Park Vista Nursing And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, review of the manufacturer recommendations for a glucometer and facility policy review, the facility failed to ensure Residents #1 and #95, with physician ordered isolation precautions, had the appropriate signage on the entrance door to the resident's rooms indicating the type of precautions and type of personal protective equipment (PPE) required when providing care. This finding affected two residents (#1 and #96) of four residents reviewed for isolation precautions and had the potential to affect an additional 35 residents (#5, #11, #12, #16, #24, #26, #30, #33, #34, #38, #40, #43, #47, #53, #55, #57, #58, #61, #63, #64, #65, #82, #83, #84, #89, #90, #94, #98, #99, #102, #203, #205, #206, #253, #256) residing on the 200 and 300 Rehab Units. In addition, the facility failed to ensure the glucometer blood glucose testing machine (BGT) was appropriately cleaned and sanitized after use on Resident #40 to prevent the potential for cross contamination of bloodborne…

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's #46 and #98 were transported to their scheduled appointments. This affected two residents (#46 and #98) out of three residents reviewed for transportation to appointments. The facility census was 101. Findings include: 1. Review of Resident #46's medical record revealed an admission date of 12/12/22 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, dysphagia following cerebral infarction, and anxiety disorder. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 was cognitively intact. Resident #46 required partial to moderate assistance rolling left and right, the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, and the ability to transfer to and from a bed to a chair or wheelchair. Review of the care plan revised 12/20/24 included Resident #46 had 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 observation, interview, record review and review of the facility policy, the facility failed to ensure Residents #57 and #90 and had a clean, sanitary and homelike environment. This affected two residents (#57 and #90) out of three residents reviewed for sanitary homelike environment. The facility census was 101. Findings include: 1. Review of Resident #57's medical record revealed an admission date of 08/06/24 with diagnoses including bipolar disorder, major depressive disorder, and nontraumatic intracranial hemorrhage. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #57 was cognitively intact. Resident #57 had no impairment of the upper and lower extremities. Resident #57 required set-up or clean-up assistance for activity of daily living (ADL). Observation on 02/12/25 at 10:21 A.M. of Resident #57 revealed she walked up to Registered Nurse (RN) #997 and was very upset and told RN #997 her room needed cleaned. Resident #57 stated her trash can was so full…

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 did not ensure a baseline care plan was completed within 48 hours for Residents #11, #92, and #257. This affected three residents (#11, #92, and #257) of the 30 resident records reviewed. The facility census was 101. Findings include: 1. Record review revealed Resident #11 was admitted [DATE] with diagnoses of acute osteomyelitis of the right ankle and foot, legal blindness, chronic diastolic (congestive) heart failure, and chronic obstructive pulmonary disease. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11's cognition was intact as evidenced by the Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15. The resident required moderate assistance for toileting, dressing, showers and transfers. Review of the care plan revealed a baseline care plan was initiated on 12/28/24. Interview on 02/18/25 at 10:24 A.M. with Unit Manager #859 confirmed a baseline care plan was not…

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 an initial care conference was completed for Resident #11 and failed to ensure the quarterly care conference was completed for Resident #31. This affected two residents (#11 and #31) of the 30 resident records reviewed. The facility census was 101. Findings include: 1. Record review revealed Resident #11 was admitted [DATE] with diagnoses of acute osteomyelitis of the right ankle and foot, legal blindness, chronic diastolic (congestive) heart failure, and chronic obstructive pulmonary disease. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11's cognition was intact as evidenced by the Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15. The resident required moderate assistance for toileting, dressing, showers and transfers. Review of Resident #11's medical record revealed no documented evidence a care conference had occurred. Interview on 02/18/25 at…

