medications were administered with an error rate of less than 5% and in accordance with manufacturer instructions. This resulted in three errors out of 28 opportunities resulting in a 10.7% medication error rate. This affected two (Residents #22 and #34) of six residents observed for medication administration. Findings include: 1. On 01/28/20 at 9:12 A.M., Licensed Practical Nurse (LPN) #500 was observed administering medication to Resident #34. One puff of Breo Ellipta, 100 micrograms (mcg)/25 mcg (asthma medication) was administered. Without instructing Resident #34 to rinse his mouth, LPN #500 then administered one dose of Spiriva, 18 mcg right after the Breo Ellipta. LPN #500 had Resident #34 rinse his mouth after the Spiriva was administered. Review of information on the Medscape website revealed after the use of Breo Ellipta, the mouth was to be rinsed to prevent dry mouth and throat irritation. Instructions revealed staff were to wait at least one minute between the use of each medication if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure resident documentation was complete for Residents #8 and #82. This affected two of 20 residents reviewed for accuracy of medical records. Findings include: 1. Resident #8 was initially admitted to the facility on [DATE] with diagnoses including compression fracture of thoracic vertebra, type two diabetes mellitus, and dementia. Review of Resident #8's quarterly Minimum Data Set (MDS) assessment, dated 10/18/19, indicated Resident #8 had severe cognitive impairment scoring a 5 out of 15 on the Brief Interview for Mental Status (BIMS). The 10/18/19 MDS also indicated Resident #8 had severe depression scoring a 20 out of 30 on the Patient Health Questionnaire-9 (PHQ-9) (a scale to monitor depression for the previous 14 days). One specific question on the PHQ-9 asked if Resident #8 had thoughts of being better off dead or of hurting herself in some way and Resident #8 stated yes and the assessment said it happened two to six days during the previous…

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.