Fernhill Rehabilitation And Care

Based on observation, interview and record review it was determined the facility failed to obtain vision services for 1 of 1 sampled resident (#41) reviewed for vision. This placed residents at risk for not adequately addressing vision related needs. Findings include:The facility's Care of the Visually Impaired Resident policy, dated 3/2021, indicated it was the facility's responsibility to assist the resident and representatives in locating available resources, scheduling appointments and arranging transportation to obtain needed services. Resident 41 was admitted to the facility in 4/2020 with diagnoses including a stroke and diabetes. A 3/4/25 Ocular (related to the eyes) Progress Note completed by the facility optometrist (an eye care specialist) indicated Resident 41 was referred to a retina specialist (a medical doctor specializing in the diagnoses and treatment of eye diseases and conditions) on 2/1/24 but the resident was not seen by a specialist. Recommendations instructed the facility to follow-up regarding Resident 41's 2/1/24 referral because the resident reported 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 obtain dental services for 1 of 1 sampled resident (#41) reviewed for dental services. This placed residents at risk for unaddressed dental care needs. Findings include:The facility's Dental Services policy, dated 3/2021, indicated the following: -The social services representative would assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible. -All dental services provided were recorded in the resident's medical record. Resident 41 was admitted to the facility in 4/2020 with diagnoses including a stroke and diabetes. Resident 41's 4/13/25 Annual MDS indicated the resident had no cognitive impairments. Resident 41's 5/19/25 oral/dental health care plan indicated the resident was missing her/his top teeth and the majority of her/his lower teeth. Interventions included coordinating arrangements for dental care and transportation as needed/ordered. A review of Resident 41's electronic record revealed no evidence…

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 a resident did not elope for 1 of 3 sampled residents (#1) reviewed for elopement. This placed residents at risk for injury. Findings include: Resident 1 admitted to the facility in 5/2024 with a mental health diagnosis. A 5/13/24 hospital Discharge Summary revealed Resident 1 experienced houselessness for more than 40 years and was diagnosed with a mental health condition several decades earlier. Resident 1's mental health was stable until she/he refused to take all medications. Resident 1's cognition was not able to be assessed due to her/his polite refusal to answer most questions. Resident 1's Care Plan revised on 4/23/25 revealed she/he was at risk for elopement. Interventions included staff were to monitor the resident regularly, staff were to redirect, offer foods and fluids, and provide activities during Resident 1's episodes of wandering or exit seeking. Staff were also to provide 1:1 supervision until the exiting behavior resolved. Resident 1's 5/20/25 Elopement Risk Evaluation revealed…

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 protect the resident's right to be free from physical abuse for 1 of 3 sampled residents (#6) reviewed for abuse. This placed residents at risk for abuse. Resident 7 was admitted to the facility in 5/2024, with diagnoses including acute pancreatitis (a condition that inflames the pancreas) and alcohol induced disorder (a condition that triggers mood disorders due to alcohol consumption). A Behavioral Care Plan was initiated on 6/14/24 and revised on 9/12/24, which indicated Resident 7 had a history of problematic manner which were characterized through abusive language, and threats due to a history of alcohol dependence. Staff were directed to remove other residents away from Resident 7 should she/he become aggressive or initiate verbal altercations with residents or staff. In addition, care staff were instructed to remove Resident 7 from the area and provide low stimulus activities and or to leave Resident 7 in a safe area and reapproach again later. Resident 6 was admitted to the facility in 5/2024, with…

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 residents were free from significant medication errors for 1 of 3 sampled residents (#2) reviewed for medications. This placed residents at risk of adverse side effects for lack of medication administration. Findings include: Resident 2 was admitted to the facility in 2/2024, with diagnoses including atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Resident 2's 2/14/24 Physician orders revealed the resident was to receive 5 mg of apixaban (an anticoagulant medication which thins the blood) twice a day for atrial fibrillation. On 8/29/24 the State Survey Agency received a public complaint, which alleged Resident 4 did not receive her/his medication for three days following a hospitalization and re-admission to the facility. The complainant stated the resident called her on Tuesday, 8/27/25 stating she/he had a headache and had not received her/his medication since returning from 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 the plan of care for 1 of 3 sampled residents (#1) reviewed for resident safety and elopement. This placed residents at risk of an unsafe elopement. Findings include: Resident 1 admitted to the facility in 5/2024, with diagnoses including schizophrenia and dementia. Resident 1's 8/23/24 MDS Quarterly revealed a BIMS score of 0, indicating severe cognitive impairment. An elopement risk evaluation dated 8/23/24, revealed Resident 1 was a high elopement risk and she/he frequently stood by the entrance door, stating she/he wanted to leave. Resident 1's care plan dated 10/15/24 revealed she/he was an elopement risk/wanderer with a history of attempts to leave the building unattended and she/he had impaired safety awareness. Interventions were to distract the resident by offering diversions, activities, food, conversation, television or a book. On 12/3/24 at 11:39 AM, Staff 10 (CNA) stated she was Resident 1's assigned CNA. She stated staff was aware to watch the resident from leaving and…

