Memory Care Center At Emerald

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure: a. the services of an RN was available in the facility eight hours daily seven days a week, and b. there was a RN designated as full time DON. The administrator identified 56 residents resided in the facility. Findings: A Nursing Services and Sufficient Staff policy, read in part, .Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours, 7 days a week. A document of in and out time punches for April 1st, 2024 through May 5th, 2024 documented RN #1's shifts worked as follows: 1. 04/05/24 12.37 hours worked. 2. 04/06/24 12.17 hours worked. 3. 04/18/24 17.70 hours worked. 4. 04/19/24 12.65 hours worked. 5. 04/25/24 12.48 hours worked. 6. 04/29/24 12.23 hours worked. 7. 05/03/24 12.42 hours worked. A document of in and out time punches for April 1st, 2024 through May 5th, 2024 documented RN #2's shifts worked as follows: 1. 04/12/24 8.77 hours worked. 2. 04/13/24 8.97 hours worked. 3. 04/14/24…

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 menus were followed for one of one meal preparation and service observed. The ADON identified all 56 residents received their meals from the kitchen. Findings: A Menus and Adequate nutrition policy, dated 01/2024, read in part, The purpose of this policy is to assure menus are developed and prepared, based on reasonable efforts, to meet resident choices and reflect the resident's nutritional, religious, cultural, and ethnic needs, while using established guidelines and considering resident preferences. The policy also read, The facility will ensure that menus, The policy also read, Be followed; The policy also read, All residents have the right to make their own personal dietary choices. On 05/06/24 at 9:59 a.m., [NAME] #1 stated the lunch menu was chicken paprikash, egg noodles, squash, and mixed fruit. The menu was observed and it documented the noon meal was to have been chicken paprikash, buttered egg noodles, squash medley, melon cubes, and beverage. On 05/06/24 at 1:25 p.m., [NAME] #1 was…

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

Based on observation, record review, and interview, the facility failed to ensure oxygen tubing was stored in a manner to prevent cross contamination for one (#6) of one sampled resident who was observed for oxygen therapy. The ADON identified six residents who received oxygen therapy. Findings: Resident #6 had diagnoses which included acute respiratory failure with hypoxia. Resident #6's Monthly Physician's Orders, included oxygen 2 liters via nasal cannula continuously. On 05/06/24 at 12:26 p.m., Resident #6 was observed in their room. The nasal cannula oxygen tubing hooked up to the portable oxygen tank was observed lying on the floor. On 05/09/24 at 9:15 a.m., Resident #6 was observed in the dining room wearing the oxygen nasal cannula that was hooked up to the portable oxygen tank. On 05/09/24 at 9:25 a.m., the nasal cannula hooked up the oxygen concentrator was observed hanging from the regulator and was discolored. The humidifier bottle was out of water and had water stains on the bottle. On 05/09/24 at 9:58 a.m., the ADON was shown pictures of the nasal cannula and 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 and interview, the facility failed to ensure emergency call cords were long enough to be reached by the residents if they were lying on the floor in the shower for two (#44 and #56) of two residents who were able to independently shower. The ADON identified 12 residents who would have the cognitive ability to utilize the call light. Findings: 1. Resident #44 On 05/06/24 at 10:30 a.m., CNA #8 stated Resident #44 was able to shower themselves independently. They stated they assisted them with gathering the shower supplies. On 05/06/24 at 12:36 p.m., Resident #44's bathroom was observed. The emergency call cord in the bathroom was next to the toilet and not within reach of the shower. On 05/08/24 at 2:39 p.m., the ADON stated Resident #44 should be provided stand by assistance in the shower to stay on task. The ADON stated Resident #44 would not be able to reach the call light if they fell in shower. On 05/09/24 at 11:10 a.m., Resident #44 was shown the call cord in their bathroom and was asked if they knew what the cord was for next to their toilet. Resident #44…

