Forest Hills Care And Rehabilitation Center

Based on observation, interview and record review, the facility failed to ensure food was provided to residents in a manner required for their needs to prevent choking. Cook #1 stated five residents received pureed diets from the kitchen. Findings: On 02/05/24 at 10:51 a.m., cook #1 was observed to prepare pureed food. [NAME] #1 stated the facility had five residents who required pureed food. The cook had placed six to seven hamburger patties in the blender, along with water, thickener and a calorie/protein powder supplement. Upon completion of the puree, the puree was tasted. The food was grainy and without flavor. On 02/05/24 at 11:04 a.m., cook #1 was observed to pour peas and carrots, two scoops of thickener and one scoop of calorie/protein powder supplement into the bowl of the blender for puree. The skins of the peas were observed to be throughout the mixture and not smooth. A test sample was taken with a plastic spoon and provided to the surveyor. The puree was not smooth. [NAME] #1 was asked if there were anything that could cause a resident to choke. They stated no. 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.

Based on record review and interview, the facility failed to ensure accurate code status for one (#55) of four sampled residents who were reviewed for advance directives. The administrator identified 127 residents who resided in the facility. Findings: Resident #55 had diagnoses which included chronic obstructive pulmonary disease. A signed DNR, dated 08/10/17, was in the scanned documents in the electronic clinical record. A signed DNR, dated 11/28/17, was in the scanned documents in the electronic clinical record. An Advance Directive Acknowledgement Form, dated 12/15/23, documented Resident #55 did not have an advanced directive. The Care Plan, dated 12/28/23, documented Resident #55 was a full code. The demographic banner, face sheet, and active physician orders in the electronic clinical record documented Resident #55 was a full code. On 02/07/24 at 1:01 p.m., the DON stated Resident #55 was a full code. They stated the signed DNR was from a previous admission to the facility but was still in the active electronic clinical record for Resident #55.

Based on record review and interview, the facility failed to ensure resident representatives were notified of changes in condition for one (#89) of one sampled resident who was reviewed for notification of change. The administrator identified 127 residents who resided in the facility. Findings: The Notification of a Change in Condition policy, dated 04/26/23, read in parts, .the Resident Representative will be notified of a Change in a Resident's Condition .Document in the Interdisciplinary Team [IDT] Notes .Resident Change in Condition . Resident #89 had diagnoses which included congestive heart failure. A facility incident report, dated 12/14/23, documented the resident fell. The incident report or nurse progress notes did not document the resident's POA had been notified. A nurse progress note, dated 12/29/23, documented the resident returned from a hospital visit. The note did not document the resident's POA had been notified of the resident's return. A nurse progress note, dated 01/10/24, documented the resident returned from a hospital visit. The note did not document the POA…

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

Based on record review and interview, the facility failed to ensure medications and weights documented in the MDS were accurate for one (#68) of 25 sampled residents who were reviewed for MDS accuracy. The administrator identified 127 residents resided in the facility. Findings: A facility MDS 3.0 policy, dated 04/25/19, read in part .the MDS Coordinator, in conjunction with the Interdisciplinary Team (IDT), expected to complete assessments using the MDS 3.0 Resident Assessment Instrument (RAI) specified by the state in compliance with the MDS 3.0 RAI user's manual guidelines . Resident #68 had diagnoses which included psychotic disorder with hallucinations. a. An Order Summary report, dated 08/23/23, documented Resident #68 received Nuplazid (anti-psychotic medication) at bedtime. A MAR, dated November 2023, documented Resident #68 received Nuplazid. A Quarterly Assessment, dated 11/29/23, documented the resident did not receive antipsychotic medications since the prior assessment. On 02/29/24 at 12:24 p.m., the MDS coordinator stated medications were coded by drug classification.…