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 Resident #29 was provided adequate nail care. This finding affected one resident (#29) of four residents reviewed for activities of daily living (ADL). The facility census was 101. Findings include: Review of Resident #29's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia affecting the right dominant side, dementia, and cerebral infarction. Review of Resident #29's current ADL care plan revealed an intervention dated 08/05/21 to check the nail length and trim and clean on bath days and as necessary. Report any changes to the nurse. Review of the Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #29 exhibited severe cognitive impairment and was dependent on staff for ADL care. Telephone interview on 02/11/25 at 10:02 A.M. with Resident #29's power-of-attorney (POA) revealed the POA had concerns of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to ensure Resident #49 was provided an ongoing activities program to meet the needs of the resident. This finding affected one resident (#49) of one resident reviewed for activities. The facility census was 101. Findings include: Review of the medical record revealed Resident #49 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including rheumatoid arthritis, spinal stenosis, and anxiety disorder. Review of Resident #49's current activity care plans revealed an intervention dated 11/17/23 which revealed the resident needed a variety of activity types and locations to maintain the resident's interests. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 had intact cognition. Review of Resident #49's activity logs from 01/07/25 to 02/12/25 revealed the resident received two one-to-one activity visits from the activity staff, including one on 01/07/25 and one on 02/11/25.…

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 orthotics/braces were applied as ordered for Resident #86. This affected one resident (#86) of five residents reviewed for limited range of motion (ROM) and had the potential to affect 13 residents (#5, #6, #7, #29, #31, #40, #42, #43, #64, 72, #81 and #86) identified by the facility as requiring application of orthotics/braces. The facility census was 101. Findings include: Review of the medical record for Resident #86 revealed an admission date of 02/15/24 with diagnoses including cerebral infarction, vascular dementia, diabetes type two, and difficulty walking. Review of the physician's orders revealed an order dated 10/08/24 for a right ankle foot orthosis (AFO) brace when out of bed. (An AFO brace is a brace utilized for support and control the ankle and foot. An AFO is typically used to improve mobility, reduce pain, and prevent deformities). In addition, there was an order dated 11/30/24 to consult…

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, review of the facility incident log, interview and review of the facility post fall investigation, the facility failed to ensure Resident #47 had a comprehensive fall assessment completed after experiencing falls. This affected one resident (#47) out of three residents reviewed for falls. The facility census was 101. Findings include: Review of Resident #47's medical record revealed an admission date of 12/13/24 with diagnoses including cerebral infarction due to unspecified occlusion or stenosis or right anterior cerebral artery, chronic obstructive pulmonary disease, and muscle weakness. Review of Resident #47's Fall Risk Evaluation dated 12/16/24 revealed she was at risk for falls. Review of the care plan dated 12/16/24 revealed Resident #47 was at risk for falls and potential injury related to debilitation, weakness, impaired balance, impaired cognition. Resident #47 was at high risk for falls due to impulsivity. Resident #47 would be free from major injury through the next review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Residents #34 and #203's incontinence care was provided timely and failed to ensure Resident #203's care planned interventions for reporting changes in skin status were implemented. This affected two residents (#34 and #203) out of three residents reviewed for incontinence care. The facility census was 101. Findings include: 1. Review of Resident #203's medical record revealed an admission date of 02/03/25 with diagnoses including multiple fractures of the ribs, left side, displaced fracture of lateral condyle of right femur, displaced fracture of surgical neck of unspecified humerus, displaced articular fracture of head of left femur, and type II diabetes mellitus without complications. Review of Resident #203's Weekly Wound assessment dated [DATE] included the first observation of Resident #203's left hip revealed it was well approximated with 26 staples, light serosanguinous drainage and no signs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to ensure Resident #13 was provided with the diet as ordered and failed to ensure Resident #86 was weighed weekly as ordered. This affected two residents (#13 and #86) of five residents reviewed for nutrition. The facility census was 101. Findings include: 1. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including hemiplegia, unspecified protein-calorie malnutrition, and paranoid schizophrenia. Review of Resident #13's current alteration in nutrition and hydration care plans revealed an intervention dated 03/05/24 to provide the diet as ordered. Review of the Nutritional assessment dated [DATE] revealed Resident #13 was on a regular diet, mechanical soft texture, regular/thin liquids with a nighttime snack daily and a divided plate. Review of the dietary progress note dated 02/07/25 at 8:04 P.M. revealed Resident #13 had a weight change, was on a regular diet, regular…

