Adams Lane Healthcare and Rehabilitation Center

Based on observations, record review, and staff interview, the facility failed to develop a comprehensive care plan. This affected one resident (#33) of 38 residents reviewed for comprehensive care plans. The facility census was 107. Findings include:Review of the record for Resident #33 revealed an admission date of 06/02/25 and diagnoses including dementia, metabolic encephalopathy, adult failure to thrive, and hypertension. The resident resided on the secure memory care unit. Review of a Minimum Data Set (MDS) assessment completed 03/26/26 revealed a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment. It further stated the resident was dependent upon staff for personal hygiene and bathing. Review of the plan of care for Resident #33 revealed it did not address a behavior of rectal digging or the provision of personal hygiene by staff. Observations on 06/01/26 at 2:10 P.M. and 06/04/26 at 8:00 A.M. revealed Resident #33 to have a dark brown substance under her fingernails. Interview with Licensed Practical Nurse #184 on 06/04/26 8:00 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 medical record review and staff interview the facility failed have timely care conferences and invite family to care conferences. This affected two residents (#3, #35) of five residents reviewed for care plan timing and revision. The census was 107. Findings include:1.Review of Resident #3's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included diabetes, gastroparesis, congestive heart failure, Chronic kidney disease, PTSD, ASHD, and chronic pain syndrome. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed his cognition was intact. He required set up or clean up assistance for eating, oral hygiene, supervision or touching assistance for toileting, turning and repositioning and personal hygiene, substantial/maximal assistance for shower/bathing, Occasionally incontinent of urine and always continent of bowel. Review of the record revealed a care conference was held on 10/16/25 and not again until 03/18/26 identifying five months in between. 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 medical record review and staff interview, the facility failed to follow physician orders for monitoring urinary output. This affected one resident (#4) of four residents reviewed with indwelling urinary catheters. The census was 107. Findings include: Review of Resident #4's medical record revealed he was admitted to the facility 04/07/26. Diagnoses included dementia, depression, obstructive uropathy, diabetes, fracture of the seventh cervical vertebrae, fracture of the right mandible, and fracture of the neck of the left humerus. Review of physician orders revealed an order dated 04/07/26 for an Indwelling Urinary (Foley) Catheter: measure and record output. Review of the 5-day MDS dated [DATE] revealed his cognition was not intact, He required set up or clean up assistance for eating, dependent for oral hygiene, toileting, substantial/maximal assistance for shower/bathing dressing and turning and repositioning. He had an indwelling urinary catheter and was frequently incontinent of his bowel. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview and review of the manufacture user guide, the facility failed to ensure a physician ordered low air loss mattress for pressure ulcer prevention was was powered and inflated. This deficient practice affected one resident (Resident #27) of four residents reviewed for medical equipment. The census was 107. Findings include: Review of Resident #27's medical record revealed an admission date of 12/31/23 with diagnoses including but not limited to type two diabetes mellitus, heart failure, Alzheimer's Disease, and high blood pressure.Review of Resident #27's potential for skin impairment care plan dated 09/02/25 revealed Resident #27 refused to get out of bed at times, was at risk for skin impairment, and has a low air loss mattress (LAL) mattress to bed as an intervention for development of skin impairment.Review of Resident #27's signed physician orders revealed an order dated 11/06/25 for use of a LAL mattress to the bed. Check function/inflation every shift…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, interviews, and facility policy review the facility failed to ensure safety of residents was maintained. This deficient practice affected one resident (Resident #12) out of four residents reviewed for safety adaptive equipment for cigarette smoking, affected one resident (Resident #44) out two residents for safety while out on the facility's campus, and affected one resident (Resident #71) out three residents reviewed for bed mattress safety. The facility census was 107. Findings Include: 1. Review of Resident #12's medical record revealed an admission date 09/29/25 with diagnoses including but not limited to Multiple Sclerosis, high blood pressure, depression, anxiety, and paraplegia. Review of Resident #12's smoking assessment dated [DATE] revealed Resident #12 was deemed supervision for smoking with no adaptive equipment or smoking apron required. Review