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

Based on record review and interview, the facility failed to ensure a baseline care plan was completed within 48 hours for one (#120) of one sampled resident reviewed for baseline care plan. The administrator identified 127 residents resided in the facility. Findings: A Comprehensive Person-Centered Care Plan policy, dated 01/23/19, read in part .POLICY: Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care . A Baseline Care Plan is to be developed within 48 hours. Develop initial goals based upon admission orders/resident's input and is recorded on the Baseline Care Plan . Resident #120 admitted with diagnoses which included muscle weakness, cognitive communication deficit, need for assistance with personal care, decreased white blood cell, soft tissue disorder, cellulitis to right upper limb, and encounter for other orthopedic aftercare. A Care Plan, dated 11/15/23, only documented an activity focus area. There was no other care plan located in 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 and interview, the facility failed to ensure showers were provided for one (#172) of seven sampled residents reviewed for bathing. The administrator reported 127 residents resided in the facility. Findings: Resident #172 had diagnoses which included Parkinson's disease. Resident #172's shower documentation did not document the resident had been offered a shower between January 31, 2024 and February 09, 2024. On 02/09/24 at 1:45 p.m., Resident #172 stated they had not received a shower in several days, but would like to at least have a bed bath. On 02/09/24 at 2:00 p.m., CNA #1 stated they did not have time to give Resident #172 a shower on 02/06/24 or 02/09/24. They stated they reported it to the nurse and the oncoming shift to see if they had time to give showers.

Based on observation and interview, the facility failed to ensure chemicals were secured for one (300 hall) of five halls observed for storage of chemicals. The Resident Listing Report, dated 02/05/24, documented 14 residents resided on the 300 hall. Findings: On 02/05/24 at 8:26 a.m., an unlabeled closet was observed to be unlocked. The door was observed to have a key pad lock but the inside latch of the lock was taped so it remained unlocked. The following chemicals were observed unsecured in the unlocked closet: a. Three and one half-one quart bottles of floor cleaner. The label on the bottle documented the product caused serious burns. b. One-one quart bottle of spot shot professional stain remover. The label documented to keep out of reach of children. c. One-one quart bottle of red juice stain remover that was approximately half full. The label documented it may cause irritation to the mouth, throat, and stomach and to use splash goggles and gloves during use. d. One-one quart glass cleaner. The label documented to keep out of reach of children. On 02/05/24 at 8:49 a.m., 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, record review, and interview, the facility failed to ensure controlled medications were reconciled for one (500 hall) medication cart of seven medication/treatment carts observed. The administrator identified 127 residents who resided in the facility. Findings: The Controlled Substances Count Shift Verification form, dated February 2024, documented a shift count verification of controlled substances had been completed 12 times out of 22 opportunities from 02/01/24 through 02/08/24 at 6:00 a.m. The form did not document any on-coming nurse/CMA signatures, no entries for 02/03/24 or 02/09/24 were documented, and no entries were documented for the 10:00 p.m. to 6:00 a.m. shift. On 02/08/24 at 12:02 p.m., the 500 hall medication cart was observed with CMA #1. The locked narcotic box was observed to contain a card of Cephalexin 500 mg for Resident #65. The card of Cephalexin was observed to have nine capsules remaining. The count sheet for the Cephalexin 500 mg documented CMA #1 administered one pill at 7:36 a.m. on 02/08/24 and there were ten capsules remaining.…

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

Based on observation, record review, and interview, the facility failed to ensure food contained nutritive value, was palatable, and served at preferred temperatures. The Resident Matrix provided by the facility on 02/05/24, documented 125 residents received food from the kitchen. Findings: On 02/05/24 at 9:51 a.m., Resident #83 stated the food was very cold. On 02/05/24 at 10:07 a.m., Resident #48 stated the food was not palatable. On 02/05/24 at 10:17 a.m., Resident #185 stated they wanted a decent breakfast. They stated staff bring eggs and oatmeal and they do not eat eggs, and oatmeal makes them gag. They stated this happened all weekend. Resident #185 stated lunch and dinner were usually good and if not, they requested a burger. On 02/05/24 at 10:39 a.m., Resident #55 stated the food temperature was inconsistent. They stated they ate in their room because it took too long to be served in the dining room. On 02/05/24 at 10:51 a.m., [NAME] #1 was observed to prepare pureed food. [NAME] #1 stated the facility had four or five residents who required pureed food. The cook had placed…

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 a sanitary environment, provide food and drink at safe temperatures The Resident Matrix provided by the facility on 02/05/24, documented 125 residents received food from the kitchen. Findings: On 02/05/24 at 10:50 a.m., during the kitchen observation, several male staff members were observed to not wear beard nets or hair nets while preparing food. On 02/05/24 at 10:52 a.m, the dietitian was asked what length of hair growth would require a hair net. The dietitian stated they would expect the staff to wear hair nets at any stage of hair growth.