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 Resident #66's tube feeding was infusing as ordered by the physician. This affected one resident (#66) of one resident reviewed for tube feedings. The facility census was 101. Findings include: Medical record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including cerebral infarction due to occlusion or stenosis of unspecified cerebral artery, dysphagia, oropharyngeal phase, muscle wasting and atrophy, not elsewhere classified, multiple sites, type II diabetes, vascular dementia, moderate without behavioral disturbance psychotic disturbance, mood disturbance and anxiety, moderate protein-calorie malnutrition. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #66 exhibited moderate cognitive impairment, weighed 133 pounds and did not have any oral intake. Resident #66 required a feeding tube for oral intake. Review of Resident #66's weights…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Resident #206's pain was addressed timely. This affected one resident (#206) out of three residents reviewed for pain. The facility census was 101. Findings include: Review of Resident #206's medical record revealed and admission date of 02/06/25 with diagnoses including encounter for orthopedic aftercare following surgical amputation, type II diabetes mellitus with diabetic chronic kidney disease, acquired absence of the left leg below the knee. Review of Resident #206's physician orders dated 02/06/25 revealed oxycodone HCl oral capsule (opioid pain medication) 5 milligrams (mg), give one capsule by mouth every six hours as needed for pain for five days. The order was discontinued on 02/11/25. Review of Resident #206's physician orders dated 02/07/25 revealed acetaminophen oral tablet (Tylenol) (analgesic), give 1300 mg by mouth three times a day for pain. Review of Resident #206's physician orders dated 02/10/25 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, interview and facility policy review, the facility failed to ensure Resident #4's thrill and bruit were assessed every shift per facility policy. This finding affected one resident (#4) of one resident reviewed for dialysis services. The facility census was 101. Findings include: Review of Resident #4's medical record revealed the resident was admitted on [DATE] with diagnoses including end stage renal disease and dependence on renal dialysis. Review of Resident #4's physician's orders revealed an order dated 06/27/24 for vital signs before and after dialysis and an order dated 06/26/24 for hemodialysis every Tuesday, Thursday and Saturday with an arrival time of 10:10 A.M. There was no order to assess Resident #4's thrill and bruit. Review of Resident #4's medication administration records (MARs) and treatment administration records (TARs) from 01/01/25 to 02/13/25 did not reveal evidence the resident's bruit and thrill were assessed every shift per facility policy. Interview on 02/13/25…

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 reviews, interviews and facility policy review, the facility failed to ensure Resident #31 was free from unnecessary medications and failed to ensure pharmacy recommendations were conducted monthly for Resident #14. This affected two residents (#31 and #14) of six residents reviewed for unnecessary medications. The census was 101. Findings include: 1. Record review revealed Resident #31 was admitted [DATE] with diagnoses of cerebral infarction, atherosclerotic heart disease of native coronary artery without angina pectoris, chronic obstructive pulmonary disease, major depressive disorder, and anxiety. Review of the Vital Signs and Pain Only Evaluation dated 01/22/25 revealed Resident #31's pain was moderate. Review of the Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #31's cognition was intact, and he had an impairment on one side in the upper and lower extremity. He was dependent on staff for toileting, showers, dressing, and required maximal assistance for personal…

