Park Center Healthcare And Rehabilitation

Based on observation, interview and policy review the facility failed to ensure food was stored and served in a manner to prevent contamination and food born illness. This had the potential to affect all 92 residents residing in the facility. There were no residents identified as having a nothing by mouth diet. The facility census was 92. Findings include: On 09/09/24 at 10:02 A.M. a tour of the kitchen revealed in the small upright refrigerator a two-quart plastic container of chicken noodle soup that was half full and not dated as to when it was stored. There were slices of bologna wrapped in plastic with no date. There was sliced ham 48 oz open and undated. The refrigerator also contained eight hard- boiled eggs wrapped in plastic and undated. A two- pound package of cake mix was open and wrapped in plastic with no date as to when it was opened. An interview at the time of the observation with Director of Kitchen Operations (DKO) #149 verified the aforementioned findings. DKO #149 stated the items should have been dated. On 09/09/24 at 12:00 P.M. an observation of tray service 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.

Based on observation, interview and policy review, the facility failed to provide a clean and homelike environment. This affected five residents (#42, #52, #62, #65) and had the potential to affect 16 residents living on Hall 2A (#79, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #92, #93 and #94)) and 25 residents living on Hall 3B (#52, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #75, #76, #77 and #78). The facility census was 92. Findings include: On 09/09/24 at 10:25 A.M. a tour of the building revealed the shower room in Hall 2A had an overflowing sharps container with used razors. Razors were also noted sitting on top of the sharps container. The findings were verified at the time of the observation by Registered Nurse (RN) #201. At 10:50 A.M. on observation of Resident #42's room revealed built up dirt in corners of the bathroom. Resident #42 was laying in bed and appeared sleeping. On the right side of the bed on the floor was dried spit. On the wall was dried spit. On top of register there was dried spit.…

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 did not ensure all residents were provided therapeutic activities as scheduled and in the evenings to meet their needs and preferences. This affected all 92 residents residing in the facility. The facility census was 92. Findings include: Record review of the facility activity calendar dated November 2023 revealed coffee social took place every day at 10:00 A.M., one-to-one visits every day and there were no activities scheduled after 2:30 P.M. except one day on 11/24/23 there was black Friday bingo at 3:00 P.M. There were no religious services scheduled for the month. There was no activity calendar specific to the residents residing on the secured behavior unit (unit 3A). Record review of the facility activity calendar dated December 2023 revealed the latest activity was scheduled at 4:00 P.M. on 12/13/23 and on the weekends the last activity, coffee social, was scheduled at 10:00 A.M. with activity packets also indicated on Saturdays. No religious…

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 store Tuberculin Purified Protein (serum used for intradermal injection to test for tuberculosis) and Lispro Insulin in a manner to ensure efficacy of the medication. This affected one resident (#18) whom the Lispro Insulin was prescribed for and had the potential to affect all residents residing in the facility. The facility census was 92. Findings include: On 04/17/24 at 8:54 A.M. an observation of the medication storage room with Registered Nurse (RN) #440 on 2A hall revealed an open container of Tuberculin Purified Protein one milliliter in the refrigerator. There was approximately one-half milliliter of serum in the vial. The container was undated as to when it was opened. There was also an open vial of Lispro Insulin for Resident #18. The vial was undated as to when it was opened. Interview with RN #440 on 04/17/24 at the time of the observation verified both vials of medication were undated as to when they were opened. A review of the package insert for the Tuberculin Purified Protein revealed…