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

Based on observation, interview, and record review it was determined the facility failed to provide adequate supervision and failed to thoroughly evaluate and analyze an elopement for 1 of 3 sampled residents (#1) reviewed for elopement. This placed residents at risk for an unsafe elopement. Findings include: a. Resident 1 was admitted to the facility in 5/2024, with diagnoses including schizophrenia and dementia. Resident 1's 8/23/24 Quarterly MDS revealed a BIMS score of 0, which indicated severe cognitive impairment. An elopement risk evaluation dated 8/23/24 revealed Resident 1 was a high elopement risk and she/he frequently stood by the entrance door, stating she/he wanted to leave. Resident 1's most recent care plan dated 10/15/24 revealed she/he was an elopement risk/wanderer with a history of attempts to leave the facility unattended and she/he had impaired safety awareness. Interventions were to distract the resident by offering diversions, activities, food, conversation, television or a book. On 11/25/24 the facility submitted a Facility Reported Incident (FRI) report 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 observation and interview it was determined the facility failed to provide a comfortable, clean and homelike environment for 1 of 1 dining/activity room and 1 of 1 resident lounge reviewed for environment. This placed residents at risk for an unsatisfying meal and activity experience and living in an institutionalized environment. Findings include: On 3/18/24 at 11:20 AM a resident was observed to sit with a staff member in the resident lounge. They were seated at the table and were surrounded by the following items: -Three mechanical lifts. -Rolling maintenance cart with a hammer and drill on top. -Crash cart (emergency medical equipment). -Lamp. -Large box with containers of disinfectant wipes. -Large weight scale. -Utility ladder. -Empty opened cardboard TV box. -PPE (personal protective equipment) three drawer containers. On 3/18/24 at 11:52 AM the dining/activity room was observed to contain a mechanical lift, a large motorized wheelchair with a tear in the head piece and a worn resident mattress up against the wall. On 3/18/24 at 3:28 PM Staff 1 (Administrator)…

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 residents were referred to the appropriate state-designated authority for a Level II PASARR evaluation (evaluation for individuals with a mental disorder) for 4 of 4 sampled residents (#s 9, 14, 18 and 34) reviewed for PASARRs. This placed residents at risk for not receiving specialized mental health services. Findings include: 1. Resident 9 was admitted to the facility in 6/2023 with diagnoses including Post-Traumatic Stress Disorder (mental condition which makes it difficult to recover from a terrifying event) and schizophrenia (serious mental condition with breakdowns in thoughts, emotions, and behaviors). A review of Resident 9's Electronic Health Record at the time of the survey revealed there was no Level Il PASARR present. In an interview on 3/21/24 at 3:15 PM Staff 22 (Social Services) stated she was aware of Resident 9's mental health diagnoses and challenging behaviors. She confirmed Resident 9 did not have a Level ll PASARR evaluation or referral for an evaluation completed. On 3/22/24 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 observation, interview and record review, it was determined the facility failed to provide an ongoing program to support individual activity interests and preferences for 3 of 4 sampled residents (#s 9, 13 and 19) reviewed for activities. This placed residents at risk for unmet psychosocial needs and diminished quality of life. Findings include: 1. Resident 19 was admitted to the facility with diagnoses including hemiplegia (paralysis on one side of the body). Resident 19's 11/5/23 Annual MDS revealed the resident's cognition and activity preferences were not assessed. Resident 19's 11/15/23 Activities Care Plan revealed a goal to participate in three activities every week. The interventions included the following: - give the resident verbal reminders of activities before commencement of the activity. - enjoy conversing about family, history, places to travel. - enjoy bingo, special events/entertainment, music appreciation, movies/documentaries/Ted Talks, book club, spa day, wheeling outdoors and sitting in the sun, listening to music, watching television/news/movies/talk…

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 food was flavorful, palatable, attractive and served at an appetizing temperature for 3 of 3 sampled residents (#s 10, 196 and 246) reviewed for food. This placed residents at risk for diminished nutrition and quality of life. Findings include: 1. Resident 10 was admitted to the facility in 4/2020 with diagnoses including quadriplegia (paralysis). On 3/18/24 at 10:47 AM Resident 10 stated the food could be better and stated the food was cold when served. On 3/18/24 at 12:23 PM Resident 10 was served lunch which consisted of an unidentified shredded meat, green beans, rice, a dinner roll and milk. Resident 10 stated he did not like the food and it was cold. 2. On 5/26/23 a public concern was reported to the State Agency which alleged Resident 196's food was always cold. Resident 196 no longer resided at the facility. 3. Resident 246 was admitted to the facility in 3/2024 with diagnoses including depression. The 3/9/24 Food and Nutrition admission Interview indicated Resident 246 was on 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 interview and record review it was determined the facility failed to ensure snacks were available at non-traditional times or outside of scheduled meal service times for 1 of 1 kitchen and 1 of 4 sampled residents (#246) reviewed for food. This placed residents at risk for unmet nutritional needs. Findings include: 1. During the Resident Council meeting on 3/21/24 at 11:30 AM, the residents reported the lack of snack availability. The residents stated the snacks often ran out and staff told them the kitchen was locked and closed, therefore no snacks were available. Residents reported they obtained their own snacks due to hunger. Residents reported snacks were better this week because you are here. We have complained but nothing really changes. Record review of the Resident Grievance Forms for 2/2024 and 3/2024 revealed resident complaints about the lack of snack availability on 2/15/24, 3/8/24, 3/13/24 and twice on 3/14/24. On 3/21/24 between the hours of 5:30 AM to 4:00 PM Staff 24 (CNA) stated she/he recalled many shifts where snacks were limited and not always available…

