Continuing Healthcare At Cedar Hill

Based on observations, medical record review, resident interview, staff interview, and facility policy/procedure review, the facility failed to maintain a sanitary living environment. This affected one resident (#68) of three residents reviewed for a sanitary living environment. The facility census was 75. Findings include: Observations on 05/29/24 at 10:30 A.M. and 10:45 A.M. revealed mouse droppings in a basket in Resident #68's bedroom. The basket had personal items in it, as well as a box of snack cakes (each individual cake was sealed). Resident #68 was admitted to the facility 11/24/22 with diagnoses including type II diabetes, chronic obstructive pulmonary disease, vascular dementia, need for assistance with personal care, difficulty walking, dysphagia, cerebral aneurysm, autonomic neuropathy, insomnia, ventral hernia, hyperlipidemia, depression, obesity, atrial fibrillation, hypothyroidism, and hypertension. Review of the Minimum Data Set (MDS) assessment, dated 03/01/24, revealed Resident #68 was cognitively intact. Interview with Resident #68 on 05/29/24 at 10:35 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, interview, record review and facility investigation review the facility failed to prevent Resident #20 from exiting the facility without staff assistance. This affected one resident (Resident #20) of three residents reviewed for accidents. The facility census was 80. Finding include: Review of the medical record for Resident #20 revealed an admission date on 06/09/23. Diagnosis included unspecified dementia, anxiety, and encephalopathy. Review of Resident #20's physician order dated 06/26/23 revealed the resident had a wanderguard (a magnetized fob that is placed on the wrist or ankle to alert staff when a resident is exiting an alarmed door) placed on her ankle and for placement to be checked every shift. Review of Resident #20's Care Plan revealed the resident was a risk for elopement related to impaired cognition, wandering, a history of attempting to leave the…

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

Based on observation, staff interview, and facility policy review for food storage and hand hygiene, the facility failed to ensure food was properly stored and meal trays were prepared in a sanitary manner. This affected all residents residing in the facility at this time. The facility census was 77. Findings include: Observation on 07/10/23 at 8:11 A.M. revealed during initial tour of the kitchen, there were bags of food located in the walk-in freezer that was not properly sealed. There was one bag of breaded chicken tenders, one bag of tater tots, and one bag of french fries. All three bags were noted to be open with the food exposed to the open air. Interview on 07/10/23 at 8:50 A.M. with Dietary Manager #342 confirmed the three open bags of food. Dietary Manager #342 also confirmed any food stored in the freezer needed to be properly sealed to protect the food from the freezer air. Review of facility's policy titled Food Storage, revised 09/08/2021 revealed, all food stock and products are stored in NSF approved sanitary storage container, of food quality plastic bags, covered,…

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

Based on observation, interview, and facility record review, the facility failed to ensure the clean laundry room, which had a gas powered dryer, had a carbon monoxide detector. This had the potential to affect all 77 residents residing in the facility. Findings included: Observation on 07/13/23 at 8:30 A.M. of the clean laundry room revealed there were two dryers, one electric powered and one gas powered. Further observation revealed no carbon monoxide detector in the laundry room. Interview on 07/13/23 at 8:40 A.M. with Housekeeping Staff #347 revealed she had never seen a carbon monoxide detector in the clean laundry room with the gas dryer. Interview on 07/13/23 at 9:00 A.M. with Maintenance Staff #418 verified the UniMac dryer was a gas powered dryer and there was no carbon monoxide detector in the room. He also verified there should be a carbon monoxide detector in the room, and he didn't know how he missed it. Review of the facility Carbon Monoxide Detector Monitoring Log revealed there was no carbon monoxide detector in the laundry room with the gas dryer.

