Willowbrook Post Acute

Based on interview and record review the facility failed to ensure a clinical rational for administering a psychotropic medication for 1 of 5 sampled residents (#9) reviewed for medications. This placed residents at increased risk for adverse consequence of antipsychotic medication. Findings include:Resident 9 was admitted to the facility on 6/2025 with diagnosis including Parkinsons and difficulty walking.A review of Drugs.com - Prescription Drug Information revealed the following common side effects of trazodone included drowsiness, dizziness and tiredness. After a single dose in a healthy adult, trazadone was mostly eliminated from the system within one to three days. The half-life of trazadone was approximately five to 13 hours, meaning every five to 13 hours, the blood concentration of the drug decreased by 50 percent. The elimination half-life of a medication referred to the time required for its blood levels to be reduced by half. Factors such as metabolism, age, health status, weight and the amount and frequency of the drug taken influenced the rate at which the body cleared…

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 interview and record review it was determined the facility failed to complete a person-centered care plan related to ostomy care for 1 of 1 sampled resident (#30) reviewed for bowel and bladder. This placed residents at risk for infections and lack of ADL care. Findings include:Resident 30 was admitted to the facility in 2024 with diagnoses including a stroke and anxiety.A Care Plan dated 5/6/24 revealed Resident 30 had an alteration in gastro-intestinal status including colostomy. Interventions included bowel-colostomy, give medications as ordered, monitor and document effectiveness. The care plan did not include monitoring for signs/symptoms of potential infection, leakage, or how to clean the stoma (surgically created, opening on the surface of the abdomen) and peristomal (area of skin surrounding an ostomy stoma, where the artificial appliance is attached to collect bodily waste) skin.A 5/13/25 Annual MDS revealed Resident 30 had a BIMS score of 15 which indicated she/he was cognitively intact. The resident had an indwelling catheter and an ostomy (an appliance worn…

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 interview and record review the facility failed to prevent an avoidable fall for 1 of 4 sampled residents (#3) reviewed for falls. This placed residents at risk for injury. Findings include:Resident 3 was admitted to the facility in 3/2025 with diagnoses including a stroke and dysphagia (difficulty swallowing foods and liquids). Resident 3's 3/18/25 admission MDS indicated the resident had severe cognitive impairment and was dependent for all care needs including toileting and bed mobility. Resident 3's 6/7/25 fall investigation report indicated at approximately 4:00 AM, the nurse was on a break when Resident 3 was found in her/his room, on the floor, between the bed and the wall. The report indicated Staff 27 (CNA) changed Resident 3's brief around 3:30 AM and at 4:00 AM, Staff 26 (CNA) heard the resident yelling and crying and found Resident 3 on the floor. Resident 3's bed was not pushed back against the wall as it should have been, and the facility only had two CNAs scheduled for 50 residents. There were no reported injuries and Resident 3 refused to be transported 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 interview and record review it was determined the facility failed to ensure pharmacy recommendations were addressed by the physician for 1 of 5 sampled residents (#9) reviewed for unnecessary medications. This placed residents at risk for adverse side effects of medications. Findings include:Resident 9 was admitted to the facility on 6/2025 with diagnosis including Parkinsons and difficulty walking. Resident 9's 6/2025 and 7/2025 Pharmacy Recommendation and Review indicated Resident 9 a new order for trazodone (an antidepressant medication) with an unknown diagnosis. The recommendation was given to provide a diagnosis for the new psychotropic medication.A review of Resident 9's 6/2025 and 7/2025 MARs revealed the resident received trazodone at bedtime from 6/10/25 through 7/10/25 (29 days).On 8/22/25 at 8:33 AM and 10:28 AM, Staff 39 (Pharmacist) stated residents were reviewed monthly to ensure they had appropriate clinical diagnoses for use of all medications, including psychotropics. Staff 39 stated Resident 9 did not have an appropriate diagnosis or clinical rationale…