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's quality assessment and performance improvement committee (QAPI) failed to systematically identify and correct deficiencies in the areas of abuse, completing assessments, care plan revisions, activities of daily living, activities meeting resident's needs and preferences, range of motion and mobility and medication error rates. This placed residents at risk of abuse, unassessed care needs, inaccurate care plans, unmet hygiene needs, reduced quality of life, reduced mobility and increased pain and adverse medication side effects. Findings include: The facility's 4/2014 Quality Assurance and Performance Improvement (QAPI) Plan indicated the following: -The QAPI committee shall establish and implement plans to correct deficiencies and to monitor the effects of these action plans on resident outcomes. The facility's 3/22/24 survey identified the following: 1. The facility failed to protect the resident's right to be free from physical abuse. This deficiency was also identified on the 12/20/22 survey. Refer to F600. 2.…

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 residents were treated in a dignified manner for 1 of 1 sampled resident (#23) reviewed for dignity. This placed residents at risk for decreased quality of life. Findings include: Resident 23 was admitted to the facility in 2/2024 with diagnoses including bipolar disorder (mental condition with mood swings). A 2/14/24 admission MDS indicated Resident 23 had normal cognitive function. A 3/15/24 Resident Grievance Form reported Resident 23 stated she/he was awakened by Staff 20 (CNA) on 3/14/24 with her hands down her/his pants, checking to see if she/he needed a brief change. Resident 23 stated she/he did not provide permission and was not sure what Staff 20 was doing at the time of the incident. On 3/21/24 at 12:03 PM Resident 23 stated she/he was asleep during the incident and was uncomfortable because [she/he] woke up with [Staff 20's] hands down my pants. Resident 23 stated she/he felt slightly apprehensive during the night for the following few days but the discomfort has since resolved. On…

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

Based on observation, interview, and record review it was determined the facility failed to assess a resident's ability to self-administer medications for 1 of 1 sampled resident (#12) reviewed for self-administration of medications. This placed residents at risk for adverse side effects. Findings include: Resident 12 was admitted to the facility in 7/2023 with diagnoses including chronic respiratory failure. An 8/1/23 physician order instructed albuterol (respiratory inhaler) was to be administered to Resident 12 by a clinician as needed every four hours. On 3/18/24 at 10:27 AM an albuterol inhaler was observed on Resident 12's table. Resident 12 stated the inhaler was left in her/his room and she/he used the inhaler independently as needed. On 3/19/24 at 12:45 PM Staff 5 (LPN Care Manager) stated a resident needed to be assessed prior to being allowed to self-administer any medication. Staff 5 confirmed Resident 12 was not assessed for self-administration of the albuterol inhaler and should not have had the inhaler left at her/his bedside until she/he was determined to be safe for…

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

Based on interview and record review it was determined the facility failed to support a resident's choice to smoke for 1 of 4 sampled residents (#31) reviewed for choices. This placed residents at risk for lack of self-determination. Findings include: The facility's undated Smoking Policy indicated the following: -The facility was to safely accommodate residents who choose to smoke. -A smoking assessment was completed for residents who wanted to smoke and determined if a resident was an independent smoker, or if they required staff supervision or assistance during smoking sessions. Resident 31 was admitted to the facility in 6/2023 with diagnoses including quadriplegia (partial or complete paralysis of both the arms and legs). Resident 31's 1/6/24 Quarterly MDS indicated the resident experienced upper extremity impairment on both sides of her/his body. Resident 31's 1/29/24 Smoking Assessment indicated the following: -The resident did not have cognitive loss. -The resident required a staff member to place a cigarette into her/his mouth and light it. -The resident was able to hold…

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

Based on observation and interview it was determined the facility failed to ensure a resident's privacy was maintained for 2 of 2 sampled residents (#s13 and 23) reviewed for privacy. This placed residents at risk for loss of dignity and privacy. Findings include: 1. Resident 13 was admitted to the facility in 4/2023 with diagnoses including paraplegia (paralysis that affects all or part of the trunk, legs and pelvic organs). Resident 13's 4/28/23 admission MDS indicated the resident was cognitively intact. On 3/18/24 at 12:07 PM Staff 4 (LPN) entered Resident 13's room without knocking. On 3/18/24 at 12:10 PM Resident 13 stated staff entered her/his room without knocking all the time. Resident 13 further stated only a few staff knock before entering and the rest just burst in. On 3/21/24 at 10:15 AM Staff 1 (Administrator) stated he expected staff to knock and introduce themselves prior to entering a resident room. 2. Resident 23 was admitted to the facility in 2/2024 with diagnoses including metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the…

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

Based on interview and record review it was determined the facility failed to ensure resident funds were not used for unauthorized purchases for 1 of 4 sampled residents (#10) reviewed for choices. This placed residents at risk for misappropriation of money. Findings include: Resident 10 was admitted to the facility in 4/2020 with diagnoses including quadriplegia (paralysis). Resident 10's Profile Sheet indicated she/he was her/his own financial responsible person. Resident 10's 1/19/23 and 1/20/24 Quarterly MDS assessments revealed the resident had a BIMS of 12, which indicated moderate cognitive impairment. Review of the 1/27/23 Statement of Goods and Services Selected (receipts) for the cremation and monument space had, what appeared to be, three different signatures on the first page. One signature was a scribble and not legible, the others were Staff 34's (Former Social Services Director) and Staff 17's (Business Office). Resident 10's Trust Fund Account revealed two checks were issued on 1/27/23. One check in the amount of $2,185.00 was for cremation and another check in the…