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 #42 was treated with dignity and respect. This affected one resident (#42) of two residents reviewed for dignity. The facility census was 77. Findings included: Review of Resident #42's medical record revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, type two diabetes mellitus without complications, lymphedema, and essential hypertension. Review of Resident #42's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/02/23, revealed she was cognitively independent. Observation on 07/10/23 at 11:06 A.M. and 3:30 P.M. and 07/11/23 at 8:11 A.M. revealed a paper sign on Resident #42's door stating, (resident's proper name) has right arm lymphedema and cannot have blood pressure taken or blood drawn from this arm! (Resident's proper name) also has a port in her chest from previous chemotherapy. Please be careful not to bump! Thank you!. Observation 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 medical record review, and staff interview, the facility failed to ensure each residents Minimum Data Set (MDS) accurately reflected the use of antipsychotic medication or reflected the contraindication for a gradual dose reduction (GDR) for that antipsychotic. This affected two residents (Resident #42, and #50) of the 20 residents reviewed for accurate MDS. The facility census was 77. Findings include: 1. Review of the medical record for Resident #42 revealed an admission date of 12/22/2020. Diagnosis included Alzheimer disease, bipolar disorder, major depressive disorder, dementia with behavioral disturbances, and mood affective disorder. Review of Resident #42's physician orders revealed a order dated 12/2020 for Perphenazine (antipsychotic) 2 milligrams (mg) twice a day for bipolar disorder. Review of the plan of care dated 01/03/2021 and revised 10/31/2022 revealed Resident #42 was at risk of adverse reactions related to depression, the use of psychoactive medications, and an affective mood…

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 review of facility policy for preadmission screening and resident review (PASRR), the facility failed to ensure a new PASRR was submitted for residents with a new mental health diagnosis. This affected two residents (Resident #38, and #23) of the two residents reviewed for accurate PASRR assessments. The facility census was 77. Findings include: 1. Review of the medical record for Resident #38 revealed an admission date of 05/22/2019. Diagnoses included anxiety disorder, depressive disorder, protein-calorie malnutrition, and schizoaffective disorder. Review of Resident #38's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating an intact cognition for daily decision making abilities. Review of Resident #38's most recently completed PASRR dated 06/17/2019 revealed under Section D, indications of serious mental illness, the diagnosis schizophrenia was the only diagnosis marked for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure a resident who was on fluid restriction had fluid intake monitored and documented. This affected one Resident (#24) of one resident reviewed for nutrition. The facility census was 77. Findings included: Review of Resident #24's medical record revealed she was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including end stage renal disease, type two diabetes mellitus with diabetic chronic kidney disease, dependence on renal dialysis, essential hypertension, and generalized muscle weakness. Review of Resident #24's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/10/23, revealed she was slightly cognitively impaired and had active diagnoses of renal insufficiency, renal failure and end stage renal disease. Further review revealed she was independent with setup help only for eating. Review of Resident #24's MDS timeline revealed she was out of the facility from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure a resident who was receiving hemodialysis was assessed prior to and upon return from dialysis and there was communication between the facility and the dialysis center. This affected one resident (#24) of one resident reviewed for dialysis. The facility census was 77. Findings included: Review of Resident #24's medical record revealed she was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including end stage renal disease, type two diabetes mellitus with diabetic chronic kidney disease, dependence on renal dialysis, essential hypertension, and generalized muscle weakness. Review of Resident #24's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/10/23, revealed she was slightly cognitively impaired and had active diagnoses of renal insufficiency, renal failure and end stage renal disease. Further review revealed she received dialysis prior to and while being 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 medical record review and staff interview, the facility failed to ensure antibiotics were not prescribed prior to receiving lab testing results and prescribed appropriately according to lab testing results. This affected one (Resident #23) of five residents reviewed for antibiotic use. The facility census was 77. Findings include: Review of Resident #23's medical record revealed an admission date of 01/19/23 with diagnoses that included cerebrovascular accident with hemiplegia and obstructive and reflux uropathy. Review of Resident #23's progress notes revealed on 04/27/23 the resident was transferred to the local emergency room (ER) for evaluation. Resident #23 returned to the facility on [DATE] after ER evaluation with a diagnosis of urinary tract infection (UTI) and new orders for cefdinir (antibiotic) 300 milligrams (mg) twice daily for seven days. A urinalysis with culture and sensitivity was obtained at the ER during evaluation. The urinalysis with culture and sensitivity was completed and…

