Village Health Care Center

Based on observation, record review and interview, the facility failed to ensure residents were free from physical restraints which were not required to treat a resident's medical symptom for four (#7, 13, 14, and #24) of four residents reviewed for restraints. The administrator identified 44 residents who resided at the facility. Findings: A Physical Restraints & Hazards Policy, undated, read in part, .Physical restraints are defined as any manual method or physical device, material, or equipment attached so that the individual cannot remove easily, which restricts freedom of movement to one's body .No resident will be restrained for convenience . 1. Resident #7 had diagnosis which included dementia. A quarterly assessment, dated 02/29/24, documented the resident was moderately impaired in daily decision making and required moderate assistance with ADLs. 2. Resident #13 had a diagnosis which included dementia. A quarterly assessment, dated 02/27/24, documented the resident was severly impaired in daily decision making and required moderate to maximum assistance with ADLs. 3.…

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 the accuracy of assessments for one (#17) of twelve residents reviewed for accuracy of assessments. The administrator identified 44 residents who resided at the facility. Findings: Resident #17 admitted with diagnoses which included cerebral infarction (stroke), reduced mobility, and hypertension. Review of the quarterly assessment, dated 02/25/24 for Resident #17, revealed a diagnosis of pneumonia. Review of physician orders, for Resident #17, revealed no antibiotics ordered currently or in the recent past for pneumonia. Review of diagnoses for Resident #17 revealed a history of pneumonia in 2017. On 04/10/24 at 10:52 a.m., the MDS coordinator stated they reviewed the diagnoses, progress notes and physician orders to complete the MDS assessment. The coordinator stated they would review the clinical record and return with where they found the pneumonia information for the quarterly assessment. On 04/10/24 at 1:48 p.m., the MDS coordinator stated they were not able to locate where they had found the information…

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 care plans were updated for one (#38) of twelve reviewed for updated care plans. The administrator identified 44 residents who resided at the facility. Findings: Resident #38 was admitted with diagnoses which included congestive heart failure, hypertension, and atrial fibrillation. The care plan, revised 01/23/24, documented a stage two pressure ulcer to the coccyx. The care plan did not document the stage two pressure ulcer had healed. The care plan did not document the resident was admitted to hospice, and was not updated to included hospice. A Physician's Order, dated 01/26/24, documented to admit Resident #38 to hospice. On 04/11/24 at 8:22 a.m., the MDS coordinator stated they updated the care plan with wounds or infections and during reviews. The MDS coordinator stated Resident #38 did have a stage two wound in January but it had resolved earlier this week. They stated they had forgot to update the care plan for the healed wound and for hospice.