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

Based on interview and record review it was determined the facility failed to comprehensively assess residents for 3 of 10 sampled residents (#s 9, 14 and 19) reviewed for medications, skin conditions and activities. This placed residents at risk for unassessed and unmet needs. Findings include: 1. Resident 14 was admitted to the facility in 5/2021 with diagnoses including dementia. Resident 14's 7/15/23 Annual MDS revealed the resident was not assessed for pain. On 3/21/24 at 10:54 AM Staff 1 (Administrator) and Staff 3 (Regional Nurse Consultant) were notified of the findings of this investigation and acknowledged Resident 14's assessment was incomplete. 2. Resident 19 was admitted to the facility with diagnoses including hemiplegia (paralysis on one side of the body). Resident 19's 11/5/23 Annual MDS revealed the resident was not assessed for cognition and preferences. On 3/21/24 at 10:54 AM Staff 1 (Administrator) and Staff 3 (Regional Nurse Consultant) were notified of the findings of this investigation and acknowledged Resident 19's assessment was incomplete. 3. Resident 9 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 interview and record review it was determined the facility failed to ensure MDS assessments were coded accurately for 2 of 2 sampled residents (#s 22 and 31) reviewed for hospice services (specialized care for people near end of life) and hospitalization. This placed residents at risk for inaccurate assessments. Findings include: 1. Resident 22 was admitted to the facility in 2/2022 with diagnoses including dementia. On 10/22/23 Resident 22 was referred to hospice services. On 11/3/23 the facility met with hospice services for Resident 22. Resident 22's 11/21/23 Significant Change of Condition MDS indicated she/he did not have a disease that may result in a life expectancy of less than six months (hospice services). On 3/22/24 at 11:04 AM Staff 3 (Regional Nurse Consultant) confirmed the MDS was inaccurate for Resident 22. 2. Resident 31 was admitted to the facility in 6/2023 with diagnoses including quadriplegia (partial or complete paralysis of both the arms and legs). A review of Resident 31's weights revealed the resident weighed 250 pounds on 12/5/23 and 231 pounds on…

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

Based on interview and record review it was determined the facility failed to develop a person-centered care plan for activities for 1 of 4 sampled residents (# 9) who were reviewed for activities. This placed residents at risk for unmet care needs. Findings include: Resident 9 was admitted to the facility in 6/2023 with diagnoses including a stroke. Record review revealed Resident 9's Activities admission Assessment was completed on 12/12/23. The assessment revealed Resident 9 enjoyed playing basketball with the moveable hoop with a foam basketball, talking about food and places she/he wanted to go, and listening to music such as Rhythm and Blues and the Temptations. Resident 9's revised 2/21/24 Activities Care Plan identified the resident was an elopement and/or wandering risk. The goal was to keep her/him safe. The interventions directed staff that activities staff were to keep Resident 9 busy when she/he was exit seeking. Staff were to attempt music distraction or conversation about her/his life. If the resident grabbed the staff, staff were to talk quietly and if she/he started…

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 care plans were revised to accurately reflect the needs of residents for 1 of 2 sampled residents (#35) reviewed for care plans. This placed residents at risk for unmet needs. Findings include: Resident 35 was admitted to the facility in 9/2023 with diagnoses including stroke. Resident 35's 10/11/23 admission MDS indicated the resident had no cognitive impairments. Resident 35's 1/11/24 Quarterly MDS indicated the resident had no inattention or concerns with disorganized thinking and Resident 35 was always continent of bowel and bladder. Resident 35 ate meals and completed oral care independently, toileted, which included emptying her/his colostomy bag (a small pouch used to collect bowel contents), without assistance and dressed and completed all of her/his own personal hygiene care. Resident 35 was able to walk independently using a walker. Resident 35's current care plan indicated the following: -Resident 35 had a cognitive impairment so staff were to ask Resident 35 yes and 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 ensure residents received showers for 1 of 6 sampled residents (#31) reviewed for ADLs. This placed residents at risk for unmet hygiene needs. Findings include: Resident 31 was admitted to the facility in 6/2023 with diagnoses including quadriplegia (partial or complete paralysis of both the arms and legs). Resident 31's 6/30/23 admission MDS indicated the resident was cognitively intact and experienced upper and lower extremity impairment on both sides of her/his body. Resident 31's 2/19/24 Care Plan revealed the resident was totally dependent on staff for all ADLs and her/his shower days were Tuesday and Friday evenings. A review of Resident 31's 3/2024 Bathing Task revealed the following: -3/1/24: refused -3/12/24: refused -3/15/24: accepted No evidence was found in Resident 31's clinical record to indicate the resident was offered a shower between 3/2/24 and 3/11/24. There was no evidence to indicate Resident 31 was re-offered a shower when the resident was documented to have refused. On 3/18/24 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 interview and record review it was determined the facility failed to follow physician orders for 3 of 7 sampled residents (#s 6, 10 and 26) reviewed for medications, change of condition and dialysis. This placed residents at risk for unmet care needs and illness. Findings include: 1. Resident 10 was admitted to the facility in 4/2020 with diagnoses including quadriplegia (paralysis). On 3/18/24 at 10:44 AM Resident 10 stated she/he asked for the shingles vaccine several times over the past two months and she/he had not received the vaccine. Review of Resident 10's Physician Orders revealed the following order dated 1/19/24: - Shingrix Intramuscular Suspension Reconstituted 50 MCG/0.5ML (shingles vaccine), Inject one dose intramuscularly one time only for vaccine. Resident 10's health record revealed no evidence the resident received the shingles vaccine. On 3/20/24 at 10:57 AM Staff 2 (DNS) reviewed Resident 10's health record and acknowledged the 1/19/24 Physician Order for the shingles vaccine. Staff 2 confirmed Resident 10 did not receive the vaccine as ordered. 2.…