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

Based on observation and staff interview, the facility failed to prepare and serve food under sanitary conditions. This had the potential to affect all 75 of 75 residents who received their meals from the kitchen. Findings include: 1. On 05/10/21 9:45 A.M. initial tour revealed the deep fryer with fried food particles on outside of fryer. 2. On 05/12/21 at 10:29 A.M. upon entering the kitchen to observe puree, [NAME] #7 removed her gloves, put on new gloves without washing her hands and then pulled up her uniform pants. [NAME] #7 used her gloved hands to place chicken in blender. After pureeing, she took the dirty dishes to dirty side and removed her gloves and put on new ones without washing her hands and pureed the noodles. Again, [NAME] #7 took dirty dishes over and placed on a cart, removed her gloves and again put on new ones without washing her hands. [NAME] #7 again touched her uniform pulling top down. [NAME] #7 then placed mixed vegetables in blender and used gloved hand to scrape out vegetables left in pan after dumping. On 05/12/21 at 10:55 A.M. this was verified during…

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, resident interview, and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately in the areas of Preadmission Screening and Resident Review (PASRR), hearing, activities and skin/ ulcer treatments. This affected five (Resident #39, #41, #44, #46 and #51) of 21 residents reviewed for assessments. Findings include: 1 (a.). A review of Resident #39's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included schizophrenia, dementia, bipolar disorder, and major depressive disorder. A review of Resident #39's PASRR review dated 09/09/16 revealed the resident did not have any indications of a serious mental illness as of the date the PASRR was completed. The PASRR identification screen for Section (D.), which was for marking diagnoses for indications of serious mental illness revealed schizophrenia was not marked at that time as a diagnosis the resident was known to have. There was no evidence of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure new Preadmission Screening and Resident Reviews (PASRR) were completed for residents who had a newly diagnosed serious mental illness added to their diagnoses. This affected five (Resident #39, #41, #44, #46 and #54) of five residents reviewed for PASRR's. Findings include: 1. A review of Resident #39's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included bipolar disorder, major depressive disorder, dementia and schizophrenia. The diagnosis of schizophrenia was added on 12/27/18. A review of Resident #39's PASRR dated 09/09/16 revealed the resident did not have any indications of a serious mental illness at the time the PASRR was completed. A PASRR identification screen that was completed as part of the PASRR revealed the assessor was to check any indications of a serious mental illness under Section (D.) A mood disorder was marked as the only diagnosis the resident had at the time the screen was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, family interview, staff interview and policy review, the facility failed to ensure four residents (Resident #16, #39, #51 and #53) received quarterly care conferences as required and care plans were revised for two residents (Resident #26 and #41) in the area of activities. Four residents were reviewed for care conferences and 21 residents were reviewed for care plan revision. Findings include: 1. A review of Resident #16's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included chronic obstructive pulmonary disease, history of a CVA (stroke), adult onset diabetes mellitus, major depressive disorder, generalized anxiety disorder, hypertension and congestive heart failure. A review of Resident #16's quarterly Minimum Data Set (MDS) assessment completed on 02/05/21 revealed the resident did not have any communication issues. He was able to make himself understood and was able to understand others. He was cognitively intact and 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 observation, medical record review, and staff interview, the facility failed to provide each resident an ongoing activity program to support their preferences and choices. This affected six (Residents #4, #14, #26, #41, #44, and #46) of seven resident investigated for activities. The census was 75. Findings include: 1. Review of Resident #4's medical record revealed he was admitted on [DATE] with diagnoses that included Alzheimer's dementia, anxiety, protein calorie malnutrition, hallucinations and insomnia. Further review of the minimum data set (MDS) assessment dated [DATE] revealed his cognition was not intact, he required extensive assistance of one staff member for bed mobility and personal hygiene, and extensive assistance of two or more staff members for toileting and dressing. Review of the activity documentation log revealed for 02/21 two independent activities and two one to one activities, 03/21 two group activities, 04/21 two independent and one group activity, and 05/21 as of 05/12/21 one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview, the facility failed to maintain resident dignity during dining. This affected one (Resident #25) of three residents observed in the East lobby. Findings include: Medical record review revealed Resident #25 was admitted on [DATE] with diagnoses including Cerebral vascular accident and dementia. Review of the annual Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #25 was severely impaired for daily decision-making and was dependent on staff for eating. On 05/10/21 at 11:56 A.M., observation of the lunch meal revealed Resident #25 was at the nurses station seated in a specialized wheelchair while State Tested Nurse Aide (STNA) #47 stood next to her and fed the resident her lunch. On 05/10/21 at 12:03 P.M., the Administrator walked onto the unit and asked STNA #47 to sit in a chair while feeding residents. The Administrator approached the surveyor and stated she would start educating staff not to stand while feeding residents.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to notify the family of a significant weight loss. This affected one (Resident #4) of one resident investigated for notification of change. The census was 75. Findings include: Review of Resident #4's medical record revealed he was admitted on [DATE] with diagnoses that included Alzheimer's dementia, anxiety, protein calorie malnutrition, hallucinations and insomnia. Further review of the minimum data set (MDS) assessment dated [DATE] revealed his cognition was not intact, he required extensive assistance of one staff member for bed mobility and personal hygiene, and extensive assistance of two or more staff members for toileting and dressing. Review of the medical record revealed Resident #4 on 01//08/21 weighed 153.8 pounds. On 02/23/21 weight was 132.2 pounds. On 04/14/21 weight was 126.6 pounds and on 05/03/21 128 pounds. Resident #4 received a regular diet with ice cream for lunch and dinner, house supplement three times a day, house…