Based on record review and interview, the facility failed to ensure as needed narcotic pain medication was available for two (#4 and #6) of four sampled residents were reviewed for access to pain medication. The DON identified 83 residents with orders for narcotic pain medication. Findings: 1. Resident #4 had diagnoses which included pain, dorsalgia, and discitis of the thoracolumbar region. The physician's order note, dated 08/03/23 at 11:10 a.m., documented the resident was to receive oxycodone-acetaminophen 10-325 mg, one tablet every four hours as needed for pain. The pain assessment, dated 08/03/23 at 4:06 p.m., documented the resident rated their pain at nine out of ten. The progress note, dated 08/03/23 at 4:20 p.m., documented the resident requested oxycodone for pain. The pharmacy shipping log documented the oxycodone-acetaminophen 10-325 mg was filled and shipped on 08/04/23 at 5:29 p.m. The narcotic record documented the resident received their first dose of oxycodone-acetaminophen 10-325 mg on 08/05/23 at 8:15 a.m. On 10/13/23 at 12:00 p.m., LPN #2 stated when they…

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: a. residents were offered the choice to formulate advance directives for six (#4, 5, 15, 22, 61, and #85), and b. a code status form was valid for one (#87) of seven sampled residents reviewed for advance directives. The Resident Census and Conditions of Residents report, dated 04/24/23, documented 108 residents resided in the facility. It documented 42 residents who had advance directives. Findings: 1. Res #4 was admitted to the facility on [DATE]. There was no documentation the resident and/or their representative was offered the choice to formulate an advance directive. On 04/18/23 at 4:04 p.m., the administrator and corporate nurse consultant #1 were asked to provide documentation the resident and/or their representative was offered the choice to formulate an advance directive. On 04/19/23 at 10:01 a.m., the regional director stated they found the problem with the advance directives on 08/25/22. They stated they corrected the problem 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, record review, and interview, the facility failed to develop and implement care plans related to the residents' pain for two (#31 and #33) of 27 sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents form, dated 04/24/23, documented 108 residents resided in the facility. Findings: 1. Res #31 had diagnoses which included polyosteoarthritis and Alzheimer's disease. A physician order, dated 10/15/22, documented to administer Tylenol 325 mg every six hours as needed for pain. A quarterly MDS, dated [DATE], documented the resident was moderately cognitively impaired, required limited assistance with ADLs, and received as needed pain medications during the review period. A care plan, reviewed 02/07/23, did not document a care plan related to pain. On 04/18/23 at 12:59 p.m., Res #31 was observed in bed in their room. The resident was overheard asking a CMA for pain medication. The CMA was heard stating Tylenol had already been given but the nurse would be…

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 dependent residents received showers for three (#62, 108, and #111) of four sampled residents reviewed for ADLs. The Resident Census and Conditions of Residents form, dated 04/24/23, documented 108 residents required assistance with bathing. Findings: 1. Res #111 admitted to the facility on [DATE] with diagnoses of atrioventricular block, hypertension, and convulsions. The ADL log for June 2022 was reviewed and documented the resident received one shower. On 04/24/23 at 3:30 p.m., the DON and corporate nurse reported the resident's showers were performed by Hospice and they will call and see if they can get the records. On 04/25/23 at 10:51 a.m., the DON reported the resident only had a referral for hospice and was never admitted to hospice. The DON was asked to review the ADL log for the resident for June 2022 and was asked if the resident had more than one bath for the month. The DON stated it wasn't documented. 2. Res #62 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.