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 resident was treated with dignity during dining for one (#20) of four sampled residents observed during two meals. The ADON identified 10 residents who required assistance with meals. Findings: The facility's, Activities of Daily Living (ADLs) policy, revised 01/2024, read in part, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition . Resident #20 had diagnoses which included dementia. Resident #20's annual assessment, dated 03/12/24, documented they were dependent on staff for eating. On 05/09/24 at 8:45 a.m., RN #1 was observed feeding Resident #20, they got up from the table, Resident #20 had food remaining on her plate and went across the room to encourage another resident to eat. RN #1 came back to the table and assisted another resident to eat while Resident #20 was sitting at the table with a plate of food in front of them. On 05/09/24 at 8:49 a.m., Resident #6 was heard telling Resident #20 Take a bite, you can do it.…

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 an investigation was initiated for one (#13) of six resident sampled for abuse. The Administrator identified 56 residents resided in the facility. Findings: A Abuse, Neglect and Exploitation policy, revised 1-2024, read in part, a. Respond to the needs of the resident and protect them from further incident (document), b. Notify the Director of Nursing and Administrator (document), c. initiate an investigation immediately. The policy also read, f. Contact the State Agency and the local Ombudsman office to report the alleged abuse. The policy also read, h. Monitor and document the resident's condition, including the response to medical treatment or nursing interventions, i. Document actions taken in steps above in the medical record. Resident #13 admitted to the facility on [DATE] with diagnoses of unspecified dementia, senile degeneration of the brain, and anxiety disorder, unspecified. A quarterly assessment dated , 03/13/24, documented 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 MDS assessments were accurate for one (#20) of two sampled residents reviewed for accuracy of documentation for limited range of motion on the MDS assessment. The ADON identified 10 residents who had limited range of motion and three residents who had contractures. Findings: Resident #20's annual assessment, dated 03/12/24, documented they had no impairment for limited range of motion to the shoulder, elbow, wrist, or hand. On 05/07/24 at 11:58 a.m., Resident #20's family member stated the resident's hand was contracted. On 05/09/24 at 8:54 a.m., Resident # 20's left hand was observed to be closed. On 05/09/24 at 9:07 a.m., CNA #7 stated Resident #20's hand was contracted. On 05/14/24 at 10:03 a.m., the ADON stated Resident #20's hand was contracted. They reviewed the MDS assessment and stated the assessment was filled out incorrectly. They stated the assessment documented no impairment in range of motion to upper extremities.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to include a care plan regarding isolation for one (#13) of 19 sampled resident reviewed for care planning. The Administrator identified 56 residents resided in the facility. Findings: A Care Plan Process policy, revised 09/2019, read in part, The plan of care must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and social well-being. The policy also read, Maintains care plans on a current status. The policy also read, Aid in preventing or reducing declines in the residents's functional status and/or functional levels. Resident #13 admitted to the facility on [DATE] with diagnosis which included unspecified dementia, senile degeneration of brain, anxiety disorder, unspecified. An Infection Note dated 04/08/24, documented, nurse practioner gave orders to begin isolation precautions until completion of antibiotic treatment. There was no documentation on the care plan of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure neurological checks were completed after a fall with head injury for one (#41) of four sampled residents reviewed for accident hazards. The Administrator identified 56 residents resided in the facility. Findings: An Accidents/Neuro Checks policy, revised 1-24, read in part, The purpose of this procedure is to provide guidelines for a neurological assessment:. The policy also read, Neurological assessments are indicated:. The policy also read, Following an unwitnessed fall;. The policy also read, Following a fall or other accident/injury involving head trauma;. Resident #41 admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, unspecified, dementia in other disease class, and bipolar disorder. Resident #41's significant change assessment documented the resident had severe cognitive impairment. An Incident Note, dated 12/24/23, documented, Resident standing at counter. Resident from [room number withheld] approached…