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, interviews and facility policy review, the facility failed ensure Resident #86's medical record accurately reflected the status of a right lower extremity brace. This affected one resident (#86) of 33 residents who had a review of medical records. The facility census was 101. Findings include: Review of the medical record for Resident #86 revealed an admission date of 02/15/24 with diagnoses including cerebral infarction, vascular dementia, diabetes type two, and difficulty walking. Review of the physician's orders revealed an order dated 10/08/24 for a right ankle foot orthosis (AFO) brace when out of bed. (An AFO brace is a brace utilized for support and control the ankle and foot. An AFO is typically used to improve mobility, reduce pain, and prevent deformities). In addition, there was an order dated 11/30/24 to consult Western Reserve Orthotics for right AFO as the current AFO is broken. There was no documented evidence in the medical record on 11/30/24 that the facility called 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 record review, interview, and facility policy review, the facility failed to ensure a base line care plan was completed for one resident (#99) out of three reviewed for care plans. The facility census was 96. Findings include: Review of the medical record for Resident #99 revealed an admission date of 09/10/24 and a discharge date of 09/19/24. Diagnoses included acute respiratory failure with hypercapnia, chronic obstructive pulmonary disease (COPD), tracheostomy status, gastrostomy status, other seizures, peripheral vascular disease, gastro-esophageal reflux disease (GERD) without esophagitis. Review of the Medicare five-day Minimum Data Set (MDS) assessment, dated 09/12/24, revealed it was still in progress. Review of the facility assessment titled N Adv-Clinical Admission, dated 09/10/24, revealed Resident #99 was alert and oriented with some forgetfulness. She exhibited shortness of breath upon exertion, while sitting, and while laying flat. She received oxygen via her tracheostomy. Her gait was unsteady, and she had poor balance. She was bedrest all or most of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility policy review, the facility failed to ensure the kitchen was clean and sanitary and items were properly stored and dated. This had the potential to affect all 82 residents residing in the facility. The facility identified all residents as receiving meals from the kitchen. Findings include: Observation of the kitchen on 05/14/24 from 4:12 P.M. to 4:29 P.M. with Dietary Director #407 revealed the following concerns: • The square chest freezer in the hallway outside of the dry storage area had a buildup of ice approximately three to four inches thick around the perimeter of the unit. There was a buildup of debris on the sliding doors and around the perimeter of the doors. There was no thermometer in the unit. Dietary Director #407 confirmed the areas of concern at the time of observation. • In the milk and juice walk-in cooler there were three unopened quarts of heaving whipping cream with a use by date of 05/01/24 sitting on an elevated shelf. Dietary Director #407…

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 physician's orders were followed for Residents #69 and #83. This affected two residents (#69 and #83) of three residents reviewed for following physician's orders. The facility census was 82. Findings include: 1. Review of the medical record for Resident #83 revealed an admission date of 03/27/24 and a discharge date of 04/27/24. Medical diagnoses included hypertensive heart and chronic kidney disease with heart failure with stage five chronic kidney disease, type two diabetes mellitus with diabetic chronic kidney disease, unspecified severe protein-calorie malnutrition, and end stage renal disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #83 was severely cognitively impaired. Resident #83 was dependent on staff with toileting, and lower body dressing, and required substantial to maximal assistance with oral hygiene, shower/bathing, upper body dressing, and personal hygiene. Review of the physician…

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

Based on interview, record review, review of a self-reported incident (SRI), and review of the facility policy revealed the facility did not timely report an allegation of misappropriation to the state agency. This affected one resident (#88) out of one resident reviewed for misappropriation. The facility census was 87. Findings include: Review of the closed medical record for Resident #88 revealed an admission date of 12/19/23. Resident #88 was discharged to the assisted living on 04/04/24. Diagnoses included hypotension, cerebral palsy, anxiety disorder, and chronic pain. Review of the witness statement dated 03/29/24 and completed by Resident #88 revealed she had an envelope of four hundred dollars that was missing from her purse in her drawer. The witness statement stated that she checked the money at least two times daily and more if needed. She had signed and dated the witness statement for 03/29/24. Review of the witness statement dated 03/29/24 at 6:30 P.M. and completed by Licensed Practical Nurse (LPN) #552 revealed LPN #552 was getting ready to go into another room 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 record review and interviews, the facility did not ensure a thorough post-fall investigation was completed to identify hazards, and evaluate and analyze hazards and risks to prevent falls for Resident #89. This affected one resident (#89) of four residents reviewed for accidents/hazards. The facility census was 88. Findings include: Review of the medical record revealed Resident #89 was admitted to the facility on [DATE] and discharged from the facility on 02/20/24 to another nursing facility. Medical Diagnoses included multiple myeloma, anemia due to chemotherapy, type two diabetes, chronic kidney disease , diabetic cataract, lack of coordination, and muscle atrophy. Review of the Minimum Data Set ( MDS) 3.0 assessment dated [DATE] revealed moderate cognitive impairment. Resident #89 required moderate assistance to roll in bed, sit to lie flat on the bed, lie to sit on side of bed, sit to stand, chair to bed transfer and toilet transfer. Resident #89 did not attempt to walk ten feet nor attempt to pick…