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

Based on interview and record review, the facility failed to ensure they had a qualified food service director. This had the potential to affect 92 residents who received food from the kitchen. The facility identified all residents in the facility received food from the kitchen. The facility census was 92. Findings include: Interviews conducted on 04/15/24 between 8:09 A.M. and 04/18/24 at 2:35 P.M. with Food Service Director (FSD) #499 revealed the dietitian was at the facility weekly and wasn't involved in the kitchen so had not been providing regular consultations to FSD #499. FSD #499 stated she had not been a food service director until she had moved into the position of food service director, had no formal dietary education, but had a food protection manager certificate. Interview on 04/15/24 at 10:49 A.M. with resident #52 revealed the food was horrible. She revealed the person running the kitchen used to work in laundry and she did not believe she was qualified to run the kitchen. Interview on 04/18/24 at 9:45 A.M. with Registered Dietitian #503 revealed it depended 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, interviews, and review of facility policy, the facility failed to ensure the facility menu was well balanced in regards to calcium sources for all residents. This had the potential to affect all 92 residents receiving meals from the kitchen. The facility identified zero residents as receiving nothing by mouth (NPO). The facility census was 92. Findings include: Interview on 04/16/24 at 8:56 A.M. with the Ombudsman #507 revealed her biggest concern at the facility was the food. She stated she had gone back and forth with the Administrator about almost no residents getting milk on their lunch and dinner trays. She stated she had advocated for all residents to be asked what they want. Observation of tray line on 04/16/24 from 12:00 P.M. to 12:33 P.M. revealed there were three residents (#15, #53, and #84) meal trays with milk placed on them out of the 92 resident meals being served at the meal. Interview on 04/16/24 at 12:01 P.M. with Dietary [NAME] #498 revealed the beverage carts were stocked with Kool aid and coffee. Milk and supplements were placed 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, interviews, record reviews and review of facility policy, the facility failed to ensure resident food preferences were honored and appropriate substitutions were made per resident preferences. This had the potential to affect all 92 residents who received meals from the kitchen. The facility identified zero residents as receiving nothing by mouth (NPO). The facility census was 92. Findings include: Interview on 04/16/24 at 8:56 A.M. with the Ombudsman #507 revealed her biggest concern at the facility was the food. She stated she had advocated for all residents to be asked what they want to eat. Observation of tray line on 04/16/24 at 12:00 P.M. revealed on the steam table was ham, mechanical soft ham, carrots, roast red skin potatoes, and fish patties. (There was no alternate vegetable prepared). Interview on 04/16/24 at 12:33 P.M. with Food Service Director (FSD) #499 stated the residents don't like the recipes. She stated the number of meal item dislikes that could be listed on a resident's tray card was limited, which left the staff to memorize what 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 review of facility policy, the facility failed to ensure proper sanitation was followed in the kitchen and during meal tray delivery. This had the potential to affect all 92 residents in the facility. The facility identified zero residents as receiving nothing by mouth (NPO). The facility census was 92. Findings include: 1. Observation of the tray line process on 04/16/24 from 12:00 P.M. to 12:33 P.M. revealed at 12:14 P.M. Dietary [NAME] #498 and Dietary Aide #506 took a food cart out of the kitchen for delivery. Upon return to the kitchen at 12:16 P.M. Dietary [NAME] #498 and Dietary Aide #506 did not wash their hands. At 12:19 P.M. Dietary [NAME] #498 and Dietary Aide #506 took another food cart out of the kitchen for delivery. Upon return to the kitchen at 12:22 P.M., they did not wash their hands. At 12:24 P.M. Dietary [NAME] #498 and Dietary Aide #506 took another food cart out of the kitchen for delivery. Upon return to the kitchen at 12:31 P.M., they did not wash their hands. Interview on 04/16/24 at 12:33 P.M. with Food Service Director…

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 the facility policy, the facility did not maintain garbage and refuse properly in a closed dumpster free of surrounding litter. This had the potential to affect all residents residing in the facility. The census was 92. Findings include: Observation of the dumpster area during the initial kitchen tour on 04/15/24 from 8:09 A.M. to 8:29 A.M. with Food Service Director (FSD) #499 revealed the left lid was open and the right lid was closed. There was a buildup of debris around the base of the dumpster, which included approximately 20 blue medical examination gloves, numerous plastic white spoons, numerous cigarette butts, one broken blue storage bin observed to be approximately six inches by six inches, one small unidentifiable white plastic bottle with a lid, and numerous dried up white papers, which appeared to be paper towels or napkins. This lack of sanitation predisposed the faciity to the risk of pests such as rodents and insects although no pests were seen at the time of the observation. Interview on 04/15/24 at 8:20 A.M. with FSD…

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, job description review, and interview the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This had the potential to affect all 92 residents who resided in the facility. The facility census was 92. Findings include: Review of facility document titled Job Description and Performance Standards for position of Administrator revealed the Administrator had a signed job description on 12/16/21. The description revealed the purpose of this position is to establish and maintain systems that are effective and efficient to operate the facility in a manner to safely meet residents' needs in compliance with federal, state, and local requirements. To establish and maintain systems that are effective and efficient to operate the facility in a financially sound manner. The Administrator was to establish systems to enforce the facility policies and procedures, supervise all department…

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, record reviews and interviews the facility failed to develop and implement a system to address, analyze, monitor and resolve quality assurance and performance improvement related to the pervasive and ongoing food quality concerns in the facility. This had the potential to affect all 92 residents residing in the facility, as the facility identified zero residents who did not eat by mouth (NPO). The facility census was 92. Findings Include: Review of food audits conducted by facility staff from 01/24/24 to 04/14/24 revealed on 01/24/24 two out of the four residents interviewed didn't feel the food was appealing or good, on 01/18/24 two out of the four residents interviewed didn't feel the food was good or appealing, on 01/20/24 one out of the four residents interviewed didn't feel the food was good or appealing, on 02/06/24 four out of four residents interviewed didn't feel the food was appealing and those four residents had asked for alternate for the meal, on 02/26/24 four out of four residents interviewed felt the food was good and appealing, on 03/07/24 one…