Based on record review and interview, the facility failed to ensure: a. weights were obtained as ordered, b. the physician was notified of a significant weight loss, and c. food intake was monitored and recorded for one (#61) of one sampled resident reviewed for nutrition. The Resident Census and Condition of Residents report, dated 04/24/23, documented 108 resided in the facility. Findings: Res #61 had diagnoses which included GERD, muscle wasting and atrophy, dysphasia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and cerebral infarction due to unspecified occlusion or stenosis of right anterior cerebral artery. A care plan problem, initiated on 09/10/19, documented the resident had a PEG tube and received tube feedings. It was documented to monitor, record, and report to the physician a significant weight loss of greater then 5% in one month. A care plan problem, initiated on 10/02/19, documented the resident was able to eat by mouth. It was documented to provide and serve diet as ordered. It was documented…

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 administered as ordered by the physician for two (#22, 24 and #109) of six sampled residents reviewed for medications. The Resident Census and Conditions of Residents report, dated 04/24/23, documented 108 residents resided in the facility. Findings: 1. Res #109 had diagnoses which included bacteremia and ESBL infection. A physician order, dated 10/04/22, documented to administer meropenem sodium chloride solution reconstituted (an antibiotic) 1 gm/50 ml. Use 1 gram intravenously every eight hours for 45 days. The order was discontinued on 11/19/22. A physician order, dated 10/04/22, documented to administer vancomycin HCl solution (an antibiotic). Use 500 mg intravenously every eight hours for 45 days. The order was discontinued on 10/08/22. A physician order, dated 10/08/22, documented to administer vancomycin HCl solution. Use 500 mg intravenously three times a day for 45 days. The order was discontinued on 10/21/22. 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 interview, the facility failed to ensure residents' physician addressed irregularities documented on the MRR per facility policy for four (#5, 10, 22 and #24) of five residents reviewed for unnecessary medications. A facility drug regimen review policy documented the physician was to provide a written response to the report within one month after the report was sent, and the facility must maintain copies of the reports for one year. 1. Res #22 had diagnoses which included recurrent depressive disorders, schizoaffective disorder bipolar type, hypertension, and hypothyroidism. A physician order, dated 06/04/21, documented to administer cetirizine 10 mg at bedtime for seasonal allergies. A physician order, dated 09/22/21, documented to administer chlorpromazine 300 mg at bedtime for schizoaffective disorder bipolar type. A physician order, dated 12/08/21, documented to administer mirtazapine 15 mg at bedtime related to recurrent depressive disorders. A physician order, dated 01/25/22,…

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: a. offer the influenza vaccination to each resident annually for three (#3, 10, and #77) and b. offer the pneumococcal immunization for four (#3, 5, 62 and #77) of five sampled residents reviewed for influenza and pneumococcal immunizations. The Resident Census and Conditions of Residents form, dated 04/24/23, documented 108 residents resided in the facility. Findings: A facility influenza vaccine policy, dated 04/28/22, documented residents would be offered the influenza vaccine during October 1 through March 31 on an annual basis and administration would be documented in the EHR. A facility pneumococcal vaccine policy, dated 04/28/22, documented residents would be offered the pneumococcal vaccine upon admission in accordance with CDC guidelines and administration would be documented in the EHR. 1. Res #3 admitted to the facility on [DATE]. The EHR did not document the influenza was offered or declined in 2022. The record did not document 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 and interview, the facility failed to notify the resident's legal representative of a significant weight loss for one (#61) of one sampled resident reviewed for change in condition. The Resident Census and Conditions of Residents report, dated 04/24/23, documented 108 residents resided in the facility. Findings: Res #61 had diagnoses which included GERD, muscle wasting and atrophy, dysphasia following cerebral infarction, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. A weight report, dated 03/08/2023, documented the resident weighed 153.8 lbs. A weight report, dated 04/12/2023, documented the resident weighed 145.8 pounds which was a 5.20% weight loss in five weeks. There was no documentation the resident's legal representative was notified of the significant weight loss. On 04/25/23 at 12:23 p.m., the DON was asked the the resident's legal representative was notified of their significant weight loss. They stated the resident's representative was always at the facility and notified. They were asked if there was any…

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 MDS assessments were coded accurately for two (#107 and #5) of 32 sampled residents whose medical records were reviewed. The Resident Census and Conditions of Residents report, dated 04/18/23, documented 108 residents resided in the facility. Findings: 1. Res #107 had diagnoses which included metabolic encephalopathy, asthma, and cerebral infarction. A physician's order, dated 01/30/23, documented to discharge resident home today per family request. A discharge summary note, dated 01/30/23 at 5:00 p.m., documented per physician orders the resident was discharged home will all their medications, belongings and discharge paperwork. The note documented no signs or symptoms of issues or complaints noted at time of discharge. A discharge-return not anticipated assessment, dated 01/30/23 at 5:50 p.m., documented the resident was discharged to an acute care hospital. On 04/25/23 at 10:36 a.m., the MDS Coordinator #2 stated the discharge MDS assessment…