Based on record review, observation, and interview, the facility failed to ensure the ice machine was clean. The administrator identified 44 residents who resided at the facility. Findings: An untitled and undated policy, read in part, .Ice will be produced, stored, and dispensed in a manner to avoid contamination .The ice dispenser will be cleaned and sanitized at least monthly, and/or as needed. Inside and outside of machine and the area around the machine will be cleaned . An invoice dated 03/08/24, documented the bin sensor was cleaned. No other cleaning of the machine was documented. On 04/09/24 at 11:25 a.m., the ice machine was observed to have black and pink substances on the deflector plate in the bin of the ice machine. On 04/09/24 at 11:28 a.m., Dietary Aide #1 stated the ice machine had last be cleaned four weeks ago. They stated the substance was mold and should not be there. They stated the ice company was responsible for cleaning of the ice machine. On 04/09/24 at 11:30 a.m., Dietary Aide #1 stated the ice machine should be shut down and cleaned.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to: a. offer residents the choice to formulate advance directives for four (#16, 26, 27, and #32) of 16 residents reviewed for advance directives. b. ensure a resident's code status was documented in the medical record for three (#16, 26, and #32) of 16 residents reviewed for advance directives. The Resident Census and Conditions of Residents form documented 43 residents resided in the facility. It documented there were 40 residents who had advance directives. Findings: 1. Res #27 was admitted [DATE] and had diagnoses which included vascular dementia, acute kidney failure, cerebral infarction, and cardiomyopathy. A physician order, dated 04/15/22, documented the resident was a full code. A quarterly assessment, dated 10/26/22, documented the resident had moderate cognitive impairment. There was no documentation the resident and/or their representative was offered a choice to formulate an advance directive. On 02/23/23 at 9:12 a.m., RN #1 stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to: a. ensure accurate coding of MDS assessments for anticoagulant use for six (#1, 16, 18, 21, 27, and #34) of 14 residents whose MDS assessments were reviewed. b. ensure accurate coding of MDS assessment for diagnoses for one (#20) of 14 residents whose MDS assessments were reviewed. The Resident Census and Conditions of Residents form documented 43 residents resided in the facility. Findings: 1. Res #1 had diagnoses which included dementia, chronic ischemic heart disease, and hypertension. An admission assessment, dated 01/09/23, documented Res #1 received an anticoagulant seven out of seven days during the review period. On 02/23/23 at 10:55 a.m., Res #1's records were reviewed and did not document an order for anticoagulants during the review period. 2. Res #16 had diagnoses which included hypertension, and history of aneurysm. A quarterly MDS, dated [DATE], documented Res #16 received an anticoagulant seven out of seven days during the 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, and interview, the facility failed to ensure a comprehensive care plan was completed for one (#190) of one residents reviewed for new admission. The Resident Census and Conditions of Residents form documented 43 residents resided in the facility. Findings: Resident #190 admitted to the facility on [DATE] with diagnoses which include chronic heart failure, major depressive disorder, hemiplegia, bipolar disorder, atrial fibrillation, chronic respiratory failure, anxiety, and hypertension. On 02/22/23 at 12:05 p.m., Res #190 was observed in bed with eyes closed with oxygen supplied by nasal cannula. On 02/23/22 at 08:13 a.m., Res #190's record was reviewed and documented a care plan initiated 02/06/23. The care plan was blank. On 02/23/23 at 11:50 a.m., the ADON/MDS coordinator stated Res #190's care plan was not started. She stated there was not a comprehensive care plan completed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure: a. physician orders were followed for treatment of an arterial wound for one (#16) of one residents reviewed for non-pressure ulcers. b. daily weights were obtained for one (#5) of one resident sampled for daily weights. The Resident Census and Conditions of Residents documented 43 residents resided in the facility. Findings: 1. Res #16 had diagnoses which included paralytic syndrome following cerebral infarction and Parkinson's disease. A quarterly MDS, dated [DATE], documented Res #16 was severely cognitively impaired, required total assistance with ADLs, and had dressings applied to the feet. A physician order, dated 01/11/23, documented to cleanse wound to the posterior right foot with wound cleanser, apply Iodosorb cream, cover with gauze, wrap with Kerlix, and secure with tape every day shift. A wound physician progress note, dated 02/01/23, documented an arterial wound to the right distal lateral foot. The note 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, observation, and interview, the facility failed to: a. provide dietary supplements as ordered for one (#20) and b. obtain physician ordered weekly weights for one (#18) of three residents reviewed for weight loss. The Resident Census and Conditions of Residents form documented 15 residents with weight loss and the ADON identified 22 residents with orders for dietary supplements. Findings: 1. Resident #20 had diagnoses which included COPD, heart failure, depression, and age-related physical debility. A dietitian progress note, dated 11/25/22, documented Res #20 had a six percent loss of body weight since the previous month. The note documented Res #20 was receiving Med Pass 2.0 90 ml three times daily. The dietitian recommended to consider giving Med Pass 2.0 between meals in the even of early satiety at meals. A dietitian progress note, dated 12/28/22 at 9:51 a.m., documented Res #20 had an eight percent loss of body weight since 09/2022. The note documented Res #20 was receiving Med Pass…

