Liberty Health Care Center INC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, facility policy review and Centers for Disease Control and Prevention (CDC) guidance review, the facility failed to ensure Contact Precautions were implemented as ordered for Resident #22. This affected one resident (#22) of five residents reviewed for infection control and had the potential to affect all 50 additional residents (#3, #4, #7, #8, #10, #11, #13, #14, #16, #17, #19, #23, #24, #26 #29, #30, #31, #33, #37, #39, #41, #42, #43, #48, #50, #53, #55, #56, #58, #59, #60, #62, #63, #65, #68, # 69, #71, #75, #76, #79, #80, #85, #88, #96, #255, #256, #257, #305, #307 and #405) residing on the East Wing. The facility census was 101. Findings include: Review of the medical record for Resident #22 revealed an admission date of 07/24/18 with diagnoses including dementia, depression, diabetes, breast cancer, and Parkinson's disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was moderately cognitively impaired. She…

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 facility policy review, the facility failed to ensure staff spoke to Resident #15 in a dignified manner. This affected one resident (#15) of three residents reviewed for dignity had the potential to affect all residents in the facility. The facility census was 101. Findings include: Review of the medical record revealed Resident #15 was admitted on [DATE] with diagnoses including chronic respiratory failure, congestive heart failure, diabetes mellitus type two, depression, anxiety, hypertension, and morbid obesity. Resident #15 was also on Enhanced Barrier Precautions (EBP). Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was cognitively intact and had occasional bladder incontinence and frequent bowel incontinence. On 04/30/24 at 9:15 A.M. an observation revealed State Tested Nurse Aide (STNA) #561 standing at the doorway of Resident #15 and hollering into the room asking the resident what was needed. Resident #15 was requesting…

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, facility self-reported incident (SRI) review and facility policy review, the facility failed to implement their abuse policy regarding thoroughly investigating an injury of unknown origin for Resident #8 and an allegation of staff-to-resident abuse for Resident #77. This affected two residents (#8 and #77) of three residents reviewed for abuse and had the potential to affect all 101 residents residing in the facility. Findings include: 1. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including dementia, acute kidney failure, anxiety disorder, and adult failure to thrive. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was severely cognitively impaired. She required limited assistance of one person for transfers, dressing, eating, toilet use, and hygiene. Review of the facility SRI tracking number 241607 dated 11/29/23 revealed on the afternoon of 11/29/24 a bruise was noted…

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, facility self-reported incident (SRI) review and facility policy review, the facility failed to thoroughly investigate an injury of unknown origin for Resident #8 and an allegation of staff-to-resident abuse for Resident #77. This affected two residents (#8 and #77) of three residents reviewed for abuse and had the potential to affect all 101 residents residing in the facility. Findings include: 1. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including dementia, acute kidney failure, anxiety disorder, and adult failure to thrive. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was severely cognitively impaired. She required limited assistance of one person for transfers, dressing, eating, toilet use, and hygiene. Review of the facility SRI tracking number 241607 dated 11/29/23 revealed on the afternoon of 11/29/24 a bruise was noted under Resident #8's right eye and brought to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop a comprehensive care plan for the care and maintenance of an enteral feeding tube for Resident #92. This affected one resident (#92) of two residents reviewed for enteral feedings. The facility census was 101. Findings include: Review of the medical record for Resident #92 revealed an admission date of 10/20/23 with diagnoses including muscle wasting and atrophy, dysphagia, dementia, and chronic kidney disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #92 received 51% or more calories per day and 501 ml or more fluid per day from tube feeding. Review of the order history for Resident #92 revealed she had consistently had physician's orders for enteral feedings or flushes since 12/18/23. Current physician's orders included nothing by mouth (NPO) effective 04/09/24, check enteral tube placement every eight hours effective 04/25/24, cleanse enteral feeding site with soap and water every night shift…