of Resident #12's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #12 had intact cognition with a Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview and facility policy and procedure review, the facility failed to follow physician orders for flushing the gastrostomy tube (tube through the abdominal wall into the stomach for nutrition) during medication administration . This affected one (Resident #85) of one resident observed for medication administration through a gastrostomy tube. The census was 107. Findings include: Review of Resident #85's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included cerebral palsy, severe intellectual disability, seizures, encephalopathy, and gastrostomy. Review of the physicians orders for 10/23/2023 revealed an order for every shift to flush the gastrostomy tube with 30 milliliters (ml) of water pre/post medication administration and 5 to 10 mls of water between each medication. The resident was also ordered to receive dicyclomine hydrochloride (Bentyl used to treat spasms of the intestines) 10 milligrams (mg) per five ml of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure medications were administered within ordered physician parameters. This affected one (Resident #3) of five residents reviewed for unnecessary medications. The census was 107. Findings include: Review of Resident #3's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included diabetes, congestive heart failure, chronic kidney disease,and chronic pain syndrome. Review of the quarterly minimum data set assessment dated [DATE] revealed his cognition was intact. He required set up or clean up assistance for eating and oral hygiene, Supervision or touching assistance for toileting, turning and repositioning and personal hygiene, substantial/maximal assistance for shower/bathing, Occasionally incontinent of urine and always continent of bowel. Review of the physician orders revealed an order dated 04/14/2026 for Humalog insulin Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject 17 units…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff, and resident interview, the facility failed to obtain dental services for one (Resident #3) of nine residents reviewed for dental services. The census was 107. Findings include: Review of Resident #3's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included diabetes, gastroparesis, congestive heart failure, chronic kidney disease, and chronic pain syndrome. Review of the quarterly minimum data set assessment dated [DATE] revealed his cognition was intact. He requires set up or clean up assistance for eating, oral hygiene, Supervision or touching assistance for toileting, turning and repositioning and personal hygiene, substantial/maximal assistance for shower/bathing, Occasionally incontinent of urine and always continent of bowel. Interview with on 06/02/2026 at 9:35 A,M. with Resident #3 revealed he has been here a year and has asked to see a dentist and hasn't. There was one here yesterday and I thought they would come and get me.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff, and resident interview, the facility failed to obtain dental services for one (Resident #10) of nine residents reviewed for dental services. The census was 107. Findings include:Review of Resident #10's medical record revealed he admitted to the facility on [DATE]. Diagnoses included diabetes, encephalopathy, Downs syndrome, obstructive and reflux uropathy, urinary retention, chronic kidney disease, Stage 3. Review of the annual MDS dated [DATE] revealed his cognition is severely impaired. He requires supervision or touching assistance for eating, partial/moderate assistance for oral hygiene, personal hygiene and turning and repositioning, dependent for toileting, substantial/maximal assistance for shower/bathing and dressing. Indwelling urinary catheter and always incontinent of bowel. Review of the plan of care dated 03/31/2025 revealed the resident has oral/dental health problems due to he has his own teeth in poor condition with some broken 06/01/2026 5:07 P.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 record review, observation, and interview the facility failed to maintain accurate medical records related to pressure relieving interventions. This deficient practice affected one resident (Resident #27) of four residents reviewed for medical equipment. The census was 107.Findings Include:Review of Resident #27's medical record revealed admission date 12/31/23 with diagnoses including but not limited to type two Diabetes Mellites, heart failure, Alzheimer's Disease, and high blood pressure.Review of Resident #27's signed physician orders revealed an order dated 11/06/25 for use of a Low Air Loss (LAL) mattress to bed. Check function/inflation every shift (QS).Review of Resident #27's annual Minimum Data Set (MDS) dated [DATE] revealed Resident #27 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of 3 out of possible 15, had impairment on one side of the body, used a wheelchair for mobility, was at risk for developing skin impairment, and was dependent on staff for Activities…