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, observation, and interview, the facility failed to change oxygen tubing as ordered by the physician for five (#5, 10, 19, 21, and #190) of five residents sampled for respiratory therapy. The Resident Census and Conditions of Residents documented 10 residents required respiratory therapy. Findings: 1. Res #5 had diagnoses of chronic obstructive pulmonary disease and heart failure. A physician's order, dated 1/5/23, documented to change the oxygen tubing every Thursday on night shift. On 02/23/23 at 8:10 a.m., the resident's oxygen tubing was not labeled with the replacement date. 2. Res #10 had diagnoses of chronic diastolic heart failure and essential hypertension. A physician's order, dated 01/05/23, documented to change the resident's oxygen tubing every night shift on Thursday. On 02/23/23 at 8:40 a.m., the resident's oxygen tubing was observed not labled with the date. 3. Res #19 had diagnoses of anxiety, depression, and atrial fibrillation. A physician order, dated 01/5/23, documented to change the oxygen tubing weekly every night shift on Thursday. 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, observation, and interview, the facility failed to ensure bed rails were assessed before use, physician order was obtained, and consent was obtained for one (#190) of one resident assessed for accident hazards. The Resident Census and Conditions of Residents form documented 43 residents resided in the facility. Findings: Res #190 had diagnoses which included chronic heart failure, hemiplegia of right dominant side, and chronic respiratory failure. Res #190's health record was reviewed and did not document a physician order, assessment, or consent for use of bed rails. On 02/22/23 at 12:05 p.m., Res #190 was observed in bed. The bed was observed with quarter handrails raised on both sides at the head of the bed. An air mattress was observed on the bed. A motor for an air mattress was observed on the foot of the bed powered on and functioning. On 02/23/23 at 11:28 a.m., Res #190 was observed in bed. The hand rails remained up at the head of the bed. On 02/24/23 at 7:42 a.m., the ADON stated Res #190 had not been assessed for bed rail use. She stated she had put…

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 have the services of a DON or an RN for at least eight consecutive hours a day, seven days a week. The Resident Census and Condition of Residents form identified 43 residents who resided in the facility. Findings: Staffing sheets for 02/08/23 through 02/15/23 were not provided. Staffing sheets for 02/16/23 through 02/22/23 were provided. There was only RN coverage on 02/18 and 02/19/23. The staffing report had no RN coverage for 02/16, 02/17, 02/20, and 02/21/23. On 02/22/23 at 11:30 a.m., the administrator was asked if there was a DON/RN on staff. She reported, No the DON quit on 02/08/23. She reported I have had an agency RN working, not as a DON, but to make sure we have an RN in the building. On 02/23/23 at 10:15 a.m., the ADON/MDS/IP/LPN reported I have been wearing a lot of hats. We haven't had a DON/RN for a couple of weeks. On 02/24/23 at 12:25 p.m., the Administrator reported, Staffing is an ongoing issue but I do have enough extra agency nurses hired to make sure they are meeting the needs of the residents. 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 record review and interview, the facility failed to ensure the resident's physician addressed recommendations on the MRR per the facility policy for one (#1) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form identified 43 residents who resided in the facility. Findings: Resident #1's active diagnoses included down syndrome and dementia. A facility policy, titled Drug Regimen Review Report Irregular Act /On, dated 12/10/14, read in part, .2. Report - The Pharmacist must report any irregularities to the attending physician and the Director of Nurses. 3. Completed - These reports must be acted upon . A MRR, dated 01/01/23, documented the pharmacist made a recommendation for Levothyroxine 88 mcg taken daily at 8:00 a.m. to be given at either 7:00 a.m. or 8:00 p.m. to minimize the the risk of interactions. Also the pharmacist documented the antipsychotic, Olanzapine, had been given without a supporting diagnosis. Please provide the supporting diagnosis/rationale for the use of this medication. The admission 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and and interview, the facility failed to perform monitoring for anticoagulant medications for one (#19) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form identified 43 residents who resided in the facility. Findings: Res #19 was admitted to the facility on [DATE] with diagnoses of atrial fibrillation. A physician order, dated 02/16/22, documented Res #19 was to be administered Eliquis (a blood thinner) 2.5 mg two times a day. The clinical record did not contain documentation of the side effects or monitoring of the blood thinner. On 02/23/23 at 11:18 a.m., the ADON reported the side effects should have been documented and monitored.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to monitor for side effects and behaviors of psychotropic medications for three (#18, 19, and #20) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents documented 33 residents received psychotropic medications. Findings: 1. Res #18 had diagnoses which included dysthymic disorder, anxiety disorder, and dementia with behavioral disturbance. The care plan, dated 03/28/22, documented the resident had impaired cognitive functions or impaired thought processes related to delusions and flight of ideas with an intervention to monitor/document/report to the physician any changes in cognitive function. The care plan documented the resident used quetiapine related to behavior management with an intervention to administer medications as ordered and to monitor/document side effects and effectiveness. The care plan documented the resident use escitalopram for depression with an intervention to monitor/document/report…