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, medical record review, and policy review the facility failed to ensure Resident #32 was treated in a dignified manner that included providing privacy during incontinence care. This affected one resident (#32) of three residents reviewed for incontinence care. The facility census was 86. Findings include: Review of medical record for Resident #32 revealed an admission date of 04/17/23 with medical diagnoses including hypertension, cognitive communication deficit, diverticulosis of intestine, need for assistance with personal care. Review of annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #32 was dependent on toileting and was frequently incontinent of bowel and bladder. Review of the care plan dated 04/17/23 revealed Resident #32 had mixed bladder incontinence related to impaired right shoulder fusion and diuretic use. Interventions included to clean peri-area with each incontinence episode. Observation of incontinence care for Resident #32 completed by…

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 medical record review, the facility failed to provide nail care to Resident #55. This affected one resident (#55) of three residents reviewed for activities of daily living. The facility census was 86. Findings include: Review of the medical record for Resident #55 revealed an admission date of 07/06/23 with medical diagnoses including unspecified injury of head, Alzheimer's disease, hypertension, type two diabetes mellitus, major depressive disorder, cognitive communication deficit, and adult failure to thrive. Review of the care plan dated 07/06/23 revealed Resident #55 had an activities of daily living (ADL) self-care performance deficit related to confusion and impaired balance. Interventions included checking nail length and trimming and cleaning nails on bath day and as necessary. Resident #55 required partial moderate assistance with personal hygiene. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #55 revealed 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.

Based on record review, interview, and facility policy review the facility failed to ensure routine, ongoing, and systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections to maintain or improve resident health status was completed timely. This finding had the potential to affect all 97 residents residing in the facility. Findings include: Review of the infection control surveillance tracking system from 01/01/23 to 09/28/23 revealed no evidence the appropriate infection control surveillance including monitoring, evaluating, reporting, and responding to infections was conducted for 06/23, 07/23, and 08/23. Interview on 09/28/23 at 12:50 P.M. with Registered Nurse (RN) Assistant Director of Nursing (ADON) #881 revealed she was the infection preventionist of the facility and it was her responsibility to tracking infections and conduct the appropriate infection surveillance. She indicated she was unable to complete the tracking for 06/23, 07/23, and 08/23 due to nursing staff call-offs which required her to work on the floor as 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.

Based on observation and interview, the facility failed to ensure the facility was maintained in a clean and sanitary manner. This affected Nursing Unit One and its 24 residents (#3, #4, #8, #9, #11, #13, #14, #17, #23, #24, #32, #39, #40, #44, #48, #49, #52, #60, #70, #72, #85, #92, #94, and #96) and had the potential to affect all 97 residents residing in the facility. Findings include: Interview on 09/22/23 at 3:40 P.M. with Ombudsman #818 revealed her concern regarding the cleanliness and sanitariness of the nursing units. Observations on 09/25/23 from 9:15 A.M. to 10:30 A.M. revealed plastic wrap debris, coffee cups, and general dirty floors in Nursing Unit One. Nursing Unit Two and Rehab Unit Two were clean, sanitary, and free from dirt and debris. Interviews on 09/25/23 from 9:15 A.M. to 10:30 A.M. with Residents #85, #49, and #11 indicated the housekeepers could use some help. Interview on 09/25/23 at 4:00 P.M. with the Administrator revealed she was aware of the concerns with the cleanliness and was actively working on hiring housekeepers. This deficiency represents…

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 timely follow-up on Resident #99's family concern regarding missing items. This finding affected one resident (#99) of three residents reviewed for grievances. Findings include: Review of Resident #99's medical record revealed the resident was admitted on [DATE] and discharged on 08/18/23 with diagnoses including vascular dementia, chronic diastolic congestive heart failure, and diabetes. Review of Resident #99's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #99's Missing/Lost Item Replacement Documentation form dated 08/18/23 indicated a standard black wheelchair was missing and dentures were missing with the family to obtain a new set. The form stated on 09/22/23 the daughter was coming to the facility on [DATE] to pick up a wheelchair. The form also indicated on 09/27/23 the family had reported additional missing items…