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 oxygen tubing was labeled, dated, and changed per facility policy for one (#6) of one sampled resident who was observed for oxygen therapy. The ADON identified six residents who received oxygen therapy. Findings: The facility's, Special Needs policy, revised 01/2024, read in part, To address special needs, this facility will provide the necessary care and treatment .consistent with professional standards of practice. Resident #6 had diagnoses which included acute respiratory failure with hypoxia. Resident #6's Monthly Physician's Orders, included oxygen 2 liters via nasal cannula continuously. On 05/06/24 at 12:26 p.m., Resident #6 was observed in their room. The oxygen tubing hooked up to the oxygen concentrator was not dated. On 05/09/24 at 9:15 a.m., Resident #6 was observed in the dining room wearing the oxygen nasal cannula hooked up to the portable oxygen tank. The oxygen tubing was dated 03/29/24. CNA #7 observed the date on the tubing and verified the date. On 05/09/24 at 9:25 a.m., the nasal…

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 antipsychotic medications were ordered with an appropriate diagnoses for one (#5) of five sampled residents reviewed for unnecessary medications. The ADON identified 23 residents were prescribed psychotropic medications. Findings: Resident #5 admitted to the facility on [DATE] with diagnoses that included unspecified dementia and general anxiety disorder. A Physician's Order, dated 09/20/22, documented aripiprazole tablet 5 mg by mouth one time a day for unspecified dementia with behavioral disturbance. On 05/14/24 at 9:52 a.m., the ADON stated schizophrenia, bipolar, and depression where appropriate diagnoses for aripiprazole. On 05/14/24 at 9:53 a.m., the ADON stated that dementia to their knowledge was not an appropriate diagnosis for aripiprazole.

Based on record review and interview, the facility failed to explain the arbitration agreement in a manner the resident representative could understand for one (#21) of three sampled residents who entered into a binding arbitration agreement. The administrator identified 25 residents who had entered into a binding arbitration agreement. Findings: A document titled, Voluntary Arbitration Agreement, dated 04/08/24, documented Resident #21's family member signed the agreement. On 05/09/24 at 8:08 a.m., Resident #21's representative was asked if they understood the arbitration agreement they signed. The family member stated they did not realize what they were signing. They stated they did not realize they were giving up their right to have litigation in court. They stated they were stressed out and signing a lot of paperwork. The family member stated the facility went over the paper work so fast, they guessed they should have paid more attention. They stated they were not told they could withdraw from the agreement within 30 days of signing the agreement. On 05/10/24 at 9:31 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to convey remaining funds to the legal representatives of deceased residents within 30 days for two (#1 and #3) of three sampled residents reviewed for finances. An Action Summary report, dated [DATE], documented 12 residents had died while residing at the facility in the five months prior to the survey. Findings: 1. Resident #1 was admitted to the facility on [DATE] and discharged on [DATE]. A financial statement, dated [DATE], documented that on [DATE] Resident #1 had a credit owed in the amount of $2,688.00. A Refund Request Form dated [DATE], documented $2,688.00 was paid to the Resident #1's spouse. 2. Resident #3 was admitted to the facility on [DATE] and discharged on [DATE]. A financial statement, dated [DATE], documented Resident #3 had a credit of $8,550.00. On [DATE] at 1:15 p.m. the BOM reported they had been unaware of the credits owed to the estates of Residents #1 and #3. They stated the organization used a contracted agency for billing 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 record review and interview, the facility failed to notify a resident representative of a new skin issue after its discovery for one (#2) of three sampled residents reviewed for notification of change. A Detailed Census Report form, dated 10/16/23, documented 57 residents resided in the facility. Findings: Resident #2 had diagnoses which included dementia and abnormalities of gait [inability to walk in a normal manner]. A Notification of Change policy, dated May 2017, read in part .It is the policy of this facility that changes in a resident's condition or treatment is are immediately shared with the resident and/or the resident representative, according to their authority . A Skin/Wound Weekly Observation form, dated 09/05/23, documented a discoloration of bruise that was shaped like the letter C and located on the left buttock. A progress note, dated 09/06/23 at 2:23 p.m., documented a hospice nurse had reported a bruise on the upper left buttock, left hip area that measured approximately two inches in length. The note further documented the primary care physician 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 and interview, the facility failed to ensure a code status was documented and the person with legal authority signed the DNR form for two (#2 and #26) of 24 residents reviewed for advance directives. The facility failed to ensure: a. a code status was documented for Res #26, and b. the person with legal authority signed the DNR form for Res #2. The facility census and condition report documented 56 residents lived in the facility. Findings: Resident #26 was admitted to the facility on [DATE] with diagnoses which included heart failure, atherosclerotic heart disease, and other specified heart block. The annual assessment, dated [DATE], documented the resident was severely impaired for daily decision making. There was no documentation of code status or physician order for code status on the resident's EHR. The care plan, dated [DATE], documented the resident had a terminal prognosis and was on hospice. On [DATE] at 10:30 a.m., an interview was conducted with LPN #2, and she 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.