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 oral care for Resident #23 and fingernail care for Resident #50. This affected two residents (#23 and #50) of 83 residents observed for assistance with personal care. The facility census was 101. Findings include: 1. Review of the medical record revealed Resident #23 was admitted on [DATE] with diagnoses including chronic kidney disease, acute kidney failure, diabetes mellitus type two, cerebral infarct, and muscle wasting. Review of the Medicare Five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact. A care plan dated 03/01/24 revealed Resident #23 needed the assistance of two people for bathing, grooming, and hygiene. A review of Resident #23 shower sheets revealed the most recent shower was 04/24/24. On 04/29/24 at 9:42 A.M. an observation and interview of Resident #23 revealed a white buildup between his lower teeth. Resident #23 stated staff had not assisted…

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 proper positioning in a wheelchair as ordered for Resident #10. This affected one resident (#10) of 34 residents reviewed for positioning. The facility census was 101. Findings include: Review of the medical record revealed Resident #10 was admitted on [DATE] with diagnoses including hemiplegia following a cerebral infarction (a weakening of one side of the body following a stroke), epileptic seizures, depression, and chronic obstructive pulmonary disease. Significant orders included Hoyer lift (a mechanical lift used to transfer due to inability to transfer independently) for transfers, check residents left arm placement while in wheelchair to prevent being pinched inside of chair, and left arm to be elevated on pillow while in the wheelchair. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had severe cognitive impairment. Review of the plan of care dated 04/05/24…

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 hearing aides were ordered and available as needed for Residents #3 and #13). This affected two residents (#3 and #13) of three residents reviewed for communication concerns. The facility census was 101. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 12/11/22 with diagnoses including Alzheimer's disease, chronic pain, depression, end stage renal disease, hypertension, and unspecified hearing loss. Review of the audiology visit dated 09/18/23 for Resident #3 revealed the resident was referred by the facility for decreased hearing. She was recommended for hearing aids with follow up in one to three months. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact. She was independent with eating, required supervision for toileting, set up help for oral hygiene and personal hygiene and partial to moderate…

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

Based on medical record review, review of the dialysis agreements, staff interviews and review of the facility policy, the facility failed to complete dialysis assessments according to the physician's orders and failed to ensure residents had reliable transportation to and from the dialysis center. This affected two residents (#35 and #406) of two residents reviewed for dialysis treatments. The facility census was 101. Findings include: 1. Review of the medical record for Resident #35 revealed an admission date of 11/10/22 and readmission date of 11/05/23. Diagnoses included end stage renal disease, dependence on renal dialysis, type two diabetes mellitus, and anemia in chronic kidney disease. Review of the physician's orders for April 2024 identified orders for dialysis on Monday, Wednesday, and Friday at 11:30 A.M. (ordered 01/04/24), pre-dialysis assessment on dialysis days every day shift on Monday, Wednesday, Friday (ordered 05/17/23), and post-dialysis assessment on dialysis days every evening shift on Monday, Wednesday, Friday (ordered 05/15/23). Review of the progress notes…

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 clear instructions were in place for the use of narcotic pain medication and did not ensure non-pharmacological interventions were attempted prior to the administration of pain medication. This affected two residents (#53 and #64) of five residents reviewed for unnecessary medications. The facility census was 101. Findings include: 1. Review of the medical record for Resident #53 revealed an admission date of 06/16/23 with diagnoses including heart failure, muscle wasting, hypertension, diabetes, depression, and insomnia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 was cognitively intact. She required partial to moderate assistance for eating and oral hygiene and was dependent for toileting, showering, and personal hygiene. Review of the physician's orders for April 2024 revealed an order for Acetaminophen 325 milligrams (mg) (analgesic) every four hours as needed (prn)…