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

Based on observations and staff interviews, the facility failed to ensure a safe homelike environment for the 22 (Residents #58, #59, #60, #61, #62, #62, #63, #64, #65, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, and #80) in the memory care unit when the unit was left with a black moldlike substance in the hallway, and there was a strong odor of urine noted throughout the unit. This affected 22 residents in memory care unit of 94 residents reviewed for environment. The facility census was 94.Findings include: Observations on 07/15/25 from 3:22 P.M.- to 4:05 P.M., a tour of the facility was completed. The facility had an East Unit that was comprised of 100 and 200 halls. They had a North Unit that included the 500, 600, and 700 halls. They had a secure memory care unit that included the 300 and 400 halls. No odors or evidence of residents not receiving proper incontinence care was noted when touring the East and the North Units. Those areas of the facility were free of any odors and none of the residents observed showed signs of incontinence as evidenced by saturated…

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 review of the facility policies, the facility failed to maintain appropriate infection control and enhanced barrier precautions (EBP) for one (Resident # 87) out of 41 residents in EBP. The facility census was 94. Findings include: Review of the medical record for Resident #87 revealed an admission date of 06/26/25. Diagnoses included metabolic encephalopathy, hypertension, peripheral vascular disease, major depressive disorder, cirrhosis of liver, type two diabetes mellitus, bipolar disorder, and chronic pain syndrome. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of three out of 15, indicating Resident #87 had severe cognitive impairment. The resident was assessed to require partial/moderate assistance for meals/eating, and oral hygiene. Resident #87 was dependent on staff for toileting, shower/bathing, dressing, and personal hygiene. Resident #87 was admitted with one Stage…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, resident interview, vendor staff interview, and facility policy review, the facility failed to provide medically necessary social services regarding discharge processes. This affected one (Resident #11) of three residents reviewed for discharge. The census was 108. Findings Include: Resident #11 was admitted to the facility on [DATE]. Her diagnoses were congestive heart failure, chronic respiratory failure with hypoxia, hypo-osmolality and hyponatremia, atrial fibrillation, gout, anemia, hypertension, anxiety disorder, glaucoma, bipolar disorder, fibromyalgia, COPD, and depression. Review of her minimum data set (MDS) assessment, dated 03/14/25, revealed she was cognitively intact. Review of Resident #11's quarterly care conference notes, dated 11/04/24, 01/27/25, and 04/21/25 revealed the facility addressed on-going discharge questions. It stated, she was undecided as to whether she wanted to discharge, but she wanted to be asked at each care conference if 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.