Based on observation and interview, the facility failed to ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly, and comfortable interior for seven (#9, 15, 20, 34, 35, 39, and #51) of eight residents observed for a clean, comfortable, homelike environment. The Resident Census and Conditions of Residents form documented 56 residents resided in the facility. Findings: On 03/27/23 at 2:37 p.m., Res #35's bathroom was observed with part of the vinyl trim missing and/or pulled away from the wall. Parts of the wall had cracks in the paint and plaster. During the observation the maintenance man came in the room. He was shown the area which needed repair. He stated he was not aware of the room needing repair. He stated he did monthly rounds in the facility to check if repairs were needed. He stated staff were to log maintenance issues on the maintenance log. On 03/27/23 at 3:00 p.m., Res #34 complained of a sticky area on her bathroom floor in front of her toilet. The area was observed to be approximately two feet in length and three to four inches…

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 were permitted to return to the facility after they were hospitalized for one (#111) of three residents reviewed for discharges. The MDS coordinator identified 21 residents who had been discharged from the facility in the last six months. Findings: Res #111 was admitted to the facility on [DATE] and had diagnoses which included Alzheimer's disease, delusional disorders, anxiety disorder, major depressive disorder, chronic pain, migraines, and cerebrovascular disease. A quarterly MDS assessment, dated 07/01/22, documented the resident's cognition was severely impaired, required the extensive assistance of one person with bed mobility, transfers, dressing, and toileting. A nurse note, dated 09/23/22 at 5:17, documented a CNA came to that nurse and reported the resident had bit the aide on the arm. The nurse informed the ADON, administrator, and family member. A social services note, dated 09/23/22 at 5:30, documented SSD, ADON, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to conduct a significant change assessment within 14 days after a change in condition for two (#2 and #31) of 24 sampled residents whose assessments were reviewed. The Resident Census and Conditions of Residents form documented 56 residents who resided in the facility. Findings: 1. Res #31's annual assessment, dated 09/12/22, documented the resident was cognitively intact and needed limited assistance with most ADLs. The assessment documented the resident was frequently incontinent of bladder, occasionally incontinent of bowel, and required supervised bathing. A quarterly assessment dated [DATE], documented the resident was cognitively intact and needed extensive assistance with most ADLs. The assessment documented the resident was frequently incontinent of bowel and bladder, and totally dependent with bathing. A significant change assessment dated [DATE], had been started but was not complete as of 03/29/23. On 03/29/23 at 5:40 p.m., the MDS coordinator…