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 appropriate diagnoses and rationale for prescribed medications. This affected two residents (#22 and #53) of five reviewed for unnecessary medications. The facility census was 101. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 07/24/18 with diagnoses including dementia, depression, diabetes, breast cancer, and Parkinson's disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was moderately cognitively impaired. She required set up help for eating, supervision for oral hygiene and personal hygiene, and substantial assistance for toileting and showering. Review of the physician's orders for April 2024 revealed an order for Klonopin (a sedative used to treat seizures, panic disorder, and anxiety) 0.5 milligrams (mg) two times per day (BID) for dementia. The order began on 09/25/23. Interview on 05/01/24 at 12:53 P.M. 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 medical record review and staff interview, the facility failed to provide a pneumococcal vaccination after consent was provided for Resident #77. This affected one resident (#77) of five reviewed for immunizations. The facility census was 101. Findings include: Review of the medical record for Resident #77 revealed an admission date of 02/20/23 with diagnoses including major depressive disorder, anxiety, and muscle weakness. Review of Resident #77's pneumococcal polysaccharide vaccine (PPSV 23) consent form revealed Resident #77 agreed to receive the vaccination on 03/07/23. Further review of the medical record for Resident #77 revealed there was no documentation that the vaccination had been administered. On 05/02/24 at 11:04 A.M., interview with Corporate Quality Assurance (QA) Nurse #648 verified there was no evidence Resident #77 received the pneumococcal polysaccharide vaccine.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to implement their abuse policy regarding an allegation of potential staff-to-resident abuse for Resident #77. This affected one resident (#77) of seven residents reviewed for abuse. The facility census was 97. Findings include: Review of the medical record for Resident #77 revealed an admission date of 04/07/23 with diagnoses including Amyotrophic Lateral Sclerosis (ALS) a progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord, arthritis, depression, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 was cognitively intact. She required set up help for eating, oral hygiene, and personal hygiene, substantial or maximum assistance for showing or bathing, and was dependent on staff for toileting. Interview on 02/06/24 at 11:35 A.M. with Resident #77 revealed State Tested Nurse's Aide (STNA) #203 had been rough with her twice on 01/30/24.…

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 report an allegation of staff-to-resident abuse to the state agency as required. This affected one resident (#77) of seven residents reviewed for abuse. The facility census was 97. Findings include: Review of the medical record for Resident #77 revealed an admission date of 04/07/23. Diagnoses included Amyotrophic Lateral Sclerosis (ALS) a progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord, arthritis, depression, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 was cognitively intact. She required set up help for eating, oral hygiene, and personal hygiene, substantial or maximum assistance for showing or bathing, and was dependent on staff for toileting. Interview on 02/06/24 at 11:35 A.M. with Resident #77 revealed State Tested Nurse's Aide (STNA) #203 was rough with her twice on 01/30/234. She revealed STNA #203 attempted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to investigate an allegation of staff-to-resident abuse as required. This affected one resident (#77) of seven residents reviewed for abuse. The facility census was 97. Findings include: Review of the medical record for Resident #77 revealed an admission date of 04/07/23. Diagnoses included Amyotrophic Lateral Sclerosis (ALS) a progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord, arthritis, depression, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 was cognitively intact. She required set up help for eating, oral hygiene, and personal hygiene, substantial or maximum assistance for showing or bathing, and was dependent on staff for toileting. Interview on 02/06/24 at 11:35 A.M. with Resident #77 revealed State Tested Nurse's Aide (STNA) #203 was rough with her twice on 01/30/234. She revealed STNA #203 attempted to move the Hoyer…