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 appropriate treatment and services to prevent a potential decrease in range in motion for 1 of 2 sampled residents (#31) reviewed for position and mobility. This placed residents at risk for worsening contractures (a permanent tightening of the muscle, tendons and skin causing the joint to shorten and stiffen) and conditions. Findings include: Resident 31 was admitted to the facility in 6/2023 with diagnoses including quadriplegia (partial or complete paralysis of both the arms and legs). Resident 31's 6/30/23 admission MDS indicated the resident was cognitively intact and experienced upper and lower extremity impairment on both sides of her/his body. Resident 31's 12/7/23 through 12/22/23 PT Discharge Summary indicated the resident needed to be placed on an RA program. Resident 31's 2/19/24 Care Plan revealed the following: -The resident was totally dependent on staff for all ADLs. -The resident had a passive ROM/stretching program for her/his bilateral (involving both sides) upper…

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 the environment was free of potential accident hazards and the facility failed to ensure assistive devices were in safe operating condition to prevent accidents for 2 of 4 sampled residents (#s 7 and 9) reviewed for accidents. This placed the residents at risk for potential accidents. Findings include: 1. Resident 9 was admitted to the facility in 6/2023 with diagnoses including a stroke. Resident 9's 7/5/23 admission MDS revealed she/he had severe cognitive impairment. A 1/9/24 SNF Morse Fall Scale (Skilled Nursing Facility method to assess a person's likelihood for falls) assessed Resident 9 at a score of 75.0 (high risk). Resident 9's 3/19/24 care plan indicated she/he had fallen in the past, was at risk for future falls and often pulled her/himself out of bed. Multiple observations were made of Resident 9 lying in her/his bed on 3/19/24 through 3/21/24 between the hours of 5:15 AM and 3:55 PM. Fall mats were on the floor on both sides of her/his bed. On 3/19/24 at 12:06 PM Resident 9's bed 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 provide appropriate and timely pain management for 1 of 1 sampled resident (#40) reviewed for pain. This placed residents at risk for unresolved pain. Findings include: Resident 40 was admitted to the facility in 12/2023 with diagnoses including stroke and anxiety. A 12/25/23 physician order directed staff to administer acetaminophen (mild pain medication) 1000mg one tablet 3 times a day for mild pain. Resident 40's Care Plan, initiated 12/25/23 and revised 1/8/24, directed staff she/he experienced pain. Staff were to administer medications as ordered and monitor for side effects. Staff were to use non-pharmaceutical interventions, such as a warm or cold pack, prior to administering PRN medications. A 12/29/23 physician order directed staff to administer Oxycodone (pain medication) 5mg one tablet every four hours PRN. Resident 40's 1/3/24 admission MDS revealed the resident's cognition was not assessed, she/he used pain medication routinely to include PRN pain medication, no non-pharmaceutical…

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 communication occurred between the facility and the dialysis provider for 1 of 1 sampled residents (#26) reviewed for dialysis. This placed residents at risk for delayed treatment. Findings include: The facility's 9/2010 End-Stage Renal Disease, Policy and Procedure revealed the following: Education and training of staff includes: -The type of assessment data that was to be gathered about the resident's condition on a daily or per shift basis. -How information will be exchanged between the facilities. Resident 26 was admitted to the facility in 2024 with diagnoses including end-stage renal disease. A 12/19/23 Physician Order revealed Resident 26 received dialysis three days per week. A 2/29/24 Physician Order instructed the facility to send Dialysis Communication Binder with the resident and to collect it upon return. Staff were to fill out the top of the form before dialysis and the bottom of the form when the resident returned from dialysis. A review of Resident 26's Dialysis…

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 medication pass error rate of less than 5%. There were three errors in 32 opportunities resulting in an 9.38% error rate. This placed residents at risk for adverse medication side effects. Findings include: 1. Resident 296 was admitted to the facility in 3/2024 with diagnoses including paraplegia (paralysis). Resident 296's 3/2024 Physician Orders included the following: - metoclopramide (medication for gastric reflux disease) 5 mg, give one tablet by mouth two times a day at 7:00 AM and 7:00 PM. - pantoprazole (medication used to decrease stomach acid) 20 mg, give 20 mg by mouth one time a day at 7:00 AM. On 3/20/24 at 9:08 AM Staff 26 (CMA) administered Resident 296's medications which included metoclopramide 5 mg and pantoprazole 20 mg. On 3/20/24 at 11:43 AM Staff 26 reviewed the metoclopramide and pantoprazole orders and acknowledged the medications were ordered to be administered at 7:00 AM. Staff 26 stated medications were considered to be administered timely if given one hour…