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 assessments accurately reflected residents' status for five (#25, 30, 36, 52 and #57) of 24 sampled residents whose assessments were reviewed. The facility failed to accurately assess: a. wandering for Res #30 and #52. b. falls for Res #25 and #57. c. skin conditions for Res #25 and #36. The Resident Census and Conditions of Residents report documented 56 residents who resided in the facility. Findings: 1. Res #30 had diagnoses which included Alzheimer's disease. A significant change assessment, dated 01/20/23, documented the resident's cognition was severly impaired and did not have wandering behaviors. On 03/27/23 at 1:51 p.m., an observation was made of resident #30 wandering out of room [ROOM NUMBER] with a pillow and placed it in the common area. On 03/27/23 at 2:01 p.m., an observation was made of resident #30 wandering in and out of rooms on Hall 500. On 03/27/23 at 2:13 p.m., an observation was made of resident #30…

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 develop comprehensive person-centered care plans related to nutrition/weight loss for two (#2 an #50) of two residents reviewed for nutrition. The Resident Census and Conditions of Residents report documented 56 residents who resided in the facility. Findings: 1. Res #50 had diagnoses which included adult failure to thrive, hypokalemia, Alzheimer's disease, congestive heart failure, and diabetes mellitus. The EHR documented, on 02/04/23, a weight of 140.6 lbs. The EHR documented, on 03/06/23, a weight of 130.4 lbs. A quarterly assessment, dated 03/19/23, documented the resident had severe impaired cognition and did not have a significant weight loss of over 5% in one month. A dietary note, dated 03/23/23, documented a significant weight loss and recommended Mighty Shakes three times a day to promote stable weight. The care plan did not include nutrition or the resident's weight loss. On 03/28/23 at 5:35 p.m., an observation was made of the resident sitting at the table picking at food on plate. The resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise care plans for five (#14, 25, 36, 52, and #57) of 18 sampled residents whose care plans were reviewed. The facility failed to revise or update care plans related to: a. falls for Res #14, 25, and #57, b. wounds for Res #25 and #36, and c. psychoactive medication for Res #52. The Resident Census and Conditions of Residents form documented 56 residents resided at the facility. Findings: The facility's Fall Protocols Policy, dated 10/21/19, read in parts, .An incident investigation will be completed to determine root cause of fall .The care plan will be revised for any new fall prevention interventions .Fall intervention book will be updated immediately with fall intervention for staff reference . 1. Res #14's significant change assessment, dated 10/20/22, documented the resident's cognition was moderately impaired; had no behaviors; required the limited assistance of one person with bed mobility and locomotion on the unit with a w/c;…

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 record review, the facility failed to ensure a resident received interventions to maintain nutritional status within acceptable parameters for two (#2 and #50) of two residents sampled for nutritional status. The Resident Census and Conditions of Residents report documented 56 residents resided in the facility. Findings: 1. Res #50 had diagnoses which included adult failure to thrive, hypokalemia, Alzheimer's disease, congestive heart failure, and diabetes mellitus. The weight record, dated 02/04/23, documented a weight of 140.6 lbs. The weight record, dated 03/06/23, documented a weight of 130.4 lbs. A quarterly assessment, dated 03/19/23, documented the resident had severe impaired cognition and did not have a significant weight loss of over 5% in one month. A dietary note, dated 03/23/23, documented a significant weight loss and recommended Mighty Shakes three times a day to promote stable weight. The care plan did not include nutrition or the resident's weight loss. On 03/28/23 at 5:35 p.m., an observation was made of the resident sitting at…

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

Based on record review and interview, the facility failed to ensure medications were administered as ordered by the physician for two (#48 and #160) of five sampled residents whose medications were reviewed. The facility failed to ensure: a. the heart rate was monitored before administering heart medication for Res #48. b. medication was available and administered as ordered for Res #160. The Resident Census and Conditions of Residents documented 56 residents resided in the facility. Findings: 1. Res #48 had diagnoses which included hypertension, arthritis, depression, anxiety, insomnia, and Alzheimer's disease. A physician order, dated 01/18/23, documented diclofenac 75 mg two times a day for arthritis pain A physician order dated 01/19/23, documented trazodone 150 mg at bedtime for insomnia. An admission assessment, dated 01/24/23, documented the resident was severely impaired with cognition and received antipsychotic, antianxiety, and antidepressant medications. A physician order, dated 02/08/23, documented losartan potassium 100 mg one time a day for HTN. Hold if BP <110/50 or…