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 appropriate infection control procedures were followed regarding transmission-based precautions (TBP) and enhanced barrier precautions (EBP), failed to separate clean and dirty linens, failed to ensure an effective Legionella water management program, failed to ensure appropriate nebulizer and oxygen tubing storage, and failed to clean multiuse glucometers according to facility policy. This affected 17 residents (#2, #5, #9, #16, #27, #31, #32, #43, #45, #46, #49, #50, #58, #79, #84, #195 and #197) of 32 residents reviewed for infection control and had the potential to affect all 92 residents residing in the facility. Findings include: 1. Review of the facility provided resident matrix dated 04/15/24 revealed Resident #32 was the only resident in the facility on TBP precautions. Observation on 04/15/24/at 7:20 A.M. of the 200-hall revealed Resident #27 had a sign on his door that stated the resident was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of facility policy, the facility did not ensure all residents were treated with a dignified dining experience due to serving meal trays without providing knives to cut food and apply condiments to their foods. This affected all 64 residents receiving meals from the kitchen excluding two residents the facility identified as receiving pureed diets (Resident #8 and #85) and 24 residents (#6, #7, #10, #15, #30, #33, #34, #37, #39, #40, #41, #45, #53, #55, #59, #64, #68, #70, #72, #75, #78, #80, #86, and #89) who resided on the secured behavior unit where knives were not provided at meal times for safety. The facility also did not ensure Resident #45 had a privacy curtain. This affected one resident (#45) of 92 residents reviewed for privacy curtains. The facility census was 92. Findings include: 1. Observation of the tray line on 04/16/24 at 12:10 P.M. revealed a Hawaiian ham slice, four ounces of red skin potatoes, four ounces of carrots, a dinner roll and…

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

Based on record review and interviews, the facility failed to resolve ongoing food related concerns expressed at resident council. This affected five residents (Resident # #1, #4, #22, #29 and #54) of 92 residents receiving meals from the kitchen. The facility census was 92. Findings Include: Review of Resident Council meeting minutes from 09/28/23 to 03/26/24 revealed on 10/26/23 dietary still unsatisfactory', on 11/28/23 Food Service Director (FSD) #499 had responded to dietary concerns and Resident Council was not satisfied with the response, on 01/18/24 dietary continued to have same issues and the Administrator was always busy, on 02/21/24 dietary continued to have same issues and the administrator still too busy to attend, on 03/26/24 the residents voiced concerns related to not enough food, being tired of peanut butter and jelly sandwiches, and Food Service Director (FSD) #499 was not supportive of the residents concerns related to double portions. The Administrator attended and stated he would follow up with the kitchen issues. Interviews were conducted on 04/17/24 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.

Based on observation, interview and policy review the facility failed to repair or replace broken window blinds for 14 residents (#11, #17, #24, #36, #42, #43, #46, #49, #54, #56, #60, #62, #71 and #91) and failed to provide an adequately clean room for Resident #16. This affected a total of 15 residents out of 92 residents reviewed for a safe/clean/comfortable environment. The facility census was 92. Findings include: On 04/15/24 at 10:35 A.M. an observation of the room for Resident #16 revealed built-up visible dust on the chair rail going around the room. State Tested Nurse Aide (STNA) #415 verified the built-up visible dust on the chair rail at the time of the observation. On 04/17/24 between 10:10 A.M. and 10:55 A.M. an observation of resident rooms for Residents #11, #17, #24, #36, #42, #43, #46, #49, #54, #56, #60, #62, #71 and #91 revealed broken window blinds in need of repair or replacement. The broken window blinds were verified at the time of the observation by STNAs #416 and #426. On 04/18/24 at 10:49 A.M. an interview with. the Director of Environmental Services (DES)…

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 oxygen and nebulizers were stored and administered according to physician's orders. This affected five residents (Residents #16, #45, #52, #71, and #246) of five reviewed for respiratory care. The facility identified 10 residents as using oxygen and/or nebulizer treatments. The facility census was 92. Findings include: 1. Review of the medical record for resident #52 revealed an admission date of 06/10/21. Diagnoses included chronic obstructive pulmonary disease (COPD), lung cancer, muscle weakness, depression and insomnia. Review of the physician's orders for April 2024 revealed orders for Albuterol solution 0.5-2.5 milligrams (mg) every four hours, Symbicort inhalation aerosol 160-4.5 micrograms (mcg) two puffs per day and oxygen at four liters continuously. Oxygen tubing was to be changed weekly. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. 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 record review, the facility failed to ensure call lights were within reach for Resident #8 and #67. This affected two residents (#8 and #67) of 32 residents reviewed for call light accessibility. The facility census was 92. Findings include: 1. Review of the medical record for Resident #8 revealed an admission date of 10/15/12. Diagnoses included muscle wasting, irregular heartbeat, schizophrenia, emphysema and repeated falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment date 03/17/24 revealed the resident was rarely or never understood. He required supervision for eating, partial or moderate assistance for oral hygiene and substantial/maximum assistance of toileting, showering and dressing. Review of the care plan dated 01/18/24 revealed the resident was at risk for falls due to impaired balance, involuntary movements, medication side effects and decreased safety awareness. Interventions included minimizing the risk for falls, ensuring the call bell was in…