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 appropriate infection control during Covid-19 testing for 2 of 2 sampled residents (#s 13 and 33) reviewed for Covid-19 testing. This placed residents at risk for inaccurate Covid-19 test results, cross-contamination and infection. Findings include: The Centers for Disease Control and Prevention's (CDC) undated [NAME] Binaxnow Covid-19 AG Card Test Helpful Testing Tips directed the following when performing an at-home nasal swab test for the purpose of detecting a Covid-19 infection: -Gloves should be changed immediately after collecting, handling and processing a new specimen. Discard used gloves in a biohazardous waste container. -Make sure to label specimens or test cards correctly to avoid record keeping issues. -Avoid cross-contamination between specimens, which includes decontaminating surfaces before processing another specimen. Resident 13 was admitted to the facility in 4/2023 with diagnoses including…

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 notify a resident's representative of a resident's hospitalization for 1 of 2 sampled residents (#96) reviewed for notification of change. This placed residents at risk of their representatives being uninformed. Findings include: Resident 96 was readmitted to the facility in 10/2023 with diagnoses including multiple sclerosis (a disorder of the central nervous system marked by weakness, numbness, a loss of muscle coordination and problems with vision, speech and bladder control). Resident 96's 1/2024 Face Sheet (a document that gives a resident's information at a quick glance) listed Witness 5 (Complainant/Sister) as the resident's power of attorney (the authority to act for another person in specified or all legal or financial matters) for care, first emergency contact and financial responsible party. A review of Resident 96's clinical record indicated the resident was hospitalized from [DATE] to 1/18/24. A 1/16/24 Late Entry Progress…

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 residents were free from abuse for 3 of 6 sampled residents (#s 16, 18, 22, 34 and 40) reviewed for abuse. This placed residents at risk for physical abuse. Findings include: 1. Resident 16 was admitted to the facility in 4/2018 with diagnoses including depression. Resident 16's 2/2/24 Quarterly MDS indicated staff assessed the resident as moderately impaired with the ability to make decisions regarding tasks of daily life and no behaviors. Resident 34 was admitted to the facility in 5/2023 with diagnoses including bipolar disorder (episodes of mood swings). Resident 34's 2/16/24 Quarterly MDS indicated a BIMS score of 14 (cognitively intact) and no behaviors. On 2/5/24 the facility submitted a FRI which indicated Resident 34 hit Resident 16 on the side of the face. The incident was reviewed on the facility video recording and both residents were engaged in the altercation. On 3/19/24 at 12:20 PM Staff 1 (Administrator) confirmed the 2/5/24 incident between Resident 34 and Resident 16 occurred. 2.…

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 have a qualified and trained Infection Preventionist in place for 1 of 1 facility reviewed for infection prevention and control. This placed residents at risk for inadequate infection control. Findings include: On 12/15/22 at 1:59 PM Staff 2 (DNS) identified herself as the Infection Preventionist for the facility, a position she stated she had held for the previous 15 months. Staff 2 stated she had not completed any specialized training in infection prevention and control and was only recently made aware of the training requirement for this position. On 12/20/22 at 9:20 AM Staff 1 (Administrator) confirmed Staff 2 had not completed any specialized training in infection prevention and control.

Based on observation, interview and record review it was determined the facility failed to provide adequate bathing, hygiene and grooming for 6 of 10 sampled residents (#s 5, 8, 9, 13, 15, 227) reviewed for ADLs. This placed residents at risk for unmet hygiene and grooming needs. Findings include: The facility's 3/2018 Activities of Daily Living Policy and Procedure detailed the following: - Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain grooming and personal and oral hygiene; - If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate. 1. Resident 5 was admitted to the facility in 7/2020 with diagnoses including Alzheimer's Disease. Resident 5's 3/31/22 Annual MDS indicated the resident was totally dependent on staff for bathing,…

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 a psychotropic medication consent was provided for 3 of 5 sampled residents (#s 3,18 and 21) reviewed for unnecessary medications. This placed residents at risk for being uninformed of risks and benefits of medications. Findings include: 1. Resident 3 was admitted to the facility in 4/2020 with diagnoses including Alzheimer's disease, major depressive disorder, and anxiety disorder. Review of Resident 3's health record indicated the resident was her/his own responsible party. Resident 3's 7/26/22 Quarterly MDS indicated the resident had moderate cognitive impairment. A 10/27/22 physician order included Wellbutrin ER 100 mg (psychotropic drug used to treat major depressive disorder) by mouth one time a day. A November and December 2022 MAR revealed the resident received the Wellbutrin ER daily. Resident 3's health record revealed an unsigned Consent for Use of Psychotropic Medication form, which included the risks and benefits of Wellbutrin ER. On 12/19/22 at 9:35 AM Staff 3 (LPN/Resident Care…