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 the physician responded to a pharmacist medication regimen review for two (#48 and #52) of five residents sampled for medication regimen reviews. The Resident Census and Conditions of Residents report documented 56 residents who resided in the facility. Findings: 1. Resident #52 was admitted to the facility on [DATE]. A quarterly assessment, dated 01/04/23, documented the resident had severely impaired cognition and received psychotropic medication. A physician order, dated 12/06/22, documented to administer Trazodone 50 mg at bedtime for insomnia. A physician order, dated 01/17/23, documented to administer Trazodone 25 mg at bedtime for insomnia. A monthly pharmacist medication review, dated 01/24/23, documented a recommendation for a gradual dose reduction for Trazadone. There was no documentation the physician responded to the medication review. On 03/30/23 at 1:30 p.m., the DON stated she could find the physician response to the pharmacy…

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 food was palatable and at appetizing temperatures for one of one meal service observed. The Resident Census and Conditions of Residents documented 56 residents resided in the facility. Findings: On 03/29/23 at 7:55 a.m., during the second kitchen tour breakfast was already on the steam table and no steam noted. DA #1 was ready to go serve the halls breakfast. She was asked to temp the food on the steam table. The eggs (only for one resident) was 155 degrees F, sausages 81.6 degrees F, waffles 150 degrees F, and oatmeal 182 degrees F. On 03/29/23 at 8:24 a.m., five meals were made and placed uncovered in the window pass on the 400 hall, seven more meals were made and placed uncovered in the window pass by 8:28 a.m., for a total of 12 meals in the window pass. On 03/29/23 at 8:29 a.m., a test tray was made and sat on the counter until the the meals were served to the residents on 400 hall. The temperature of the test tray was taken at 8:36 a.m. The waffle was 83.2 F, sausage 74.4 F, and the oatmeal 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, observation, and interview, the facility failed to store, prepare, and serve food in a sanitary manner. The Resident Census and Conditions of Residents documented 56 residents resided in the facility. Findings: On 03/27/23 at 12:50 p.m., an initial tour of the kitchen was conducted. The following was observed: a. cooked hamburger patties labeled patty melts were dated 03/24/23, b. a bag of biscuits were not labeled or dated. c. biscuits, cookies, and tater tots in the freezer were open to air, d. two cans of spinach were observed on the shelf not dated, e. a dented can of tomato sauce not dated, f. five cans of sliced apples, four cans of fruit mix, three cans of black-eyed peas were not dated, g. multiple pudding and Jell-O mixes not dated, h. cake mix packages not dated, i. chocolate cake mix open to air, j. fry mix and breadcrumbs open to air, and k. a large bag of Great Northern beans open to air. On 03/27/23 during the tour, the DM stated the biscuits were probably from this morning…

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 have an effective administration to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The administration failed to ensure: a. residents' code status were documented and the person with legal authority signed the DNR form. b. housekeeping and maintenance services were provided to maintain a sanitary, orderly, and comfortable interior. c. discharge notices contained the required components. d. residents were allowed to return to the facility after hospitalization if bed is available. e. comprehensive assessments were completed at least every 12 months. f. the facility failed to conduct a significant change assessment within 14 days after a change in condition. g. assessments accurately reflected residents' status. h. the OHCA was notified when residents received new serious mental illness diagnoses. i. comprehensive person-centered care plans were developed and revised. j. non-pressure skin lesions were…