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

Based on record review and interview, the facility failed to complete a significant change MDS for a resident started on hospice for one (#77) of two sampled residents reviewed for hospitalization. The Resident Census and Conditions of Residents form, dated 04/24/23, documented 108 residents resided in the facility. Findings: The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, dated October 2019, documented in parts .An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program .The ARD must be within 14 days from the effective date of the hospice election . Res #77 had diagnoses which included transient cerebral ischemic attack, Parkinson's disease, and acute kidney failure. A physician order, dated 03/22/23, documented to evaluate Res #77 for admission to hospice services. A hospice contract documented start of services for Res #77 as 03/23/23. On 03/28/23, a discharge return anticipated MDS was completed. On 04/02/23, an entry record MDS was completed. There was no significant change MDS assessment…

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

Based on record review and interview, the facility failed to incorporate the from the PASARR level II determination and the PASARR evaluation report into a resident's care plan for one (#77) of three sampled residents reviewed for PASARR's. The Resident Census and Conditions of Residents form, dated 04/24/23, documented 24 residents required behavioral health services. Findings: Res #77 had diagnoses which included paranoid schizophrenia and generalized anxiety disorder. A Nursing Facility Level of Care Assessment (PASARR level I), dated 12/05/22, documented Res #77 did not require a level II assessment because the resident was projected to reside in the facility less than 30 days. A care plan, reviewed 04/03/23, did not document a level II evaluation was completed or specialty care required for mental health diagnoses. On 04/19/23 at 11:51 a.m., MDS Coordinator #1 stated residents who originally had a 30 day waiver for level II PASARR assessment must have a level II completed when the facility determined the resident would stay longer than 30 days. They stated she was unsure if Res…

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

Based on record review and interview, the facility failed to accurately complete a preadmission screening for individuals with a mental disorder for one (#101) of three sampled residents reviewed for PASARR's. The Resident Census and Conditions of Residents form, dated 04/24/23, documented 24 residents required behavioral health services. Findings: Res #101 had diagnoses which included bipolar disorder. A Nursing Facility Level of Care Assessment (PASARR Level I), dated 03/03/23, documented the resident did not have a diagnosis of a serious mental illness. On 04/19/23 at 11:45 a.m., MDS Coordinator #1 stated Res #101's diagnosis of bipolar disorder should have been included on the level I assessment but was not.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to review and revise a care plan after significant change for one (#33) of 27 sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents form, dated 04/24/23, documented 108 residents resided in the facility. Findings: The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, dated October 2019, documented in parts .The care plan completion date .must be either later than or the same date as the CAA completion date ., but no later than 7 calendar days after the CAA completion date . Res #33 had diagnoses which included chronic respiratory failure, COPD, and dementia. A physician order, dated 02/21/23, documented to start hospice services. A significant change MDS, dated [DATE], documented the resident received hospice services and had a condition or chronic disease that may result in a life expectance of less than six months. The care area assessment of the MDS was signed as…

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

Based on observation, record review, and interview, the facility failed to ensure a 2 liter fluid restriction per day had been conducted for one (#73) of one sampled resident whose medical record was reviewed. The Resident Census and Conditions of Residents report, dated 04/18/23, documented 108 residents resided in the facility. Findings: 1. Res #73 had diagnoses which included dysphagia following cerebrovascular accident, chronic kidney disease, atrial fibrillation, and acute combined systolic and diastolic congestive heart failure. An admission assessment, dated 03/31/23, documented the resident had moderately impaired cognition and required one person supervision with eating and drinking. A physician order, dated 04/07/23, documented a 2 liter fluid restriction per day related to heart failure. A care plan, dated 04/10/23, documented fluid overload or potential fluid volume overload related to kidney failure/chronic kidney disease with an intervention of a 2 liter fluid restriction daily. There was no daily amount of fluid intake documented in the medical record since 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.