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 maintain a medication error rate of less than 5 percent. There were eight errors out of 30 opportunities resulting in a 26.67 percent error rate. This placed residents at risk for adverse medication side effects and pain. Findings include: Resident 9 was admitted to the facility in 6/2025 with diagnoses including Parkinson's Disease (a disorder of the central nervous system). Resident 9's 6/11/25 admission MDS indicated the resident had significant cognitive impairment.Resident 9's 8/2025 MAR indicated Resident 9 was to receive:- Carbidopa/levodopa (a medication for Parkinson's Disease) 25-100 mg TID - Allopurinol (medication for gout) 300 mg in the morning- Aspirin (medication for irregular heart rate) 81 mg in the morning- Cholecalciferol (a vitamin) 25 mcg in the morning- Finasteride (medication for an enlarged prostate) 5 mg in the morning- Senna (a laxative) 8.6 mg BID- Furosemide (medication for fluid retention) 40 mg in the morning- Metoprolol (medication for irregular heart rate) ER…

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 provide physical, occupational and speech therapy services as ordered for 3 of 3 sampled residents (#s 3, 26 and 60) reviewed for rehabilitation services. This placed residents at risk for a decline in functional abilities and diminished quality of life. Findings include: The Stroke Foundation, What to Expect From a Stroke, dated 2023, explained stroke rehabilitation (PT, OT and SLP) was the therapy and activities that drive recovery by helping to re-learn ways of doing things affected by a stroke. It aimed to stimulate the brain to change and adapt. By creating new pathways, a person could learn to use other parts of the brain to recover function of those parts affected by the stroke. Improvement after a stroke can continue for years but for many people it's quickest in the first six months. 1. Resident 3 was admitted to the facility in 3/2025 with diagnoses including a stroke, hemiparesis/hemiplegia (the loss of ability to move part or most of the body) and dysphagia (difficulty swallowing…

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 enhanced barrier precautions were implemented for 1 of 3 sampled residents (#9) reviewed for infection control. This placed residents at risk for transmission of infection. Findings include: The facility's Transmission Based Precautions Policy and Procedure dated 8/1/24 indicated the following:-To implement Transmission-Based Precautions for residents known to be, or suspected of being, infected with infectious agents.-Enhanced Barrier Precautions (EBP) when a person is colonized with a Multi-Drug-Resistant Organism or the status of colonization is unknown, enhanced barrier precautions are utilized, per CDC guidance, to reduce the risk of spread of and MDRO (actual colonized or potential). -Personal caring for a resident on EBP wears gloves and a gown. Prior to leaving the resident's room, gown and gloves are removed and hand hygiene performed. EBP is used with residents with a urinary catheter during the following situations: dressing, transferring, providing hygiene and changing…

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 it was determined the facility failed to ensure foods were labeled and stored in a way to minimize food spoilage and cross contamination, failed to maintain a clean and sanitary environment for food preparation and failed to prevent potential contamination of the ice machine in 1 of 1 kitchen reviewed for sanitation. This placed residents at risk for potential infections related to foodborne pathogens. Findings include: 1. On 5/13/24 at 11:24 AM in the facility's kitchen, the following items were observed in the middle refrigerator: -A partially-consumed one-gallon plastic container of [NAME] Salad Dressing (labeled 8/1); -A partially-consumed one-gallon plastic container of pickle spears (labeled 11/16); -A partially-consumed one-gallon plastic container of dijon mustard (labeled 8/1); -A partially-consumed one-gallon plastic container of Ranch dressing (labeled 3/20); -A partially-consumed one-gallon plastic container of black olives (labeled 3/15); -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.

Based on observation, interview and record review it was determined the facility failed to maintain a medication error rate of less than 5 percent. There were seven errors out of 28 opportunities resulting in a 25 percent error rate. This placed residents at risk for adverse medication side effects and pain. Findings include: 1. Resident 6 admitted to the facility in 2018 with diagnoses including chronic pain and osteoarthritis. The 4/12/24 physician order indicated Resident 6 was to receive: -gabapentin (pain medication) 300 mg TID; -Voltaren gel (pain gel used for osteoarthritis) apply to bilateral hands topically three times a day. a. On 5/14/24 at 12:06 PM Staff 12 (RN) was observed to administer the morning doses of gabapentin and Voltaren gel to Resident 6. The 5/14/24 time stamped MAR indicated gabapentin and Voltaren gel were due at 7:00 AM and not administered until 12:06 PM On 5/14/24 at 12:06 PM Staff 12 acknowledged the late medication administration of gabapentin and Voltaren gel. On 5/17/24 at 9:43 AM Staff 2 (Corporate RN) acknowledged the identified medication errors…