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 and record review, the facility failed to ensure: a. the arbitration agreement contained clear language related to the residents or their representatives were not required to sign the agreement as a condition of admission; and b. the arbitration agreement granted the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it for three (#9, 20, and #57) of three residents reviewed for arbitration agreements. c. there was evidence a resident representative had the legal authority to sign the binding arbitration agreement for one (#9) of three residents reviewed for arbitration agreements. The SSD identified 25 residents which resided in the facility and had entered into arbitration agreements on or after 09/16/19. Findings: 1. Res #9 admitted to the facility on [DATE]. The Voluntary Arbitration Agreement, signed by the resident's representative on 12/16/20, read in parts, .Please know you can choose care at another facility if you do not wish…

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 and record review, the facility failed to ensure the arbitration agreement provided for the selection of a neutral arbitrator agreed upon by both parties for three (#9, #20, and #57) of three residents reviewed for arbitration agreements. The SSD identified 25 residents which resided in the facility and had entered into arbitration agreements on or after 09/16/19. Findings: 1. Res #9 admitted to the facility on [DATE]. The Voluntary Arbitration Agreement, signed by the resident's representative, on 12/16/20, did not have language that specifically provided for the selection of a neutral arbitrator. On 03/31/23 at 9:33 a.m., the SSD stated the arbitration agreement had been updated by the facility's corporation with the required wording related to the neutral third party but she had not received the updated version of the agreement until now. On 03/31/23 at 3:08 p.m., the administrator stated he was not aware the facility did not have the updated version of arbitration agreement which allowed…

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 consistently monitor antibiotic use for one (#52) of five sampled residents whose medications were reviewed. The facility failed to evaluate the need for antibiotics prior to ordering and administering antibiotics. The MDS coordinator identified two residents currently on antibiotics. Findings: Res #52's physician order, dated 02/27/23, documented Macrobid 100 mg by mouth two times a day for seven days for urinary tract infection. The EHR was reviewed on 03/30/23 and there was not evidence of a UA being collected or signs or symptoms the resident was experiencing before being put on an antibiotic. On 03/30/23 at 5:33 p.m., the MDS Coordinator/Infection Preventionists stated she had taken over the antibiotic stewardship program since they moved another staff member to a sister facility. She stated she had not had the time to bring the monitoring up to date.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure: a. a copy of the discharge notice was sent to the representative of the Office of the State Long-Term Care Ombudsman; b. the discharge notice was provided by the facility at least 30 days before the resident was discharged ; c. the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act was provided; and d. the discharge notice included the specific location to which the resident is to be transferred or discharged for one (#111) of three residents reviewed for discharges. The MDS coordinator identified 21 residents who had been discharged from the facility in the last six months. Findings: Res #111 was admitted to the facility on [DATE] and had diagnoses which included Alzheimer's disease, delusional disorders, anxiety disorder, major depressive disorder, chronic pain, migraines,…

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, it was determined the facility failed to ensure comprehensive assessments were completed at least every 12 months for one (#9) of 24 sampled residents whose assessments were reviewed. The facility census and condition report documented 56 residents lived in the facility. Findings: 1. Res #9's significant change assessment, dated 03/24/22, was completed. A quarterly assessment, dated 06/21/22, was completed. A quarterly assessment, dated 09/21/22, was completed. A quarterly assessment, dated 12/18/22, was completed. A quarterly assessment, dated 03/13/23, was completed. On 03/30/23 at 12:36 p.m., the MDS coordinator was made aware Res #9 did not have a comprehensive assessment at least every 12 months. She stated there should have been an annual instead of a quarterly on 03/13/23.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the OHCA of a resident with a new serious mental illness for one (#4) of one sampled residents reviewed for PASRR evaluations. The Resident Census and Conditions of Residents report documented 39 residents who received psychoactive medication. Findings: Res #4 was admitted to the facility on [DATE]. A PASRR level I was completed on 03/06/20 and documented the resident did not have a serious mental illness. The EHR documented Res #4 received a diagnosis of delusional disorders on 07/06/21. A PASRR level I was completed on 05/04/22 and documented the resident did not have a serious mental illness A significant change assessment, dated 01/03/23, documented the resident was moderately impaired with cognition; had physical and verbal behaviors toward others one to three days during the look back period; and did not have a PASRR II evaluation. On 03/29/23 at 4:50 p.m., the admissions director stated he would have to look and find out if the resident…