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

Based on review of resident funds accounts, medical record review and staff interview, the facility failed to ensure resident funds were maintained under the Medicaid limit. This affected one resident (#8) of five residents reviewed for personal funds. The facility census was 92. Findings include: Record review revealed Resident #8 was admitted to facility on 10/05/12 with diagnoses including other secondary Parkinsonism, dysphagia, muscle wasting and atrophy, schizophrenia, anxiety, emphysema, and hypertension. Review of the resident fund account for Resident #8 revealed the facility managed his funds however Resident #8 had a guardian of person and estate. Further review of Resident #8's resident fund account revealed Resident #8 had a balance of $4,253.24 on 09/30/23, a balance of $4,408.45 on 12/31/23, and a balance of $4,565.29 on 03/31/24 in his resident funds account. Interview on 04/22/24 at 3:55 P.M. with Business Office Manager #472 confirmed Resident #8's guardian was not notified that Resident #8 had reached and exceeded the amount limit set by Medicaid.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and facility policy review the facility failed to ensure a resident's wishes regarding end-of-life measures were clearly identified in the medical record. This affected one resident (Residents #196) of three residents reviewed for Advanced Directives. The facility census was 92. Findings include: Review of the medical record for resident #196 revealed an admission date of 11/09/23. Diagnoses included end stage renal disease, colitis, anxiety and depression. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. She was independent in eating, oral hygiene and showering and required supervision or touch assistance for dressing and personal hygiene. Review of the physician orders for April 2024 revealed no evidence of a code status. Interview on 04/16/24 at 12:47 P.M. with Licensed Practical Nurse (LPN) #434 revealed code status was listed in the electronic medical record (EMR) next to the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, review of a Self-Reported Incident (SRI) and facility policy review the facility failed to thoroughly investigate potential resident to resident abuse as required. This affected two residents (#33 and #346) of three residents reviewed for abuse. The facility census was 92. Findings include: 1. Review of the medical record for Resident #33 revealed an admission date of 02/20/23. Medical diagnoses included Alzheimer's disease, bipolar disorder, schizoaffective disorder bipolar, major depressive disorder, generalized communication deficit, and unspecified mood disorder. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 was severely cognitively impaired, had delusions and was observed to have physical behavioral symptoms. Review of Resident #33's care plan dated 02/20/23 revealed the resident was independent with ambulation and transfers. Review of a Body Audit dated 04/10/24 revealed Resident #33 was found to have a new left hand skin…

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 assessments accurately reflected the dental status for Resident #28 and #196. This affected two residents (Residents #28 and #196) of 32 residents reviewed for accurate resident assessments. The facility census was 92. Findings include: 1. Review of the medical record for resident #28 revealed an admission date of 08/17/16. Diagnoses included muscle weakness, dysphagia, neuropathy and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was moderately cognitively impaired. He required set up or clean up assistance for eating and oral hygiene, partial or moderate assistance for personal hygiene and substantial or maximum assistance for toileting, showering and dressing. He had no broken or missing teeth. Review of the care plan dated 04/04/24 revealed the resident had an oral health problem related to carious (cavities or decaying) teeth.…

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 care plans were updated to accurately reflect resident's needs. This affected three residents (residents #31, #50, and #71) of 32 residents reviewed for care plans. The facility census was 92. Findings include: 1. Review of the medical record for resident #31 revealed an admission date of 07/11/22. Diagnoses included acute kidney failure, hypothyroidism, diabetes, dementia and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was moderately cognitively impaired. He was independent with eating and required supervision for oral care, showering and personal hygiene. He had no behaviors and was not on an antipsychotic or antidepressant. Review of the physician's orders for April 2024 revealed an order for Olanzapine (Zyprexa), an antipsychotic medication, 5 milligrams (mg) one tablet by mouth (po) once per day (QD) for an antipsychotic. The order began on 01/23/24. There…