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 residents received showers according to their preference. This affected three residents (#41, #70 and #77) of six residents reviewed for showers. This had the potential to affect all residents residing in the facility as the facility identified all residents require assistance with showers. The facility census was 97. Findings include: 1. Review of the medical record for Resident #41 revealed an admission date of 03/11/20 with diagnoses including heart disease, left eye blindness, hyperlipidemia, stroke, and urinary retention. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was cognitively intact. He required set up assistance for oral hygiene and personal hygiene and supervision for toileting, showering, and bathing. It was very important to him to choose between a tub bath, shower, bed bath, or a sponge bath. Review of the shower schedule revealed Resident #41 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 complete an accurate plan of care for Resident #52. This affected one resident (#52) of three residents reviewed for care planning. The facility census was 95. Findings include: Review of the medical record for Resident #52 revealed an admission date of 03/30/23 and a readmission date of 06/21/23. Diagnoses included aneurysm of unspecified site, benign prostatic hypertension, and diabetes mellitus. Review of the physician's order dated 06/21/23 for Resident #52 revealed an order for him to have an indwelling urinary catheter due to urinary retention until he followed up with urology. Review of physician's order dated 07/12/23 for Resident #52 revealed an order for an indwelling urinary catheter for him and to change monthly and as needed for blockage. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 had mild cognitive impairment. Resident #52 had an indwelling urinary…

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 policy review the facility failed to maintain acceptable infection control practices during blood glucose monitoring and medication administration to prevent the spread of infection. This affected five residents (#22, #26, #34, #56 and #68) out of five residents observed for medication administration. The facility census was 97. Findings include: 1. Review of medical record for Resident #26 revealed an admission date of 02/10/22 with diagnoses including Alzheimer's disease, peripheral vascular disease, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26's cognition was moderately impaired. Review of the physician orders for August 2023 revealed Resident #26 was ordered Novolog injection (insulin Aspart) per sliding scale as follows: if 200 to 250 inject two units, if 251 to 300 inject four units, if 301 to 350 inject six units, if 351 to 400 inject eight units, if greater than 400 call…

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 medications were timely administered upon admission to the facility. This affected one resident (#35) of three residents reviewed for new admissions. The facility census was 97. Findings include: Review of the medical record for Resident #35 revealed an admission date of 07/11/23, diagnoses included rhabdomyolysis, acute kidney failure, chronic heart failure, and Parkinson's disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively intact, required total dependence of two staff for toilet use, extensive assistance of one staff for locomotion, dressing, and personal hygiene and required limited assistance of two staff for bed mobility and transfers. Review of the physician orders for Resident #35 revealed orders for allopurinol (uric acid reducer) 300 milligrams (mg) daily, aspirin (blood thinner) 81 mg daily, benazepril (anti-hypertensive) 10 mg daily, clopidogrel (anti-platelet) 75 mg…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure proper infection control practices and procedures were in place to prevent the spread of COVID-19. This affected six residents (#2, #5, #21, #44, #67, and #73) and had to potential to affect all residents. The facility census was 89. Findings include: 1. Review of the medical record for the Resident #5 revealed an admission date of 07/20/22. Diagnoses included Alzheimer's, depression, anemia and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/04/23, revealed the resident had impaired cognition. The resident required limited assistance of two people for bed mobility, extensive assistance of two people for transfers and extensive assistance of one person for dressing and hygiene. Review of the lab results revealed a COVID-19 was administered and sent out 03/16/23. The test came back positive on 03/17/23. Review of the physician's orders dated 03/20/23 revealed the resident was to be placed in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview, the facility failed to ensure there were sufficient staff to implement restorative nursing programs as recommendeded by therapy and to ensure showers were received as scheduled. This affected two residents (Resident #2 and Resident #5) of four residents reviewed for staffing, with the potential to affect all 89 residents in the facility eligible for restorative services. Findings include: 1. Review of Resident #5's medical record revealed diagnoses including Alzheimer's disease, peripheral vascular disease, and generalized muscle weakness. A nursing admission assessment dated [DATE] indicated Resident #5 ambulated with two or more assistants. No impairment in ROM was noted. Resident #5 received Occupational Therapy (OT) from 07/21/23 to 08/31/22. An OT Discharge summary dated [DATE] did not reveal limitations in ROM. The discharge summary indicated recommendation for a restorative nursing program (RNP) for upper extremity strengthening and ROM. 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 and interview, the facility failed to ensure showers were completed for Resident #2 per the resident's preferences and shower schedule. This finding affected one (Resident #2) of three residents reviewed for showers and activities of daily living (ADL's). Findings include: Review of Resident #2's medical record revealed diagnoses including heart failure, end stage renal disease, generalized muscle weakness, spinal stenosis and chronic pain syndrome. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 was able to make herself understood, was able to understand others and was cognitively intact. The MDS indicated Resident #2 did not walk and required physical help in part of the bathing activity. On 03/29/23 at 10:34 A.M., Resident #2 was observed lying in bed. Resident #2 stated she had not had a shower for three weeks and she was crying that morning because she felt so dirty and kept digging at her head. One of the aides asked her why she was crying and when…