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 Residents #51 and #94's pressure ulcer wound care was completed as ordered. This finding affected two residents (#51 and #94) of three residents investigated for pressure ulcers. Findings include: 1. Review of Resident #51's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic diastolic congestive heart failure, essential hypertension, and difficulty in walking. Review of Resident #51's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #51's physician orders revealed an order dated 08/24/23 to cleanse the coccyx wound with normal saline, apply triad cream (sterile coating that can be used on broken skin) to the wound and cover with a dry dressing daily and as needed. Review of Resident #51's Weekly Observation Tool dated 09/14/23 revealed the resident had a stage three pressure wound (wound that had…

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 video surveillance, record review, interview, and facility policy review the facility failed to ensure resident safety was maintained during the use of Hoyer mechanical lifts and failed to ensure Hoyer mechanical lifts were in good working order. This finding affected three residents (#38, #46 and #55) of four residents investigated for Hoyer Mechanical Lifts. Findings include: 1. Review of Resident #38's medical record revealed the resident was readmitted on [DATE] with diagnoses including cerebral infarction, hemiplegia, and major depressive disorder. Review of Resident #38's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem and required extensive two person assist for bed mobility and personal hygiene as well as total dependence two person assist for transfers. Review of Resident #38's Assistance with Daily Living (ADL) Care Plan indicated an intervention on [DATE] revealed the resident was totally dependent on two staff members with a mechanical lift…

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 Resident #51 was provided education for using three incontinence briefs on the resident at one time. This finding affected one resident (#51) of three residents investigated for incontinence care. Findings include: Review of Resident #51's medical record revealed an admission date of 08/17/22 with diagnoses including congestive heart failure, diabetes, and muscle weakness. Review of Resident #51's Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed the resident exhibited intact cognition, required extensive two person assist for toileting and was always incontinent of bowel and bladder. Interview on 09/25/23 at 6:49 A.M. with State Tested Nursing Assistant (STNA) #806 indicated she provided Resident #51 incontinence care around 5:30 A.M. to Resident #51. She stated there was not enough staff to provide timely care. Observation on 09/25/23 at 9:10 A.M. of Resident #51's incontinence 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 record review and interview, the facility failed to ensure medications were documented on Resident #98's medication administration records (MARS). This finding affected one resident (#98) of seven resident records reviewed for accuracy. Findings include: Review of Resident #98's medical record revealed the resident was admitted on [DATE], discharged to the hospital on [DATE], returned to the facility on [DATE], discharged to the hospital on [DATE] with diagnoses including encounter for surgical aftercare following surgery on the genitourinary system, carcinoma in situ of bladder, and major depressive disorder. Review of Resident #98's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #98's physician orders revealed an order dated 08/29/23 and discontinued 08/31/23 for magnesium hydroxide oral suspension 400 milligrams (mg)/5 milliliters (ml) give 30 ml by mouth as needed for constipation and an order dated 08/10/23 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, and record review the facility failed to ensure Resident #42 was turned and repositioned. This affected one resident (#42) of three residents reviewed for turning and repositioning. The facility census was 88. Findings include: Review of the medical record for Resident #42 revealed an admission date of 03/29/21. Diagnoses included Alzheimer's disease, hypertension, communication deficit, and malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was rarely or never understood. She