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 implement the plan of care for 2 of 6 sampled residents (#s 32 and 139) who were reviewed for ADLs. This placed residents at risk for unmet needs and injury. Findings include: 1. Resident 139 admitted to the facility in 2023 with diagnoses including the left and right femur (upper leg bone) fractures. Resident 139's 1/15/23 admission MDS indicated a BIMS a 15 (cognitively intact). Resident 139's 3/1/23 plan of care direct staff to provide extensive assistance by two staff members with bed mobility. On 3/1/23 the facility submitted a FRI to the State Agency. The facility received information of an incident on 3/1/23 which occurred on 2/24/23. Staff 25 (CNA) was placed on administrative leave pending an investigation of the incident. Review of a 3/1/23 written statement by Staff 25 revealed Staff 25 stated she independently completed bed mobility and ADL care for Resident 139 on 2/24/23. Review of a 3/1/23 written statement by Staff 30 (Former DNS) revealed Resident 139 described an incident on 2/24/23 when Staff…

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 provide the necessary care and services to maintain personal hygiene for 1 of 6 sampled residents (#15) reviewed for ADLs. This placed residents at risk for poor personal hygiene. Findings include: Resident 140 was admitted to the facility on 4/2024 with diagnoses including a fractured femur (upper leg bone). Resident 140's 5/4/24 admission MDS indicated a BIMS score of 12 (moderately impaired cognition). On 5/13/24 at 2:36 PM Resident 140 stated she/he had not been offered a shower since admission and had just given her/himself a bed bath and would love a shower. A wet washcloth was observed on the resident's bedside table. There was no wash bin with soap and water observed at the resident's bedside. Review of Resident 140's care plan revealed she/he had an ADL self-care performance deficit and needed extensive assistance for bathing. Staff were to assist with bathing by preference of a shower every Monday and Thursday evening. Resident 140's 5/2024 Task record documented 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 observation, interview and record review it was determined the facility failed to monitor skin conditions for 1 of 1 sampled resident (#28) reviewed for skin conditions. This placed residents at risk for unmet care needs. Findings include: The facility's 9/2020 Skin At Risk/Skin Breakdown Policy and Procedure indicated the following: -Updates of current non-pressure areas coincide with the weekly full body skin audit performed by the licensed nurse. The licensed nurse monitors bruises, skin tears and abrasions on the resident TAR. All other non-pressure skin concerns should be documented on the Skin-Wound Form. -Upon discovery of a newly identified skin impairment (abrasion, bruise, burn, excoriation, pressure sore, rash, skin tear, surgical wound, etc.), the licensed nurse would document the skin impairment, including measurements of size, color, presence of odor and exudates, document identified bruises and skin tears on the resident TAR with monitoring completed with weekly and record on the TAR until deemed appropriate for discontinuance. Resident 28 was admitted to 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, interview and record review it was determined the facility failed to implement fall prevention interventions and evaluate and analyze resident falls for 2 of 5 sampled residents (#s 23 and 32) reviewed for position and mobility and accidents. This placed residents at risk for injury. Findings include: 1. Resident 23 was admitted to the facility in 6/2023 with diagnoses including spinal stenosis (narrowing of the spinal column that can cause pressure on the spinal cord). Resident 23's 9/8/23 Quarterly MDS revealed the resident was severely cognitively impaired and had experienced two or more falls with injury and two or more falls without injury since her/his prior assessment. Resident 23's 12/27/23 SNF Morse Fall Scale indicated the resident was considered at moderate risk for falling. Resident 23's 3/11/24 At Risk for Falls Care Plan revealed the following: -The resident was considered a high fall risk. -The resident had a history of self-transferring out of bed and falling on the floor. -A bedside fall mat was to be placed next to the resident's bed to reduce…