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 showers and nail care were provided consistently and according to resident preference. This affected two residents (resident #28 and #50) of five reviewed for assistance with daily living (ADL)'s. The facility census was 92. Findings include: 1. Review of the medical record for resident #28 revealed an admission date of 08/17/16. Diagnoses included muscle weakness, dysphagia, neuropathy and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was moderately cognitively impaired. He required set up or clean up assistance for eating and oral hygiene, partial or moderate assistance for personal hygiene and substantial or maximum assistance for toileting, showering and dressing. It was very important for him to choose between a tub bath, shower, bed bath or sponge bath. Review of the physician's orders for April 2024 revealed the resident preferred 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, observation, interview, and facility policy review the facility failed to ensure Resident #24 who was at risk for elopement was adequately supervised while outside smoking, did not ensure for Resident #4 that the appropriate safe smoking equipment and supervision were provided during smoking break, and did not ensure fall interventions were in place for Resident #72. This affected three residents (#4, #24 and #72) of five residents reviewed for accidents/hazards. The facility census was 92. Findings include: 1. Review of medical record for Resident #24 revealed an admission date of 11/07/19. Medical diagnoses included unspecified focal traumatic brain injury with loss of consciousness, metabolic encephalopathy, schizoaffective disorder, dementia with other behavioral disturbance, opioid abuse with intoxication, alcohol abuse, cocaine abuse, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #24 was severely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure accurate weights were obtained as ordered. This affected two residents (Residents #50 and #196) of three residents reviewed for nutrition. The facility census was 92. Findings Include: 1. Review of the medical record for Resident #50 revealed an admission date of 03/07/24. Diagnoses included pneumonia, acute kidney failure, depression, anxiety disorder, type two diabetes mellitus without complications, dysphagia (difficulty swallowing), essential hypertension (high blood pressure), and personal history of transient ischemic attack (TIA) and cerebral infarction (stroke) without resident deficits. Review of the most recent Minimum Data Set assessment dated [DATE] revealed Resident #50 was severely impaired cognitively, required supervision or touch assistance for eating, and was on a mechanically altered diet. Resident #50 would hold food in mouth, cough when eating, complain of difficulty or pain when swallowing and had no significant weight…

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 dialysis orders were accurate and assessments were completed before and after dialysis. This affected one resident (Resident #196) of two reviewed for dialysis. The facility census was 92. Findings include: Review of the medical record for resident #196 revealed an admission date of 11/09/23. Diagnoses included end stage renal disease, colitis, anxiety and depression. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. She was independent in eating, oral hygiene and showering and required supervision or touch assistance for dressing and personal hygiene. She was on dialysis. Review of the physician's orders for April 2024 revealed an order for hemodialysis on Tuesday, Thursday and Saturday and an order to check the bruit and thrill every shift. No blood draws were to be obtained from an unspecified arm. Review of the care plan dated 04/08/24 revealed the resident had renal…