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 ensure the medication error rate was less than 5% for two residents (#2 and #10) of six residents observed during medication pass. A total of 34 opportunities were observed with two errors. Total error rate was 5.88%. The Resident Census and Conditions of Residents report documented 43 residents resided in the facility. Findings: 1. Res #10 was admitted tot he facility on 09/13/20 with diagnoses of chronic diastolic heart failure and essential hypertension. A physician's order, dated 08/31/22, documented metoprolol tartrate 25mg two times a day. A medication administration report, dated 12/08/22, documented metoprolol tartrate 12.5mg two times a day. On 02/24/23 at 8:00 a.m., CMA #1 administered metoprolol tartrate 25mg to the resident. On 02/24/23 at 9:50 a.m., CMA #1 was asked to look at the resident's MAR and physician's order for metoprolol tartrate and then look at the medication card. She stated she thought the order was changed 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.

Based on record review and interview, the facility failed to ensure an effective QA/QAPI program to correct identified quality deficiencies. The Resident Census and Conditions of Residents form identified 49 residents resided in the facility. Findings: The undated Quality Assurance and Performance Improvement Program policy, read in parts, .The quality assessment and assurance committee will meets [sic] quarterly to identify issues .develops and implements appropriate plans of action to correct identified quality deficiencies . The facility had deficient practice cited in regards to nutrition status maintenance, quality of care related to wound care, activity of daily living assistance for dependent residents, catheter care, unnecessary medications related to monitoring behavior/side effects, monitoring of anticoagulant medication, and care plan review/revision on the survey dated 02/24/23. The facility was unable to correct these deficient practices by the correction date the facility identified on the plan of correction. On 04/28/23 at 3:54 p.m., the DON was asked how the QA/QAPI…

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 implement a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems. The Resident Census and Conditions of Residents documented 43 residents resided in the facility. Findings: CMS memo 17-30, revised date 06/09/17, documented CMS expects long-term care facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the facility water systems. No documentation of water management policies and procedures found from record review. On 02/23/23 at 2:00 p.m., the administrator was asked to provide documentation of water management policies and procedures. On 02/24/23 at 9:49 a.m., the administrator stated she could not locate any documentation that the facility had maintained a water management program. On 02/24/23 at 10:04 a.m., the maintenance supervisor stated the facility did not have documentation of a water management program.

Based on record review and interview, the facility failed to ensure 100 percent of staff who had not been granted a qualifying exemption, received all doses of a multiple COVID-19 vaccine series. The Census and Conditions of Residents form documented 43 residents reside in the facility. Findings: The COVID-19 Staff Vaccination Status for Providers form, dated 02/23/23, documented 73 total staff with 64 completely vaccinated, one partially vaccinated, and eight granted exemptions. The partially vaccinated staff member's COVID vaccine card documented the first vaccine of a series was on 10/06/22. On 02/23/23 at 2:40 p.m., the ADON stated one staff member was not completely vaccinated. She stated the staff member never received the second COVID-19 vaccine in the series but should have. She stated the staff member's hire date was 09/13/22.