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 liability notices, and staff interview, the facility failed to ensure residents who were discharged from Medicare (MCR) Part A services and remained in the facility received the appropriate notices to inform them of their right to appeal the decision and continue to receive the skilled service. They also failed to ensure another resident was given the appropriate 48 hour notice prior to the end of his skilled service. This affected three (Resident #39, #64 and #169) of three residents reviewed for liability notices. Findings include: 1. A review of Resident #39's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a history of a stroke, chronic obstructive pulmonary disease, chronic kidney disease, adult onset diabetes mellitus, dementia, major depressive disorder, and schizophrenia. A review of Resident #39's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form revealed the start date for the resident's MCR Part A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interview, the facility failed to ensure comprehensive care plans for residents included care plans to address urinary incontinence, hearing impairment and pressure ulcers. This affected three (Resident #12, #26 and #39) of 21 residents reviewed for care plans. Findings include: 1. A review of Resident #12's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a history of a stroke, dementia, abnormalities of gait and mobility, hypertension and hypertensive chronic kidney disease with end stage renal disease. A review of Resident #12's last continence assessment completed 04/30/20 revealed the resident was known to be occasionally incontinent of her bladder. She was determined to have functional incontinence as a result of the assessment and was on a toileting program in which she was to be toileted upon rising, before meals, at bedtime and as needed. A review of Resident #12's quarterly Minimum Data Set (MDS) assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to complete a discharge summary for a resident who was discharged from the facility. This affected one resident (Resident #69) of two closed records reviewed for discharge. The census was 75. Findings include: Review of Resident #69's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included cancer of the brain, major depression, epilepsy, anxiety and adult failure to thrive. Review of her quarterly minimum data set (MDS) assessment revealed her cognition was moderately impaired. She required supervision for bed mobility, transfers, toilet use and personal hygiene and supervision with set up help for dressing. Further review revealed Resident #69 was discharged from the facility on 04/06/21 to another facility. There was no documented evidence the facility had completed a discharge summary that reflected the residents's stay at the facility. On 05/17/21 at 11:28 A.M. interview with Registered Nurse #31…