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 3. Review of medical record for Resident #45 revealed an admission date of 04/29/21. Medical diagnoses included occlusion and stenosis of bilateral carotid arteries, ischemic cardiomyopathy, acute ischemic heart disease, chest pain, unspecified convulsions, type two diabetes mellitus, chronic obstructive pulmonary disease, unspecified dementia, post-traumatic stress disorder (PTSD), major depressive disorder, suicidal ideations, personality disorder, anxiety disorder, other psychoactive substance abuse. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #45 was moderately cognitively impaired. Resident #45 showed no mood or behavior concerns and did not exhibit the behavior of rejection of care. Resident #45 was independent with eating, required supervision or touching assistance with oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, and personal hygiene. Resident #45 had diagnosis of PTSD. Review of the care plan dated 09/29/21 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, interview and facility policy review, the facility failed to document appropriate justifications for declining a gradual dose reduction (GDR) recommendation for Resident #31. This affected one resident (#31) out of seven residents reviewed for unnecessary medications and had the potential to affect all residents in the facility. The facility census was 92. Findings include: Review of the medical record for Resident #31 revealed an admission date of 07/11/22 with diagnoses including acute kidney failure, hypothyroidism, diabetes, dementia, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was moderately cognitively impaired. He was independent with eating and required supervision for oral care, showering, and personal hygiene. He had no behavior problems and was not on an antipsychotic or antidepressant. Review of the document titled Pharmacists Recommendation to the Provider dated 02/19/24 revealed 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 record review, interview and facility policy review, the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of pain medication for Resident #52. This affected one resident (#52) of seven residents reviewed for unnecessary medication. The facility census was 92. Findings include: Review of the medical record for Resident #52 revealed an admission date of 06/10/21 with diagnoses including chronic obstructive pulmonary disease (COPD), lung cancer, muscle weakness, depression, and insomnia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 was cognitively intact. She required supervision for eating and oral care, partial to moderate assistance for personal hygiene, substantial or maximum assistance for showering, and was dependent for toileting. Review of the physician's orders for April 2024 revealed orders for Morphine Sulfate 0.25 milliliters (ml) (opioid pain medication) by mouth (PO) every hour as needed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to ensure appropriate diagnoses for medications and failed to ensure behaviors were tracked for medication efficacy. This affected three residents (#31, #35 and #71) of seven residents reviewed for unnecessary medications. The facility census was 92. Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of 07/11/22 with diagnoses including acute kidney failure, hypothyroidism, diabetes, dementia, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was moderately cognitively impaired. He was independent with eating and required supervision for oral care, showering, and personal hygiene. He had no behavior problems and was not on an antipsychotic or antidepressant. Review of the physician's orders for April 2024 revealed an order for Namenda, used to treat dementia, five mg by mouth (PO) two times per day (BID) with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, observation and policy review the facility failed to ensure daily weights were documented per physician orders related to congestive heart failure monitoring for Resident #45. The facility also failed to ensure Resident #196's diet order accurately reflected the resident's dietary needs. This affected two resident's (#45 and #196) of 32 residents reviewed for documentation. In addition, the facility failed to have documented evidence of weekly body audits on Resident #79 as ordered to monitor the status of wounds. This affected one resident (#79) of three residents reviewed for pressure ulcers and had the potential to affect nine additional residents (#9, #27, #42, #43, #46, #49, #58, #74, and #195) identified by the facility as having wounds. The facility census was 92. Findings include: 1. Review of medical record for Resident #45 revealed an admission date of 04/29/21. Medical diagnoses included occlusion and stenosis of bilateral carotid arteries, congestive heart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and review of the facility policy, the facility failed to ensure it had a functional call light system for Residents #27, #81, and #82. This affected three residents (#27, #81 and #82) out of 32 residents reviewed for call lights. The facility census was 92. Findings Include: 1. Record review for Resident #82 revealed an admission date of 06/06/23. Diagnoses included encounter for other orthopedic aftercare, presence of left artificial hip joint, bilateral primary osteoarthritis of hip, pain in left and right hip, major depressive disorder, generalized anxiety disorder, type two diabetes mellitus without complications, other abnormalities of gait and mobility, and muscle weakness (generalized). Review of most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #82 was cognitively intact, required partial/moderate assistance for toilet hygiene, and supervision or touch assistance of staff for toilet transfer and walking up to 150 feet. The resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to document in the medical record an incident involving Resident #14 getting stuck in a stairwell. This affected one resident (#14) of three residents reviewed for accurate documentation. The facility census was 91. Findings include: Record review was conducted for Resident #14 who admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus with diabetic neuropathy, cerebral infarction, morbid obesity, generalized anxiety disorder, abnormalities of gait and mobility, need for assistance for personal care, contractures of muscles lower left leg, contracture of muscle right lower leg, infarction of spinal cord, major depressive disorder recurrent severe without psychotic features, muscle weakness and borderline personality disorder. Review of the Minimum Data Set ( MDS) 3.0 assessment for Resident #14, dated 10/01/23, revealed Resident #14 had clear speech, was able to make self-understood, was able to understand…

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 interviews the facility failed to have a registered nurse (RN) for eight consecutive hours on 06/18/23. This had the potential to affect all 91 residents. Findings include: Review of the schedule while completing the staffing tool for the week of 06/18/23 revealed there was no RN present in the building for 06/18/23. Interview on 07/03/23 at 11:38 A.M. with Staffing Coordinator (SC) #1067 verified there was no RN coverage per the schedule. Interviews on 07/03/23 from 11:44 A.M. through 1:39 P.M. with management who were on a rotating on-call schedule including Minimum Data Set Nurse (MDS) #1069, Unit Manager #1003 and Unit manager #1005 revealed they did not work on 06/18/23. Interview on 07/03/23 at 4:00 P.M. with the Director of Nursing (DON) revealed she did not work on 06/18/23. She stated there was no RN that day as the one who was scheduled was hospitalized . Review of the punch details revealed there was no RN on 06/18/23.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure Resident #8's call light did not have exposed wires, failed to ensure Resident #40's call light and bed controller were working appropriately, failed to ensure Resident's #24, #39, and #75 had a call light connected to the call light system in their rooms. This affected five residents (#8, #24, #39, #40 and #75) out of six residents reviewed for call lights. The facility census was 91. Findings include: 1. Review of Resident #40's medical record revealed an admission date of 11/08/19 with diagnoses including dementia, hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting the right dominant side, and major depressive disorder. Review of Resident #40's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 had moderate cognitive impairment. Resident #40 required supervision and set-up help only for bed mobility, limited assistance of one staff member for transfers, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility policy the facility failed to ensure the temperature on the third-floor nursing units were within the required temperature range of 71 to 81 degrees Fahrenheit. This affected one resident (#19) and had the potential to affect all 54 residents (#3, #4, #5, #7, #9, #10, #11, #13, #14, #15, #16, #18, #19, #20, #21, #23, #24, #25, #33, #36, #37, #39, #40, #41, #42, #43, #44, #45, #46, #47, #49, #50, #54, #56 #57, #58, #59, #60, #63, #66, #67, #68, #70, #71, #72, #75, #79, #80, #82, #83, #85, #88, #89, #195) residing on the third-floor of the facility. The facility census was 91. Findings include: Review of Resident #19's medical record revealed an admission date of 05/17/21 with diagnoses including pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder, can be treated, cannot be cured), vascular dementia, social phobia, generalized anxiety, and schizoaffective disorder. Review of Resident #19's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to provide a written invitation or conduct an interdisciplinary team care plan meeting for Residents #22, #76, #48, #3, #11, #21, #33, #40, #45, #49, #51, #16, #44, #7, #24, #58, and #75. This affected 17 residents (#22, #76, #48, #3, #11, #21, #33, #40, #45, #49, #51, #16, #44, #7, #24, #58 and #75) out of 91 residents screened for plan of care meetings. The facility census was 91. Findings include: 1a. Review of the medical record for Resident #3 revealed an admission date of 06/01/18. Diagnoses included cerebral infarction, encephalopathy, dysphagia, and alcohol abuse. Resident #3 was cognitively intact. Review of the record revealed no evidence of a care plan meeting. b. Review of the medical record for Resident #11 revealed an admission date of 11/04/21. Diagnoses included chronic obstructive pulmonary disease, cerebral ischemia, and depression. Resident #11 was cognitively impaired. Review of the record revealed no evidence…