Based on interview and record review the facility failed to provide written notice of room change for one (#38) of three residents reviewed for room change. Findings: Resident #38 had diagnoses which included paraplegia. Review of the clinical record did not include information that the resident received written notification of room change. On 04/18/23 at 2:36 p.m. the administrator was asked if the resident was given a written notification of room change. The administrator stated I guess we forgot.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete a discharge summary for one (#39) of two residents reviewed for closed records. The Resident Census and Conditions of Residents form documented 43 residents resided in the facility. Findings: Res #39 had diagnoses which included fracture of left shoulder, history of falling, unsteadiness on feet, lack of coordination, and weakness. A five day MDS, dated [DATE], documented the resident was moderately cognitively impaired, required extensive assistance with ADLs and used a wheelchair for mobility. The EHR documented Res #39 discharged from the facility on 11/10/22. On 02/24/23, at 10:21 a.m., the administrator was asked for Res #39's discharge summary. She stated she did not have a discharge summary in her file but would look to see if it was in the DON's office. On 02/24/23 at 11:49 a.m., the administrator stated there was not a discharge summary completed for Res #39.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the ombudsman of discharge for one (#39) of two residents reviewed for closed records. The Resident Census and Conditions of Residents form documented 43 residents resided in the facility. Findings: Res #39 had diagnoses which included fracture of left shoulder, history of falling, unsteadiness on feet, lack of coordination, and weakness. A five day MDS, dated [DATE], documented the resident was moderately cognitively impaired, required extensive assistance with ADLs and used a wheelchair for mobility. The EHR documented Res #39 discharged from the facility on 11/10/22. On 02/24/23 at 11:15 a.m., the administrator stated she had not notified the ombudsman of Res #39's discharge.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure a comprehensive assessment was completed within 14 days after admission for one (#190) of one resident reviewed for new admission. The Resident Census and Conditions of Residents form documented 43 residents resided in the facility. Findings: Resident #190 admitted to the facility on [DATE] with diagnoses which include chronic heart failure, major depressive disorder, hemiplegia, bipolar disorder, atrial fibrillation, chronic respiratory failure, anxiety, and hypertension. On 02/22/23 at 12:05 p.m., Res #190 was observed in bed with eyes closed with oxygen supplied by nasal cannula. On 02/23/22 at 8:11 a.m., Res #190's record was reviewed and documented an admission assessment as In Progress. On 02/23/23 at 10:45 a.m., the ADON stated she was aware timely MDS assessments were an issue. She stated Res #190's admission assessment was not completed and should have been. She stated she was unable to complete MDS assessments timely 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure a baseline care plan was completed for one (#190) of one residents reviewed for new admission. The Resident Census and Conditions of Residents form documented 43 residents resided in the facility. Findings: Resident #190 admitted to the facility on [DATE] with diagnoses which include chronic heart failure, major depressive disorder, hemiplegia, bipolar disorder, atrial fibrillation, chronic respiratory failure, anxiety, and hypertension. On 02/22/23 at 12:05 p.m., Res #190 was observed in bed with eyes closed with oxygen supplied by nasal cannula. On 02/23/22 at 8:13 a.m., Res #190's record was reviewed and documented a care plan initiated 02/06/23. The care plan did not include a baseline care plan. On 02/23/23 at 11:50 a.m., the ADON/MDS coordinator stated Res #190's care plan was not started. She stated there was no baseline care plan completed.

Based on record review and interview, the facility failed to ensure care plans were reviewed/revised for one (#20) of five residents reviewed for care plan revision. The Resident Census and Conditions of Residents form identified 49 residents resided in the facility. Findings: Resident #20 had diagnoses which included hypertension (high blood pressure). The Care Plan, revised 01/18/23, did not reveal a review/revision had been conducted since 01/18/23. Review of the assessments, revealed a quarterly assessment had been completed on 04/04/23. Review/revision of the care plan had not been completed after the quarterly assessment. On 04/25/23 at 2:38 p.m., the ADON was asked who was responsible to ensure care plans were reviewed/revised after quarterly assessments. They stated they were responsible. The ADON was asked why the care plan for Resident #20 had not been reviewed/revised after the 04/04/23 quarterly assessment or by the plan of correction date of 04/20/23 set by the facility. They stated they had not had time. The ADON stated they had only been able to review/revise…

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, it was determined the facility failed to ensure the removal of expired mediations from the medication storage room. The Resident Census and Conditions of Residents report documented 43 residents resided in the facility. Findings: On 02/24/23 at 10:57 a.m., a tour of the medication room found the following expired medications. a. 1 vial multi- dose Flu vaccine with an open date of 11/01/22. b. 1 Levemir Flextouch pen with no name or label. c. 1 package of 10 count Bisacodyl suppositories with an expiration date of 12/22. On 02/24/23 at 11:20 a.m., the ADON reported the expired and unlabeled medications should have already been removed from the medication room.

Based on record review, observation, and interview, the facility failed to ensure bed rails were inspected for one (#190) of one resident assessed for accident hazards. The Resident Census and Conditions of Residents form documented 43 residents resided in the facility. Findings: Res #190 had diagnoses which included chronic heart failure, hemiplegia of right dominant side, and chronic respiratory failure. Res #190's health record was reviewed and documented no physician order, assessment, or consent for use of bed rails. On 02/22/23 at 12:05 p.m., Res #190 was observed in bed. The bed was observed with quarter handrails raised on both sides at the head of the bed. An air mattress was observed on the bed. A motor for an air mattress was observed on the foot of the bed powered on and functioning. On 02/23/23 at 11:28 a.m., Res #190 was observed in bed. The hand rails remained up at the head of the bed. On 02/24/23 at 7:39 a.m., the maintenance supervisor stated he inspected all the equipment that comes into the building. He stated he had not inspected the bed for Res #190 because he…

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.