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 provide advance notice to residents prior to receiving a new roommate for 1 of 1 sampled resident (#7) reviewed for notification of roommate changes. This placed residents at risk for potential adjustment difficulties. Findings include: Resident 7 was admitted to the facility in 3/2022 with diagnoses including heart failure. Resident 227 was admitted to the facility on [DATE] and moved into Resident 7's room on 12/8/22. On 12/12/22 at 11:26 AM Resident 7 stated Resident 227 moved into her/his room on 12/8/22 when she/he was out of the facility at an appointment. Resident 7 stated the facility did not provide advance notice she/he was to receive a roommate. Resident 7 stated she/he was upset by this lack of notification. No information was found in Resident 7's clinical record to indicate she/he was provided advance notice about receiving a roommate. On 12/14/22 at 1:15 PM Staff 4 (SSD) stated she was responsible for notifying residents…

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 protect the resident's right to be free from physical abuse by a resident for 1 of 2 residents (#177) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 20 was admitted to the facility in 4/2018 with diagnoses including cerebrovascular accident (stroke). Resident 177 was admitted to the the facility in 3/2022 with diagnoses including dementia and communication deficits. A progress note from 5/11/22 at 11:10 PM revealed Resident 177 attempted to enter Resident 20's room. Resident 20 responded by yelling and striking Resident 177 which resulted in a .5 cm skin tear on Resident 177's forearm. On 12/14/22 at 1:28 PM Staff 12 (CNA) recalled Resident 177 was struck by Resident 20 which resulted in a skin tear. On 12/15/22 at 10:53 AM Staff 3 (LPN/Resident Care Manager) confirmed Resident 177 was struck by Resident 20 resulting in a skin tear. On 12/15/22 3:44 PM Staff 1 (Administrator) was presented with the findings. No additional information was provided.

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 residents were assessed and monitored for physical restraints for 1 of 1 sampled resident (#8) reviewed for restraints. This placed residents at risk for inappropriate use of a restraints. Findings include: The facility's 4/2017 Use of Restraints Policy & Procedure detailed the following: - Physical restraints are defined as any manual method or physical or mechanical device which restricts freedom of movement or restricts normal access to one's body; - If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition, and this restricts her/his typical ability to change position or place, that device is considered a restraint; - Examples of devices that are/may be considered physical restraints include geri-chairs; - Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including…

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 residents' communication needs and abilities and activity interests were accurately and comprehensively assessed for 1 of 4 sampled residents (#227) reviewed for communication and activities. This placed residents at risk for unmet needs. Findings include: Resident 227 was admitted to the facility in 11/2022 with diagnoses including stroke and aphasia (a language disorder affecting a person's ability to communicate). An admission MDS dated [DATE] identified Resident 227 as follows: *Section B (Hearing, Speech, and Vision) completed by Staff 3 (LPN/Resident Care Manager) indicated the resident was usually understood and usually understands; *Section D (Mood) completed by Staff 4 (Social Services Director) indicated the resident experienced minimal depression; *Section F (Preferences for customary Routine and Activities) completed by Staff 5 (Former Activity Director) indicated the resident was rarely/never…

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 care plans were revised to accurately reflect the needs of residents for 2 of 2 sampled residents (#s 8 and 77) reviewed for restraints and dialysis. This placed residents at risk for unmet needs. Findings include: 1. Resident 8 was admitted to the facility in 8/2022 with diagnoses including Parkinson's disease and dementia. Resident 8's 11/8/22 Significant Change MDS indicated the resident used a wheelchair. Observations of Resident 8 were conducted from 12/12/22 through 12/20/22 between the hours of 6:45 AM and 5:00 PM. During these observations, Resident 8 used a geri-chair (a large, padded reclining chair with solid arm rests and a wheeled base). Resident 8 was non-ambulatory and did not use a walker. Resident 8's 8/16/22 electronic health record Care Plan, section titled Person-Centered Care included the following Mobility/Transfers approaches: - Independent ambulation with supervision; - Assistive Devices: FWW…

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 provide appropriate treatment and services in the area of communication for 1 of 1 sampled resident (#227) reviewed for communication needs. This placed residents at risk for diminished quality of life and potential decline in their ability to carry out activities of daily living. Findings include: Resident 227 was admitted to the facility in 11/2022 with diagnoses including stroke and aphasia (a language disorder affecting a person's ability to communicate). Nursing progress notes from 11/30/22 and 12/2/22 stated staff were unable to understand the resident as she/he communicated in her/his native language and the resident was unable to make her/his needs known due to a language barrier. An admission MDS dated [DATE] identified the resident as usually understood and usually understands in terms of her/his communication abilities in Section B (Hearing, Speech, and Vision) completed by Staff 3 (LPN/Resident Care Manager)…

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 develop and implement a person-centered activities program for 3 of 4 sampled residents (#s 5, 9, 227) reviewed for activities. This placed residents at risk for unmet activity needs and a diminished quality of life. Findings include: 1. Resident 5 was admitted to the facility in 7/2020 with diagnoses including Alzheimer's disease. Resident 5's 6/28/22 Annual MDS Section C: Cognitive Patterns indicated the resident was moderately impaired and Section F: Preference for Customary Routine and Activities indicated the resident was rarely understood and family was not available. Resident 5's 7/1/22 Activity Assessment completed by Staff 5 (Former Activity Director) indicated the resident's general activity preferences included music and watching television. The assessment did not include information as to how the resident's preferences were obtained. Resident 5's Care Plan included the following activity-related focus areas and…