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 #5's wound prevention intervention was implemented per the physician's orders. This finding affected one (Resident #5) of two residents reviewed for wounds. Findings include: Review of Resident #5's medical record revealed he was admitted on [DATE] with diagnoses including Alzheimer's disease, peripheral vascular disease and major depressive disorder. Review of Resident #5's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited moderate cognitive impairment. Review of Resident #5's physician orders revealed an order dated 03/15/23 for Allevyn life dressing (foam dressing) to the right lateral ankle as a preventive intervention and the dressing was to be changed every Wednesday and Saturday. Observation on 03/27/23 at 12:50 P.M. with Licensed Practical Nurse (LPN) #802 revealed Resident #5 was lying in bed with his bilateral lower legs on pillows. The resident's right ankle area did not have an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, and review of manufacturer information and interview, the facility failed to ensure fall interventions were implemented for one (Resident #146) of five residents reviewed for falls. Findings include: Review of Resident #146's medical record revealed diagnoses including stage 3 chronic kidney disease, anemia, type two diabetes mellitus, and history of a malignant neoplasm of the brain. A care plan initiated [DATE] indicated Resident #146 was at risk for falls related to gait/balance problems and a history of falls. The goal was to be free of falls. Interventions initiated [DATE] included taking and/or assisting Resident #146 to a supervised area when/if he was noted to have increased confusion or agitation. A fall risk assessment dated [DATE] indicated Resident #146 was at high risk for falls. Risk factors included intermittent confusion, need for assistance with elimination, vision impairment, inability to rise without assistance, medication use and predisposing…

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 non-pharmacological interventions were attempted prior to the administration of anti-pain medication. This affected one resident (Resident #4) of five residents reviewed for unnecessary medication. Findings include: Review of the medical record for Resident #4 revealed an admission date of 03/08/23 with diagnoses including depression, sleep apnea, bilateral above the knee amputation, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Review of Resident #4's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired. She required extensive assistance of two people for bed mobility and toilet use, limited assistance of two people for transfers, extensive assistance of one person for dressing, and supervision of one person for hygiene. Review of Resident #4's physician's orders revealed an order for Oxycodone, a medication used to treat pain, 5 milligrams (mg)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure as needed (prn) medication orders for anti-anxiety medications were limited to 14 days and failed to ensure non-pharmacological interventions were attempted prior to the administration of anti-anxiety medication. This affected one resident (Resident #4) of five reviewed for unnecessary medications. Findings include: Review of the medical record for Resident #4 revealed an admission date of 03/08/23 with diagnoses including depression, sleep apnea, bilateral above the knee amputation, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired. She required extensive assistance of two people for bed mobility and toilet use, limited assistance of two people for transfers, extensive assistance of one person for dressing, and supervision of one person for hygiene. 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 medical record review and interview, the facility failed to ensure laboratory tests were obtained in accordance with physician orders. This affected one (Resident #74) of five residents reviewed for medication use. Findings include: Review of Resident #74's medical record revealed diagnoses including dementia and moderate intellectual disabilities. Resident #74 returned to the facility on [DATE] after a hospitalization. A Complete Blood Count (CBC) with differential and Basal Metabolic Panel (BMP) were ordered every Wednesday for two weeks then every three months. Results were unable to be located. On 03/30/23 at 10:17 A.M., Corporate Quality Assurance (QA) Nurse #577 verified the laboratory tests were not obtained as ordered.