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, interviews and observations, the facility did not ensure food was served in a manner to maintain quality and palatability of all food served to the residents. This had the potential to affect all residents receiving meals from the kitchen. The facility census was 91. Findings include: Review of the resident council minutes revealed during the meeting on 12/29/22 council presented concerns regarding the food not looking appealing to the residents stating the food was unrecognizable and terrible. Twelve residents attended, ten of which were current residents (#1, #3, #11, #14, #20, #24, #25, #31, #32 and #67). Review of the grievance log, dated 06/27/22, revealed the Director of Nursing purchased pizza for all the residents because they were not satisfied with the dinner. Interview on 07/03/23 at 1:30 P.M. with the DON verified the residents were dissatisfied with the meatloaf served on 06/27/23. Interviews on 06/26/23 with Residents (#7, #9, #11 #14, #24, #41, #58 and #68) revealed the food did not look appealing and within the past month they had been served…

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, interview, and facility policy review the facility failed to ensure resident wishes regarding end-of-life measures were clearly identified in the medical record. This affected two residents (#81 and #84) of three residents reviewed for Advanced Directives. The facility census was 91. Findings include: 1. Review of the medical record for Resident #81 revealed an admission date of 02/04/23. Diagnoses included chronic kidney disease, heart failure, cirrhosis of the liver, and depression. Review of the physician's orders for June 2023 revealed Resident #81 was a Full Code. Information along the top of the record located near the allergy list also indicated a Full Code status. Review of a progress note dated 04/17/23 revealed Resident #81 changed his code status from Full Code to Do Not Resuscitate Comfort Care Arrest Do Not Intubate (DNR-CCA DNI), and the paperwork had been signed and verified. Interview on 06/28/23 at 3:04 P.M. with the Director of Nursing (DON) verified there was no evidence the change in code status from Full Code to DNRCCA DNI and…

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

Based on record review and interview, the facility failed to ensure residents discharged from skilled services were provided appropriate notification of services ending. This affected one resident (#251) of three residents reviewed for beneficiary notification. The facility census was 91. Findings include: Review of Resident #251's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form indicated the resident's last covered day of Part A services was on 03/06/23. The form revealed the SNF Advanced Beneficiary Notice (ABN) Form CMS-10055 was provided to Resident #251's son on 03/06/23. Interview on 06/28/23 at 1:40 P.M. with the Social Services Director (SSD) #1070 confirmed the SNF ABN Form CMS-10055 was not provided at least two days before the resident was cut from skilled services.

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 #88 did not have very long, dirty, yellow toenails. This affected one resident (#88) out of three residents reviewed for long toenails. In addition, the facility failed to ensure shower/bed baths were given to Resident #58 according to the physician's orders and plan of care. This affected one resident (#58) of six residents reviewed for activities of daily living (ADL). The facility census was 91. Findings include: 1. Review of Resident #88's medical record revealed an admission date of 04/25/23 with diagnoses including unspecified sequelae of other cerebrovascular disease, other specified disorders of the brain, and alcohol abuse. Review of Resident #88's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #88 was cognitively intact. Resident #88 was independent and required no set up or physical help from staff for bed mobility and transfers. Resident #88 required…