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, resident and staff interview, the facility failed to ensure a resident received set up help and had the necessary supplies to perform his own oral hygiene care. This affected one (Resident #16) of six residents reviewed for activities of daily living (adl's). Findings include: A review of Resident #16's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included chronic obstructive pulmonary disease, adult onset diabetes mellitus, abnormalities of his gait and mobility, weakness, major depressive disorder, generalized anxiety disorder and congestive heart failure. A review of Resident #16's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues. He was able to make himself understood and was able to understand others. He was not noted to have any behaviors nor was he known to reject care. He required supervision with no set up help for transfers. Supervision with set up help only was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and staff interview, the facility failed to provide activity of daily living services for residents unable to do for themselves. This affected three (Residents #10, #26 and #268) of six residents reviewed for activities of daily living. The census was 75. Findings include: 1. Review of Resident #10's medical record revealed he was admitted to the facility on [DATE] with diagnoses of paranoid schizophrenia, anxiety, anemia and nicotine abuse. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed his cognition is severely impaired. He requires supervision with personal hygiene. Review of the plan of care dated 11/06/20 revealed he is non-compliant with refusing personal care. On 05/11/21 1:30 P.M. observation revealed long fingernails with a dark substance caked under them. On 05/12/21 at 12:09 P.M. the fingernails remain long with dark substance caked under them. There was no documentation of refusal of care for these days. This was verified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview the facility failed to provide evidence that bruising to a resident's hands were assessed and care provided. This affected one (Resident #4) of one resident reviewed for skin conditions. The census was 75. Findings include: Review of Resident #4's medical record revealed he was admitted on [DATE] with diagnoses that included Alzheimer's dementia, anxiety, protein calorie malnutrition, hallucinations and insomnia. Further review of the minimum data set (MDS) assessment dated [DATE] revealed his cognition was not intact, he required extensive assistance of one staff member for bed mobility and personal hygiene, and extensive assistance of two or more staff members for toileting and dressing. Observation on 05/11/21 at 9:19 A.M. revealed bruising to the bilateral top of his hands. On 05/12/21 at 10:10 A.M. interview with Licensed Practical Nurse (LPN) #120 verified the lack of documentation for the bruising in the medical record and she was not aware…

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, resident and staff interview, the facility failed to ensure a resident was routinely offered her hearing aids to improve her hearing ability. This affected one (Resident #39) of two residents reviewed for vision/ hearing. Findings include: A review of Resident #39's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a history of a stroke, chronic obstructive pulmonary disease, bipolar disorder, dementia and schizophrenia. Record review revealed she had an audiogram completed on 08/03/17 from [NAME] Hearing Aid Center. Puretone average right was 50 and left was 53. A certificate of medical necessity/ prescription for hearing aids revealed the hearing aid evaluation supported the consumer's need for a hearing aid. Digital/ programmable hearing aid would offer superior performance over a conventional hearing aid for the specific consumer. A review of a certificate of medical necessity/ prescription for hearing aids revealed Resident #39…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and staff interview, the facility failed to ensure interventions were in place to prevent falls. This affected one (Resident #4) of two residents reviewed for accidents. The census was 75. Findings include: Review of Resident #4's medical record revealed he was admitted on [DATE] with diagnoses that included Alzheimer's dementia, anxiety, protein calorie malnutrition, hallucinations and insomnia. Further review of the minimum data set (MDS) assessment dated [DATE] revealed his cognition was not intact, he required extensive assistance of one staff member for bed mobility and personal hygiene, and extensive assistance of two or more staff members for toileting and dressing. Review of the physicians orders revealed bed by the wall, review of the plan of care dated 02/08/21 revealed bed stabilizers, lock bed, grip strips bedside bed, non-skid socks , offer activities when sitting in the lounge. Resident #4's fall assessment completed 05/01/21 revealed he was at high risk…