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

Based on observation, interview and record review it was determined the facility failed to ensure residents received appropriate treatment and services to increase range of motion for 1 of 2 sampled residents (#227) reviewed for rehabilitative and restorative services and to ensure residents with limited mobility received appropriate services and equipment for 1 of 2 sampled residents (#9) reviewed for position and mobility. This placed residents at risk for decline in ADL function and worsening contractures. Findings include: 1. Resident 227 was admitted to the facility in 11/2022 with diagnoses including stroke. An 11/20/22 Physical Therapy Treatment Note included in Resident 227's hospital discharge records indicated the resident tolerated increased mobility and was able to sit up in a chair. This note also indicated the resident participated in upper extremity and lower extremity weight shifting exercise. In a Progress Note dated 11/30/22 Resident 227's physician ordered skilled physical therapy and occupational therapy in order to regain enough strength and function to return…

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 respond to medication adverse consequences for 1 of 5 sampled residents (#21) reviewed for unnecessary medications. This placed residents at risk for worsening medication adverse side effects. Findings include: The facility's 4/2014 Adverse Consequences and Medication Errors Policy & Procedure specified residents receiving any medication that has a potential for an adverse consequence will be monitored to ensure that any such consequences are promptly identified and reported. An adverse consequence is defined as an unpleasant symptom or event that is due to or associated with a medication. Resident 21 was admitted to the facility in 1/2021 with diagnoses including schizophrenia. Resident 21's 1/9/22 Annual MDS and 10/7/22 Quarterly MDS indicated the resident received antipsychotic medications. Resident 21's 12/2022 physician orders included Olanzapine (antipsychotic medication which may cause symptoms such as involuntary lip smacking) and perphenazine (antipsychotic medication which may cause…

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 medication error rate of less than 5%. There were six errors in 28 opportunities resulting in a 21.43% error rate. This placed residents at risk for reduced medication efficacy and adverse medication side effects. Findings include: The Journal of Parenteral and Enteral Nutrition, dated 1/2017, section titled, Medication Delivery via Enteral Access Devices specified the following: - Administer each medication separately through an appropriate access; - Avoid mixing together different medications intended for administration through the feeding tube given the risks for physical and chemical incompatibilities, tube obstruction, and altered therapeutic drug responses. The facility's 4/2019 Administering Medications Policy & Procedure indicated medications are administered in accordance with prescriber orders. 1. Resident 9 was admitted to the facility in 11/2019 with diagnoses including Metachromatic leukodystrophy (a genetic disorder that affects nerves, muscles, organs and behavior).…

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 obtain specialized rehabilitative services for 1 of 2 sampled residents (#227) reviewed for rehabilitative and restorative services. This placed residents at risk for a decline in functional abilities and diminished quality of life. Findings include: Resident 227 was admitted to the facility in 11/2022 with diagnoses including stroke. An 11/30/22 Progress Note written by Resident 227's physician ordered skilled physical therapy and occupational therapy for the resident in order to regain enough strength and function to return to her/his previous living situation. There was no documented evidence in Resident 227's clinical record to show she/he received physical therapy and occupational therapy evaluations or treatment as ordered. On 12/15/22 at 9:57 AM Staff 3 (LPN/Resident Care Manager) stated the resident had not received any physical or occupational therapy. Staff 3 confirmed Resident 227 had orders on 11/30/22 for both physical and occupational therapy. On 12/19/22 at 11:05 AM Staff 15 (Rehab Director)…

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.

1. Based on observation, interview and record review it was determined the facility failed to properly clean and store reusable medical supplies for 2 of 2 residents (#s 9 and 227) reviewed for tube feeding equipment and medication administration. This placed residents at risk for infections. Findings include: a. Resident 9 was admitted to the facility in 11/2019 with diagnoses including malnutrition. The 10/28/22 Annual MDS revealed Resident 9 received enteral tube feeding (a tube placed directly into the stomach). The Centers for Disease Control and Prevention (CDC) website section titled, Disinfection and Sterilization specified to ensure, at a minimum, noncritical patient-care devices were disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily). On 12/12/22 at 2:18 PM a plastic piston syringe (a hand-held plunger used to administer water, tube feed formula and medications into a feeding tube) was observed lying on a piece of gauze on Resident 9's nightstand. The syringe was not dated and the tip of the syringe contained 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 interview and record review it was determined the facility failed to ensure residents or their representatives were provided education regarding the benefits, risks and potential side effects of the pneumococcal immunization and provided the opportunity to accept or decline pneumococcal vaccinations for 2 of 5 sampled residents (#s7 and 13) reviewed for immunizations. This placed residents at risk for making uninformed healthcare decisions and not being protected against pneumococcal disease. Findings include: 1. Resident 7 was admitted to the facility in 3/2022 with diagnoses including heart failure. A review of Resident 7's clinical records revealed no documentation to indicate the residents or their representatives were provided education regarding the benefits, risks and potential side effects of the pneumococcal immunization or an opportunity to accept or decline the pneumococcal vaccination. On 12/15/22 at 1:59 PM Staff 2 (DNS) stated the facility did not have a system in place to offer the pneumococcal vaccination to the residents. 2. Resident 13 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.