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 #82's urine culture was collected and sent to the lab per physician's orders. This affected one resident (#82) out of three residents reviewed for urine cultures. The facility census was 91. Findings include: Review of Resident #82's medical record revealed an admission date of [DATE] with diagnoses including cerebral infarction, personality disorder, and altered mental status. Review of Resident #82's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #82 had moderate cognitive impairment. Resident #82 was independent for bed mobility, required supervision and set-up help only for transfers, toileting, and eating. Review of Resident #82's physician's orders dated [DATE] revealed urinalysis with culture and sensitivity, one time only for urinary frequency until [DATE]. Review of Resident #82's Treatment Administration Record (TAR) revealed a urinalysis with culture 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, interview, and facility policy review the facility failed to prevent Resident #35's fall in the facility and failed to ensure fall prevention interventions were in place for Resident #8. This affected two residents (#35 and #8) out of five residents reviewed for falls. The facility census was 91. Findings include: 1. Resident #35 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including alcohol abuse, attention-deficit hyperactivity disorder, bipolar disorder, morbid obesity with a body mass index of 38 to 38.9, need for assistance with personal care, abnormality of gait and mobility, major depressive disorder, right below the knee amputation, muscle wasting and atrophy with generalized muscle weakness. A review or Resident #35's Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #35 needed extensive assistance with transfers. Resident #35's fall assessment dated [DATE] indicated Resident #35 had a moderate risk for falls. Resident #35's plan of care…

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

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 #36 received nutritional supplements and double portions of food per physician orders, failed to ensure weights were obtained per physician orders, failed to ensure Resident #36's meal percentages of food eaten were documented and failed to ensure Resident #36's significant weight loss was monitored from 03/16/23 through 06/26/23. The facility failed to ensure Resident #82 was provided fluids per physician orders, failed to ensure Resident #82's fluid intake was recorded and failed to ensure Resident #82's daily fluid requirements were documented by the facility Dietician in an initial nutritional assessment. The facility also failed to obtain monthly weights as ordered for resident #32. This affected three residents (Resident's #32, #36 and #82) out of three residents reviewed for nutrition. The facility census was 91. Findings include: 1. Review of the medical record for Resident #32 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to obtain Resident #6's laboratory results during dialysis treatments as ordered by the physician. This affected one resident (#6) out of one resident reviewed for hemodialysis care. The facility census was 91. Findings include: Resident #6 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including end stage renal disease, anemia, renal osteodystrophy (a bone disease that occurs in adults and children with chronic kidney disease), and chronic viral hepatitis C. Resident #6's medical record indicated on 12/02/21 a physician order to arrange transportation to the dialysis center for hemodialysis treatments on Tuesdays, Thursdays, and Saturdays. Resident #6's physician order dated 05/30/23 indicated to obtain a complete blood count, and basic metabolic panel every three months starting on the last day of the month. Further review of Resident #6's clinical record revealed no laboratory results were obtained on 05/31/23. An interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure medications were reviewed monthly. This affected one resident (#8) of five resident reviewed for unnecessary medications and had the potential to affect all residents in the facility. The facility census was 91. Findings include: Review of the medical record for Resident #8 revealed an admission date of 10/15/12. Diagnoses included Parkinson's disease, muscle wasting, atrial fibrillation, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had severe cognitive impairment. He required extensive assistance of one staff for bed mobility, transfers, toilet use, and hygiene. Review of the physician's orders for June 2023 revealed Resident #8 was ordered Seroquel (antipsychotic) 100 milligrams (mg) two times a day (BID) and Seroquel 200 mg once per day (QD), Duloxetine (antidepressant) 20mg QD, Metoprolol (medication to treat high blood pressure, chest pain, and heart failure) 25 mg QD,…

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 review of the facility policy the facility failed to ensure non-pharmacological interventions were utilized, behavioral symptoms were monitored, and anti-anxiety medications were not used for longer than 14 days without a rationale. This affected one resident (#8) of five residents reviewed for unnecessary medications. The facility census was 91. Findings include: Review of the medical record for Resident #8 revealed an admission date of 10/15/12. Diagnoses included Parkinson's disease, muscle wasting, atrial fibrillation, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident had severe cognitive impairment. He required extensive assistance of one staff for bed mobility, transfers, toilet use and hygiene. Review of the physician's orders for June 2023 revealed Resident #8 was ordered Seroquel (antipsychotic) 100 milligrams (mg) two times a day (BID) and Seroquel 200 mg once per day (QD), Duloxetine (antidepressant)…

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 staff washed their hands to prevent possible cross contamination of infections during Resident #23's incontinence care and wound care. This affected one resident (#23) out of three residents reviewed for wounds and incontinence care. The facility census was 91. Findings include: Resident #23 was admitted on [DATE] with diagnoses including iron deficiency anemia, gastrointestinal hemorrhage, Alzheimer's disease, diabetes mellitus, skin cancer, contracture of the right hip, major depression, dementia, and anxiety. Resident #23's wound documentation dated 06/26/23 indicated she had a cancer lesion located on the right trochanter measuring 1.2 centimeter (cm) in length by 1.1 cm width with no undermining or tunneling. The wound had serous exudate with edges flush with wound bed. Additional care needs included to provide incontinence management and nutrition/dietary supplementation. The wound was stable with 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.