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 obtain physician orders, ensure respiratory equipment was properly maintained and administer oxygen as ordered for 2 of 3 sampled residents (#s 28 and 32) reviewed for respiratory care. This placed residents at risk for adverse respiratory effects and discomfort. Findings include: The facility's 6/2022 Respiratory Treatment Policy and Procedure indicated the following: - The amount, method and duration of oxygen usage and diagnosis were identified on the resident's treatment record per the physician orders and care plan. - Oxygen concentrator filters were cleaned weekly and documented. 1. Resident 32 was admitted to the facility in 3/2024 with diagnoses including Rhabdomyolysis (breakdown of muscle tissue which releases protein into blood system). Resident 32's 5/3/24 Significant Change of Condition MDS indicated she/he received oxygen therapy. Resident 32 was observed on multiple occasions with oxygen administered through a nasal cannula (device which gives oxygen through nose) on 5/13/24 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 interview and record review it was determined the facility failed to document a clinical rationale for pharmacy recommendations for 2 of 5 sampled residents (#s 3 and 24) reviewed for unnecessary medications. This placed residents at risk for unnecessary medication administration. Findings include: 1. Resident 24 admitted to the facility in 2023 with diagnoses including dementia and mood disorder. The 4/26/24 pharmacist recommendation indicated the following: -Resident 24 received Abilify (an antipsychotic medication) 10 mg daily since 5/13/23. -Centers for Medicare and Medicaid Services (CMS) guidelines require that gradual dose reductions be attempted in two separate quarters (with at least one month between the attempts) during the first year; then annually thereafter, unless clinically contraindicated. Please assess if resident is a candidate for GDR for the medications. -CMS requires written rationale when declining pharmacist recommendations. Resident 24's pharmacy recommendation was signed by the physician on 5/15/24 and indicated no change to the medication. No…

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 interview and record review it was determined the facility failed to attempt gradual dose reductions (GDRs) for 1 of 5 sampled residents (#3) reviewed for medications. This placed residents at risk for unnecessary psychotropic medications. Findings include: Resident 3 admitted to the facility in 2012 with diagnoses including anxiety disorder. The 4/12/24 physician order indicated Resident 3 received clonazepam (medication used for anxiety) 0.5 mg BID for anxiety disorder. On 5/15/24 the clinical record was reviewed and indicated Resident 3 received clonazepam 0.5 mg twice daily since 4/29/23. The 4/26/24 pharmacist recommendation indicated the following: -Resident 3 received clonazepam 0.5 mg twice daily since 4/29/23. -Centers for Medicare and Medicaid Services (CMS) guidelines require that gradual dose reductions be attempted in two separate quarters (with at least one month between the attempts) during the first year; then annually thereafter, unless clinically contraindicated. Please assess if resident is a candidate for GDR for the medications. -CMS requires written…

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 interview and record review it was determined the Medical Director did not have meaningful participation in the QAPI (Quality Assessment and Performance Improvement) program for 1 of 1 QAPI team reviewed for QAPI. This placed residents at risk for lack of Medical Director oversight of all resident care policies in the facility. Findings include: Review of the August 2023, September 2023, October 2023 and November 2023 QAPI Attendance Records revealed the Medical Director did not attend the QAPI meetings. On 12/7/23 at 12:17 PM Staff 1 (Administrator) stated the current Medical Director took over in July 2023, had struggled to attend the QAPI meetings and had not attended any meeting since he entered the role of Medical Director.

Based on interview and record review it was determined Staff 1 (Administrator) failed to implement written policies and prevent further incidents of staff abuse of residents when repeatedly notified of concerns for 2 of 2 sampled residents reviewed for abuse and nine unsampled residents. The repeated failure to investigate allegations of abuse resulted in residents being exposed to mental, physical and verbal abuse and manipulation which placed the residents at risk for a decline in their overall physical, mental and psychological well-being. Findings include: 1a. On 12/3/23 Resident 2 sustained physical, mental and verbal abuse by Staff 3 (RN) . Staff 1 was notified of the allegation did not fully investigate the incident, did not take immediate action to prevent further abuse and did not report the abuse to the State Agency. On 12/6/23 at 4:15 PM and 7:16 PM Staff 1 stated he was notified of the abuse allegation when he arrived at work at 8:00 AM (15.5 hours after the incident) verified the resident refused the care which Staff 3 forced upon her/him but did not get hurt. Staff 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.

Based on interview and record review it was determined the facility failed to thoroughly investigate allegations of abuse for 2 of 3 sampled residents (#s 1 and 2) reviewed for abuse. This placed residents at risk for increased risk of physical, mental and verbal abuse. Findings include: 1. Resident 2 admitted to the facility in 5/2023 with COPD (chronic obstructive pulmonary disease), hemiplegia (paralysis on one side) and multiple cancer diagnoses. Resident 2 was on end of life, comfort care measures. The 12/3/23 Written Statements of Staff 5 (CNA) and Staff 6 (CNA) revealed on 12/3/23 around 4:30 PM Resident 2 refused oral care from Staff 5. Staff 5 informed Staff 3 (RN) who went to the room and decided a bed bath was needed. The resident said no, Staff 3 did not honor Resident 2's refusal and called Staff 6 to bring bed bath supplies into the room and to assist. The resident repeatedly said no, resisted care, clenched her/his legs, grabbed the bed rail and glared at Staff 3. Staff 3 instructed Staff 5 and Staff 6 to assist by unclenching her/his legs and to get her/his hand off…