was totally dependent on two people for transfers and required extensive assistance of two people for bed mobility. Review of the physician's orders for August 2023 revealed an order for staff to turn and reposition Resident #42 every two hours. Observation on 08/29/23 at 8:40 A.M. of Resident #42 revealed she was lying in bed on her back with the head of the bed elevated approximately 45 degrees. Interview on 08/29/23 at 8:40 A.M. with Resident #42'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 observation, interview, and record review the facility failed to ensure palm protectors were in use for Resident #42 as ordered. This affected one resident (#42) of three reviewed for skin breakdown. The facility census was 88. Findings include: Review of the medical record for Resident #42 revealed an admission date of 03/29/21. Diagnoses included Alzheimer's disease, hypertension, communication deficit, and malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was rarely or never understood. She was totally dependent on two people for transfers and toilet use, was totally dependent on one person for hygiene, required extensive assistance of two people for bed mobility, and extensive assistance of one person for dressing and eating. Review of the physician's orders for August 2023 revealed an order for palm protectors at all times except for bathing and hygiene. Review of the care plan dated 06/21/23 revealed Resident #42 had an alteration 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 observation, record review, and staff interview the facility failed to ensure an accurate medical record for Resident #34. This affected one resident (#34) of three residents reviewed for accurate medical records. The facility census was 88. Findings include: Review of the medical record for Resident #34 revealed an admission date of 02/13/23. Diagnoses included cerebral infarction, depression, glaucoma, and breast cancer. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was rarely or never understood. She was totally dependent on two people for transfers, required extensive assistance of two people for bed mobility and toilet use, and extensive assistance of one person for dressing, eating, and hygiene. Review of the physician's orders for August 2023 revealed an order for enteral feed (a method of supplying nutrients directly into the gastrointestinal tract) of Isosource 1.5 at 45 cubic centimeters (cc) from 9:00 P.M. to 6:00 A.M. each day. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to maintain sufficient levels of nursing staff on the Nursing One unit to meet the total care needs of all residents on the unit. This affected three residents (#44, #52 and #75) and had the potential to affect an additional 18 residents (#2, #3, #11, #17, #27, #32, #33, #34, #41, #47, #48, #57, #60, #64, #72, #83, #91 and #92) who resided on the Nursing One unit. The facility census was 93. Findings include: 1. Review of Resident #44's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified dementia, hyperlipidemia, and hypertension. Review of Resident #44's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she exhibited severe cognitive impairment, was always incontinent of bladder and required extensive two person assist for bed mobility and extensive two person assist for toileting. Interview on 07/31/23 at 6:30 A.M. with State Tested Nurse Aide (STNA) #803 indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and facility policy review the facility failed to ensure a medication error rate of less than five percent (%). The medication error rate was calculated to be 20% and included five medication errors of 25 medication administration opportunities. This affected three residents (#49, #50 and #65) of five residents observed for medication administration. Findings include: 1. Review of Resident #65's medical record revealed an admission date of [DATE] with diagnoses including muscle wasting and atrophy, diabetes, and major depressive disorder. Review of Resident #65's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #65's physician orders revealed an order dated [DATE] for aspirin chewable 81 mg (milligrams) one tablet by mouth one time a day for COVID-19 protocol, an order dated [DATE] for Ergocalciferol capsule (calcium) 1.25 mg or 50,000 iu (international units) give one capsule by mouth…