Based on observation, staff and resident interviews, and record review the facility failed to provide reasonable accommodation of needs and preferences when a bedside chair, a bedside nightstand, and a call light were not within reach. This affected one of 108 residents (#26). The facility census was 108. Findings Include: Record review revealed Resident #26 had an admission date of 05/19/23 with diagnoses including: Type two diabetes, displaced intertrochanteric fracture of left femur, cervical disc degeneration, coronary artery bypass graft without angina, chronic atrial fibrillation, systolic congestive heart failure, muscle wasting multiple sites, posthemorrhagic anemia, Alzheimer's disease, major depressive disorder, dementia without behavioral disturbance, unsteadiness on feet, abnormalities of gait and mobility, hyperlipidemia, hypertension, venous insufficiency, cognitive communication deficit, wrist drop left wrist, lymphedema, hypertension, urinary tract infection, full incontinence of feces, urinary incontinence, retention of urine, cardiac pacemaker, and history of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff and resident interviews, the facility failed to provide a safe, clean, comfortable and homelike environment for two residents which allowed them to use their personal belongings to the extent possible This affected three residents (#33, #40, #75) of 108 residents residing in the facility. The census was 108. Findings Include: 1. Record review revealed Resident #40 had an admission date of 03/30/18 with diagnoses including: Cerebral infarction, dysphagia, influenza, chronic obstructive pulmonary disease, morbid obesity, diverticulosis, muscle wasting and atrophy, intervertebral disc degeneration of the lumbar region, type two diabetes mellitus, chronic respiratory failure with hypoxia, major depressive disorder, cardiac pacemaker, voice and resonance disorder, low back pain, abnormalities of gait and mobility, anemia, hyperlipidemia, anxiety disorder, left bundle branch block, constipation, gastroesophageal reflux disease, difficulty in walking, history of covid-19, urge…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure pre-admission screening and resident reviews (PASSAR) were accurately completed. This affected one resident (#43) of two review for PASSAR accuracy. The census was 108. Findings include: Review of Resident #43's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included Ogilvie syndrome ( acute colonic pseudo-obstruction, is the acute dilatation of the colon in the absence of any mechanical obstruction), colostomy, gastrostomy, nausea and vomiting, schizoaffective disorder , depression and anxiety. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed his cognition was intact. He required partial/moderate assistance for oral hygiene, personal hygiene, and turning and repositioning, dependent for toileting and substantial/maximal assist for showers/bathing, lower body dressing and application of footwear. Resident #43 had an indwelling catheter and a colostomy. Receives…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to develop and implement a comprehensive person centered care plan for diuretic medication for Resident #60. This affected one resident (#60) of five residents sampled for unnecessary medications. The facility census was 108. Findings include: Review of Resident #60's medical record revealed an admission date of 10/03/20 and a reentry date of 01/13/22. Further review revealed diagnoses including malignant neoplasm of overlapping sites of rectum, anus and anal canal, secondary malignant neoplasm of large intestine and rectum, diabetes, chronic respiratory failure, morbid obesity, heart failure, and hypertension. Review of Resident #60's quarterly minimum data set (MDS) dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 15 indicating that she is cognitively intact. Further review of the MDS revealed Resident #60 was receiving diuretic medication. Review of Resident #60's physician's orders revealed an order with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and review of facility policy and procedure, the facility failed to ensure medications were locked against unauthorized access. This had the potential to affect one resident (#97) of 10 residents on the 200 hallway identified as cognitively impaired and independently mobile. The census was 108. Findings include: Observation on 02/12/25 at 10:39 A.M. revealed the medication cart in the hallway unlocked outside of room [ROOM NUMBER]-A with the door closed and no nurse in attendance of the cart. At 10:41 A.M. Registered Nurse #251 came out from the room and verified during interview she had left the medication cart unlocked and unattended in the hallway. Review of the facility Medication Storage policy and procedure (dated 04/18 and updated 01/03/25) revealed compartment (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biological's shall be locked when not in use, and trays or carts used to transport such items shall…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview the facility failed to maintain infection control with urinary catheters. This affected one resident (#3) of four residents reviewed for urinary catheters. The census was 108. Findings include Review of Resident #3's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, morbid obesity, heart failure, diabetes, atrial fibrillation, major depression, chronic kidney disease and anxiety. Review of the admission minimum data set (MDS) dated [DATE] revealed her cognition was intact. She required set up or clean-up assistance for eating, oral hygiene, is dependent for toileting, and substantial/maximal assistance with shower/bathing, partial/moderate assistance for personal hygiene, dressing and turning and repositioning. The resident had a urinary catheter and was frequently incontinent of bowel. On 02/11/25 at 11:47 A.M. observation revealed the urinary catheter tubing was observed on the floor.…