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 obtain diagnosis, assess, and monitor skin lesion for one (#25) of two residents reviewed for skin issues. The Resident Census and Conditions of Residents documented 56 residents resided in the facility. Findings: Res #25's quarterly assessment, dated 10/31/22, documented the resident was severely impaired with cognition, required extensive assistance with most ADLs, and had no skin issues. A annual assessment, dated 01/23/23, documented the resident was severely impaired with cognition, required extensive assistance with ADLs, and had no skin issues. A physician order, dated 03/14/23, documented to clean with normal saline, pat dry, and apply dressing PRN for drainage for a forehead wound. The weekly skin observations in the EHR documented no skin issues or the report could not be viewed. A care plan, last revised 12/06/22, documented skin impairment related to fragile skin. The care plan documented to see the MAR/TAR for current regimen and administer treatment as ordered. The care plan documented 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 provide pain management medications for one (#160) of five residents sampled for medication review. The Resident Census and Conditions of Residents documented 56 residents resided in the facility. Findings: Res #160 had diagnoses which included CHF, diabetes mellitus with diabetic chronic kidney disease, and dementia. A nurse note, dated 03/23/23, documented the resident had a fall while transferring self from the w/c to the recliner in the living room. The note documented the resident sustained an abrasion to the right side of the the forehead which appeared to be a carpet burn. The March 2023 TAR, documented on 03/25/23, the residents pain level was a seven out of ten. The resident did not have any pain medication documented on the MAR or a physician order for pain medicine. An admission assessment, dated 03/27/23, was in progress. On 03/27/23 at 2:31 p.m., Res #160 stated he needed some relief as he had been hurting all afternoon in his shoulders and back. He stated he had told the nurse. He stated his pain was at least…

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 record review, it was determined the facility failed to ensure a resident had medication administered as prescribed for one (#6) of six sampled residents whose medications were reviewed. The resident census and condition report documented 58 residents resided in the facility. Findings: Resident #6 was admitted with diagnoses of dementia with behavioral disturbance, depression, and anxiety. An EMR, dated 05/19/19, documented the resident was to receive Buspirone 15 mg twice a day. A MAR, dated May 2019, documented the resident's medication was scheduled to be given twice a day. The MAR documented the resident did not receive the medication on 5/19/19. The MAR documented a 9 was in the box of both morning and evening doses. The MAR documented the 9 stood for see other/progress note. An eMAR progress note, dated 5/19/19 at 8:45 a.m., documented Buspirone 15 mg, was to be given one tablet, by mouth, two times a day for anxiety/agitation. The progress note documented the medication was awaiting delivery. On 5/19/19 at 11:40 a.m., resident #6 was…

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

Based on observation, interview, and record review, it was determined the facility failed to ensure cross contamination did not occur during wound care for one (#55) of two sampled residents with wounds. The resident census and condition report documented there were two residents in the facility with a pressure ulcer. Findings: Resident #55 had diagnoses which included diabetes mellitus. An admission assessment, dated 05/10/19, documented the resident was severely impaired cognitively, was independent with most activities of daily living, was always continent of bowel and bladder, and had no pressure ulcer. A general progress note, dated 05/18/19, documented the nurse observed a blister on the resident's right foot second digit, inner right foot near the resident's right great toe, and a large blister was observed between the left great toe and the 2nd digit. The note documented the physician and family were notified and new orders were received to use skin prep to the affected areas and cover with a light dressing two times a day and as needed. On 05/19/19 at 11:15 a.m., LPN #1…

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.