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, resident and staff interview, the facility failed to ensure a resident was routinely assessed and evaluated for the need for a toileting program to help restore as much normal bladder function as possible to reduce incontinence episodes. This affected one (Resident #12) of one residents reviewed for bladder incontinence. Findings include: A review of Resident #12's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included dementia without behaviors, major depressive disorder, anxiety disorder, hypertension, chronic obstructive pulmonary disease, history of a stroke, chronic kidney disease and abnormalities of gait and mobility. A review of Resident #12's physician's orders revealed no evidence of the resident being on any scheduled toileting plan. She was not on any diuretics or medications for the treatment of an overactive bladder. A review of Resident #12's continence assessment dated [DATE] revealed the resident did use the toilet but was also known to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, resident and staff interview, and policy review, the facility failed to ensure residents oxygen tubing was being changed weekly in accordance with orders/ facility policy and failed to ensure a resident received humidified oxygen as ordered. This affected two (Resident #16 and #41) of two residents reviewed for respiratory care. Findings include: 1. A review of Resident #16's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia (low oxygen level in the blood), idiopathic pulmonary fibrosis, sleep apnea and congestive heart failure. A review of Resident #16's physician's orders included the use of oxygen at 2 to 4 liters per minute per nasal cannula as needed for shortness of breath. The orders also included the need to change the oxygen tubing every night shift on Thursdays. A review of Resident #16's quarterly Minimum Data Set (MDS) assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, family and staff interview, the facility failed to assist with obtaining guardianship. This affected one (Resident #4) of one reviewed for medically related social services. The census was 75. Findings include: Review of Resident #4's medical record revealed he was admitted on [DATE] with diagnoses that included Alzheimer's dementia, anxiety, protein calorie malnutrition, hallucinations and insomnia. Further review of the minimum data set (MDS) assessment dated [DATE] revealed his cognition was not intact, he required extensive assistance of one staff member for bed mobility and personal hygiene, and extensive assistance of two or more staff members for toileting and dressing. On 05/12/21 at 5:01 P.M. interview with family revealed they have asked the facility and they are not helping with guardianship. No family member wants the responsibility and family have asked them and the facility have him as his own responsible party. On 05/13/21 at 10:18 A.M. interview with Social Service…

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 non-pharmacological intervention were attempted prior to administering psychotropic medications. This affected one (Resident #4) of five residents reviewed for unnecessary medications. The census was 75. Findings include: Review of Resident #4's medical record revealed he was admitted on [DATE] with diagnoses that included Alzheimer's dementia, anxiety, protein calorie malnutrition, hallucinations and insomnia. Further review of the minimum data set (MDS) assessment dated [DATE] revealed his cognition was not intact, he required extensive assistance of one staff member for bed mobility and personal hygiene, and extensive assistance of two or more staff members for toileting and dressing. Review of the physician's orders revealed orders dated for Ativan 2 milligrams (mg) every 12 hours when needed for agitation and Haldol 5 mg IM (intramuscularly) every four hours as needed not to exceed 20 mg in 24 hour period related to manic…

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 interview, and policy review, the facility failed to ensure acceptable infection control practices were followed in regard to hand washing between glove changes during a dressing change. This affected one (Resident #26) of one residents observed for dressing changes. Findings include: Medical record review revealed Resident #26 was admitted on [DATE] with diagnoses including Alzheimer's disease, bipolar disease, anxiety disorder and schizophrenia. Review of the Pressure ulcer assessment dated [DATE] revealed Resident #26 had a Stage III left trochanter facility-acquired pressure ulcer with treatment orders to cleanse the left hip wound with normal saline, pat dry, apply Dakins moist gauze, lightly pack and cover with an ABD pad. On 05/11/21 between 1:42 P.M. and 1:50 P.M., Resident #26's left trochanter pressure ulcer treatment was observed. Licensed Practical Nurse (LPN) #120 opened the dressing change supplies and placed them on the mattress at the end of the bed 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.