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

Based on medical record review and staff interview, the facility failed to ensure advance directive orders and documents were consistent in the medical record and reflective of the resident/resident representative wishes. This affected one (Resident #348) of 24 residents reviewed for advance directives. The facility census was 100. Findings include: Review of Resident #348's medical record revealed an admission date of 08/08/23 with diagnoses that included Alzheimer's disease with dementia, congestive heart failure and atherosclerotic heart disease. Further review of Resident #348's physician's orders revealed the resident's code status was full code (cardiopulmonary resuscitation). Review of the paper chart revealed an advance directive form which indicated do not resuscitate comfort care (DNR-CC) measures (comfort measures in the event of cardiac/respiratory arrest) chosen by Resident #348's responsible party and signed by the physician on 08/09/23. The paper chart also contained a full code paper which indicated to staff the resident was a full code in case of emergency.…

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

Based on medical record review and interview, the facility failed to ensure a significant change assessment was initiated when a resident was admitted to hospice services. This affected one (Resident #91) of 21 residents who were reviewed regarding requirements for significant change assessments. The census was 100. Findings include: Review of Resident #91's medical record revealed diagnoses including malignant neoplasm of the prostate, secondary malignant neoplasm of the bone, abnormal weight loss, and depression. Review of hospice notes revealed an initial visit was made on 08/02/23. On 08/03/23 an order was written to admit Resident #91 to hospice. There was no evidence the facility initiated a significant change Minimum Data Set (MDS) assessment. On 08/29/23 at 8:57 A.M., Regional Nurse #206 verified Resident #91 had an order admitting him to hospice dated 08/03/23 and a significant change MDS had not been initiated but should have been.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, financial record review, and staff interview, the facility failed to provide an adequate plan to spend down resident finances when funds were above the Medicaid allowable limit. This affected three (Residents #19, #23, and #37) of six resident financial information reviewed. The census was 100. Findings Include: 1. Resident #19 was admitted to the facility on [DATE]. Her diagnoses included atherosclerotic heart disease, major depressive disorder, anxiety disorder, and cognitive communication deficit. Review of her Minimum Data Set (MDS) assessment, dated 07/16/23, revealed she had a significant cognitive impairment. Review of Resident #19's quarterly financial statements, dated 07/01/22 to 06/30/23, revealed her total amount in her resident account varied between $2986.96 and $7191.37; it was never below $2000. Review of Resident #19's medical records, which included progress notes, social service notes, and care plans, revealed no documentation to support the facility had a plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, policy review, review of drug reference information and interview, the facility failed to ensure medications were appropriately labeled and stored. This affected six residents (Resident #21, #29, #65, #67, #89 and #93) of 100 residents residing in the facility. Findings include: 1. On [DATE] at 8:54 A.M., Licensed Practical Nurse (LPN) #124 was observed preparing and administering medication to Resident #67. There was no expiration date on the bottle of enteric coated aspirin 81 milligram (mg) dose. LPN #124 verified she was unable to locate an expiration date on the aspirin bottle at the time of preparation/administration. 2. On [DATE] at 10:16 A.M., observation of the 400 hall medication cart revealed there was an open/used insulin pen for Resident #65 which was not dated. There was a box with an open vial of Humulin 70/30 insulin which was undated with no name. On [DATE] at 10:16 A.M., LPN #157 verified Resident #65's insulin pen did not contain a date when it was opened. LPN #157…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to ensure antibiotic stewardship guidelines were followed prior to antibiotic use. This affected one (Resident #299) of one resident reviewed for antibiotic stewardship. The census was 100. Findings Include: Resident #299 was admitted to the facility on [DATE]. Her diagnoses were sepsis, rectal abscess, difficulty walking, type II diabetes, muscle weakness, chest pain, obesity, anemia, vitamin D deficiency, tobacco use, hypertension, major depressive disorder, osteoarthritis, fibromyalgia, and headache. Review of her Minimum Data Set (MDS) assessment, dated 08/14/23, revealed she was cognitively intact. Review of Resident #299 physician orders revealed she was prescribed Doxycycline Hyclate Oral Tablet 100 milligrams, twice daily for seven days. Initially, this medication justification was for infection, but then it was clarified to be for an abscess to her buttocks. Review of Resident #299 medication administration…

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.