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 it was determined the facility failed to ensure call lights were answered timely on 3 of 3 halls reviewed for call light response time. This placed residents at risk for unmet needs. Findings include: 1. On 12/9/19 at 8:15 AM Staff 1 (Administrator) indicated the facility used a call light system which allowed triggered call lights to appear on a hand held device used by facility staff and displayed on a monitor located at the nurses station. Observations on 12/10/19 at 8:57 AM, 9:22 AM, 1:55 PM and 4:10 PM found the monitor tablet to be missing from the display case at the nurses' station. Evening staffing observations of call light response times on 12/11/19 at 6:38 PM found the following: - room [ROOM NUMBER]'s call light was on at 6:16 PM. At 6:49 PM the resident stated she/he was soiled with urine and had been waiting for staff to respond to her/his call light so she/he could be changed. Staff 10 (CNA) was observed to have responded to the call light at 7:03…

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 provide a clean and sanitary environment for 1 of 1 kitchen reviewed for sanitation. This placed residents at risk for unsanitary food preparation surfaces. Findings include: On 12/9/19 at 7:53 AM during the initial kitchen observation vents in the ceiling over food prep area, refrigerator, and tray line were dirty, dusty, with hanging cobwebs. Dark colored buildup of dirt and debris was observed in corners of kitchen, between appliances and against the walls. On 12/12/19 at 8:14 AM the kitchen was toured with Staff 20 (Dietary Manager) and the areas of concern were reviewed. Staff 20 confirmed the three ceiling vents, corners of kitchen and areas between appliances needed to be cleaned.

Based on interview and record review it was determined the facility failed to obtain informed consent prior to initiating therapy with antipsychotic medication for 1 of 5 residents reviewed for psychotropic medication (#11). This placed residents or their representatives at risk of making uninformed decisions. Findings include: Resident 11 was admitted to the facility in 10/2019 with diagnoses including Alzheimer's dementia with behavioral disturbance. The resident had significant cognitive impairment as measured by a BIMS score of 2. (A score of 15 indicates cognitively intact with no memory impairment.) According to Physician orders dated 10/9/19, the resident was prescribed Seroquel (an antipsychotic drug) to treat behaviors/delirium related to Alzheimer's. On 10/25/19 the physician ordered Haldol (an antipsychotic drug) once a day PRN for 14 days for agitation. The Haldol was re-ordered every 14 days through 12/11/19, following an assessment by the physician. The SNF Psychotherapeutic Medication Disclosure and Consent dated 10/10/19 was signed by Resident 11 and indicated…

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 it was determined the facility failed to ensure timely completion of MDS assessments for 2 of 7 sampled residents (#s 29 and 143) reviewed for medication and nutrition. This placed residents at risk for unassessed needs. Findings Include: The MDS 3.0 RAI Manual stated: The MDS completion date (Item Z0500B) must be no later than day 14. This date may be earlier than or the same as the CAA(s) completion date, but not later than. The CAA(s) completion date (Item V0200B2) must be no later than day 14. 1. Resident 143 was admitted to the facility on [DATE]. On 12/12/19 Resident 143's admission MDS dated [DATE] was incomplete. The admission MDS was signed 12/10/19, 22 days after admission. CAAs were incomplete and not signed, 24 days after admission. On 12/12/19 at 2:09 PM Staff 8 (RCM) confirmed Resident 140's admission MDS was incomplete. 2. Resident 29 admitted to the facility on 9/2019. Review of Resident 29's Annual MDS dated [DATE], revealed the CAAs were not completed and…