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

Based on observations and staff interviews, the facility failed to ensure a clean and home like environment. This affected Resident #62 and all of the other 18 residents, Residents #26, #36, #55, #57, #70, #79, #80, #81, #82, #83, #84, #123, #128, #129, #130, #131, and #132, who resided on the third floor. The facility census was 82. Findings include: 1. Observation on 06/14/22 at 8:01 A.M. on the third floor revealed three bags of trash on the floor with leakage on the floor and three bags of trash sitting on top of the trash can. Interview at that time with Environmental Services (EVS) Staff #818 verified the identified findings. 2. Observation on 06/15/22 at 10:05 A.M. of Resident #62's bathroom sink revealed the water was running from the faucet and was unable to be turned off. Interview on 06/15/22 at 10:05 A.M. with Maintenance #814 verified this concern and stated he had been aware of it for a couple of weeks now.

Based on observation and interview the facility failed to ensure call lights were with in reach for all residents. This affected four residents (Residents #12, #17, #32, and #35) of 30 residents initially screened. The facility census was 82. Finding include: Interview on 06/14/22 at 3:27 P.M. with Resident #32 revealed he was not aware of where his call light was. Observation at time of interview revealed Resident #32's call light was wrapped around the bottom of his bed side railing and he was unable to reach it. At the time of this observation, Resident #32's roommate, Resident #17, as asleep in bed and his call light was observed on the floor and out of reach. Observation on 06/14/22 at 3:47 P.M. with Licensed Practical Nurse (LPN) #821 confirmed Resident #32's and Resident #17's call lights were out of reach. An additional observation with LPN #821 at that time revealed Resident #35 and Resident #12 were in their beds with their call lights on the floor and out of reach. Resident #32 and #17 were not interviewable. LPN #821 confirmed their call lights were out of reach. LPN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to provide timely incontinence care to Resident #50, who was dependent on staff for toileting. This affected one of one resident observed for incontinence care. The facility census was 82. Finding include: Review of Resident #50's medical record revealed an admission date of 09/23/20 with diagnoses including muscle wasting, diabetes and anxiety. Review of the minimum data set assessment dated [DATE] revealed Resident #50 required extensive assistance from staff for toileting and was incontinent of bowel and bladder. Resident #50's brief interview for mental status revealed a score of 13, scores of 13 to 15 indicate the person is alert and oriented. Review of the care plan dated 06/10/22 revealed Resident #50 was to be checked by staff for incontinence every two hours and were to provide incontinence care as needed. Interview on 06/14/22 at 1:48 P.M. with Resident #50 revealed he had requested incontinence care at approximately 10:00 A.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure Resident #4 was served and assisted timely with meals. This affected one of eight residents reviewed for food and nutrition. Findings include: Review of the medical record revealed Resident #4 was readmitted to the facility on [DATE] with diagnoses including major depressive disorder, dementia without behavioral disturbance and anxiety. Review of the current altered nutrition/hydration status care plan revealed an intervention dated 09/28/21 for staff to provide and serve the diet as ordered and to monitor intake and record each meal. Review of Resident #4's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she exhibited severe cognitive impairment. Observation on 06/14/22 at 1:30 P.M. revealed State Tested Nursing Assistant (STNA) #802 was in Resident #4's room with the door closed. Upon entry, STNA #802 was observed in the middle of Resident #4's room. Resident #4 was awake in bed and alert but she was not interviewable.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility failed to ensure the oxygen tubing for Resident #29 was changed per physician order. This affected one of four residents (#18, #29, #50, and #75) who received oxygen on the first floor. The facility census was 82. Findings include: Review of the medical record for Resident #29 revealed an admission date of 09/09/21. Diagnoses included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and morbid (severe) obesity due to excess calories. Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #29 was alert, oriented and had intact cognition. Review of the physician orders for June 2022 revealed an order initiated on 05/08/22 for staff to change the oxygen tubing for Resident #29 every Sunday night and as needed on night shift. Observation on 06/12/22 at 12:10 P.M. revealed Resident #29 in bed receiving oxygen therapy via oxygen tubing and oxygen concentrator. There was a piece…

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 provide adequate staffing for provision of timely incontinence care to Resident #50, who was dependent on staff for toileting. This affected one of one resident observed for incontinence care. The facility census was 82. Finding include: Review of Resident #50's medical record revealed an admission date of 09/23/20 with diagnoses including muscle wasting, diabetes and anxiety. Review of the minimum data set assessment dated [DATE] revealed Resident #50 required extensive assistance from staff for toileting and was incontinent of bowel and bladder. Resident #50's brief interview for mental status revealed a score of 13, scores of 13 to 15 indicate the person is alert and oriented. Review of the care plan dated 06/10/22 revealed Resident #50 was to be checked by staff for incontinence every two hours and were to provide incontinence care as needed. Interview on 06/14/22 at 1:48 P.M. with Resident #50 revealed he had requested incontinence…

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

Based on observation and interview the facility failed to ensure Resident #32 and Resident #17's call lights were functional. This affected two of four residents reviewed for call lights. The facility census was 82. Findings include: Interview on 06/14/22 at 3:27 P.M. with Resident #32 stated his call light had not been functioning for approximately three weeks. Observation of his call light confirmed his call light was not been functioning. Observation of his roommates call light, Resident #17, revealed his call light was also not functioning. Interview on 06/14/22 at 3:47 P.M. with Licensed Practical Nurse #821 confirmed the call lights of Resident #32 and #17 had not been functioning. Interview on 06/14/22 at 3:57 P.M. with State Tested Nursing Assistant (STNA) #820 revealed she was aware Resident #32 and Resident #17's call lights had not been functioning for approximately three weeks. STNA #820 stated she had informed the nursing staff, however the issue had not been fixed.