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

Based on interview and record review it was determined the facility failed to develop a resident centered baseline care plan for 1 of 3 sampled residents (#140) reviewed for accidents. This placed residents at risk for unmet needs. Findings include: Resident 140 was admitted to the facility in 12/2019 with diagnoses including dementia, Alzheimer's disease and history of falls. The 12/5/19 admission Data Base nursing assessment identified Resident 140 at high risk for falls, had poor safety judgement and dementia with poor memory recall. Review of Resident 140's health record revealed a baseline care plan was developed on 12/5/19 but was not individualized to the resident. The fall interventions were to remind her/him of the call light, keep call light and person items in reach and wear non-skid socks. On 12/12/19 at 11:38 AM Staff 7 (RNCM) stated a baseline care plan was developed for Resident 140 with standard interventions used for all residents and was not individualized for Resident 140. On 12/12/19 at 3:40 PM Staff 2 (DNS) acknowledged Resident 140's baseline care plan was not…

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

Based on observation, interview and record review it was determined the facility failed to implement a comprehensive care plan related to falls for 2 of 3 sampled residents (#s 13 and 140) reviewed for accidents and hydration. This placed residents at risk for unmet needs. Findings include: 1. Resident 13 was admitted to the facility in 4/2016 with diagnoses including epilepsy (neurological disorder) and absence of right leg below the knee. Record review revealed Resident 13 had a fall from her/his bed on 10/17/19. Resident 13's care plan had a fall intervention for when the resident was in bed, staff were to provide a fall mat on the floor, at bedside, for the length of the bed and in the head to toe direction. Resident 13 was observed in bed with no fall mat on the floor, for the length of the bed and in the head to toe direction on the following dates: - 12/10/19 at 1:47 PM; - 12/10/19 at 3:48 PM; - 12/11/19 at 7:46 AM; - 12/11/19 at 1:39 PM; - 12/11/19 at 7:10 PM; - 12/12/19 at 9:02 AM; - 12/12/19 at 1:56 PM. On 12/12/19 at 10:46 AM, Staff 18 (CNA) confirmed Resident 13's fall…

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 interview and record review it was determined the facility failed to revise a resident's plan of care with preventative measures related to new onset pressure injury for 1 of 2 residents (#11) reviewed for pressure ulcers. This placed residents at risk for delayed treatment and healing. Findings include: Resident 11 was admitted to the facility in 10/2019 with diagnoses including diabetes, pressure related ulcers on toes and hip fracture. Nursing notes dated 12/8/19 identified new onset of an area of skin impairment on the resident's left heel. The wound was identified as a deep tissue injury (DTI). The resident's comprehensive care plan dated 10/15/19 and revised 10/30/19, identified actual impairment to skin integrity of the left great toe related to pressure. Interventions included enhanced nutrition, weekly wound monitoring, daily treatment and to encourage frequent position changes. No revisions were made to the care plan when the resident developed a new pressure related wound on her/his heel on 12/8/19. On 12/12/19 at 7:41 AM Staff 8 (RCM) confirmed he did not add…

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 it was determined the facility failed to promptly determine a cause and develop new interventions to address a pressure related skin injury and failed to follow the plan of care with documented evidence of weekly skin checks for 1 of 2 sampled residents (#11) reviewed for pressure ulcers. This placed residents at risk for further injury and delayed healing. Findings include: Resident 11 was admitted to the facility in 10/2019 with diagnoses including diabetes, peripheral neuropathy, surgical repair of a left hip fracture and pressure ulcers on toes. According to the admission MDS dated [DATE], Resident 11 required extensive assistance from two staff for bed mobility and transfers. She/he had two unstageable pressure ulcers on bilateral great toes, present upon admission to the facility, and was at risk for developing additional pressure ulcers. Resident 11's comprehensive care plan dated 10/15/19 and revised 10/30/19, identified actual impairment to skin…

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 it was determined the facility failed to ensure the resident's record reflected ongoing assessment of the resident's respiratory status, response to oxygen therapy, and the attending practitioner's orders and indication for use of supplemental oxygen for 1 of 2 sampled residents (#140) reviewed for respiratory care. This placed residents at risk for respiratory distress. Findings include: Resident 140 was admitted to the facility on [DATE] with diagnoses including dementia and hypertension. Resident 140 was observed to have oxygen administered by nasal cannula (tube) on 12/10/19 at 9:18 AM, 1:50 PM and 3:59 PM. Record review revealed no evidence of an assessment of Resident 140's respiratory status nor care plan to identify the interventions for oxygen therapy. No documentation of an order for oxygen use prior to 12/11/19 was found. On 12/12/19 at 3:50 PM Staff 2 (DNS) was informed Resident 140 was observed on 12/10/19 with oxygen and no physician order,…

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.