Willow Terrace

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that residents or their representatives were informed of treatment options, as well as the risks and benefits of the proposed care, for three of four residents reviewed for psychotropic medications (Residents R142, R139 and R158). Findings include: Review of Resident R142's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated November 14, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including cerebrovascular accident (damage to the brain from interruption of its blood supply), dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), depression (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things) and psychotic disorder (loss of contact with reality). Continued review revealed that the resident had 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 the review of clinical records, facility documentation, facility policies, and interviews with resident and staff, it was determined that the facility failed to demonstrate evidence that a resident/resident representative grievance was promptly documented and resolved for one of 32 resident records reviewed. (Resident R110) Findings Include: Review of facility policy Grievance/Concern Form; Grievance/Concern Log revised October 28, 2021 revealed Our facility will assist residents, their representatives, family members or resident advocates in filing a grievance/concern form or completing a review on the customer service kiosk when concerns are expressed, which may not be able to be handled immediately by the facility staff, requires further investigation or requires consultation with other facility staff, the attending physicians or outside service providers. Any resident, his/her representative, family member or advocate may file a Grievance/Concern. Form or complete a review on the Customer service kiosk regarding treatment, facility services, Medical care, behavior of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews with facility staff and residents and review of facility documents, it was determined that the facility failed to report an incident of alleged sexual abuse to the State Agency and the Administrator as required for one of 32 residents reviewed (Resident R110). Findings include: Review of facility policy titled Abuse Investigation and Reporting dated September 8, 2022, indicated that The Facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation/exploitation of resident/patient property by anyone including staff, family, friends, visitors, etc. The Facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation/exploitation of property. The facility must provide a safe resident environment and protect residents from abuse. This includes but is not limited to freedom from corporal punishment and involuntary seclusion. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that psychotropic medication changes met professional standards of practice for one of four residents reviewed for psychotropic medications (Resident R158). Findings include: Review of Resident R158's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated November 21, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including non-traumatic brain dysfunction, delirium (confusion) and encephalopathy (brain damage). Review of medication administration records revealed physician's orders for olanzapine (antipsychotic medication used to treat certain mental health disorders, such as schizophrenia [loss of reality with delusions and hallucinations] and bipolar [severe high and low mood changes]) 7.5 m.g (milligrams) once per day at bedtime for delirium. The medication was administered November 15, 2024, through January 8, 2025.…

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 observations, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that wound care practitioner recommendations were addressed appropriately for one of two residents reviewed for wounds (Residents R151). Findings include: Review of Resident R151's clinical record revealed that the resident was readmitted to the facility on [DATE]. Clinical record review for Resident R151 revealed a wound consultant report, dated January 22, 2025. The report indicated that the resident had a left shin wound with arterial etiology and a right distal shin wound with arterial etiology both wound was documented as full thickness wound. that was present on his readmission to the facility. The wound consultant recommended that the left shin wound be cleansed with 0.125% Dakin's solution (used to prevent and treat wound infections), treated with betadine (antimicrobial wound treatment) and leave it open to air. Further review of the wound consultant report recommended that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of care and services, clinical record review, interviews with staff and residents and reviews of facility policies, it was determined that facility failed to ensure that each resident received proper treatment and assistive devices to maintain vision for one of two residents reviewed for communication needs. (Resident R138) Findings include: Review of the facility policy titled Clinical Manual, dated March 5, 2024 revealed that it was the responsiblility of the facility to make arrangements for each resident for needed vision services. The facility was also responsible to notify the resident's responsible party about the vision care and services that were needed. The policy also said that if the resident was in need of a vision consult that it would arrange for the consultation in a timely manner. Clinical record review for Resident R138 revealed a quarterly assessment dated [DATE] that indicated this resident's preferred language was Creole. The assessment also indicated that this resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that wound care practitioner recommendations were addressed appropriately for one of two residents reviewed for wounds (Residents R271). Findings include: Review of Resident R271's Entry MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated January 25, 2025, revealed that the resident was readmitted to the facility on [DATE]. Clinical record review for Resident R271 revealed a wound consultant report, dated January 27, 2025. The report indicated that the resident had a sacral pressure ulcer that was present on his readmission to the facility. The wound consultant recommended that the wound be cleansed with 0.125% Dakin's solution (used to prevent and treat wound infections), treated with medical grade honey (antimicrobial wound treatment) and calcium alginate (absorbent wound dressing that promotes healing), then covered with a bordered foam dressing. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility documentation, review of facility policies and interviews with staff, it was determined that the facility failed conduct smoking assessment to ensure the safety of a resident who smokes for one of 32 residents reviewed. (Resident R14) Findings include: Review of facility documentation revealed that the Resident R14 was a smoker, and the resident was included in the smoking list provided by the facility. Resident was added to smoking list with smoking privileges. Review of facility investigation for Resident R14 dated January 10, 2025, revealed that During this shift resident was observed on the floor sitting upright on his buttocks in front of the bathroom without his back brace or wheelchair in place. Resident was asked why he was on the floor at which the resident stated, I fell on the way back from the bathroom. Resident was then asked why he did not call for assistance to go to the bathroom at which he got out of bed to secretly smoked in the bathroom.…

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 the review of clinical records, review of facility policy, staff interviews, it was determined that the facility failed to maintain appropriate nutritional parameters for one of four residents reviewed. (Resident 65). Findings include: Review of facility policy Nutritional Assessment dated March 18, 2024, revealed The Facility will follow current professional standards of practice that recommend weighing the Resident on admission or readmission, the day following admission (to establish a baseline Weight), weekly for the first 4 weeks after admission and at least monthly thereafter to help Identify and document trends such as slow and progressive weight loss. Weighing may also be Pertinent if there is a significant change in condition, food Intake has declined and persisted (e.g. For more than a week), or there is other evidence of altered nutritional status or fluid and Electrolyte imbalance. Review of physician orders for Resident R65 dated December 16, 2024, revealed an order to weigh resident weekly for four weeks until January 20, 2025. Review of care plan for 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 review of clinical records, review of facility policy and staff interview, it was determined that the facility failed to ensure communication with the dialysis provider for one of two residents reviewed on renal dialysis (Resident R47) Findings include: Review of facility policy title Dialysis Management (Hemodialysis) dated March 28, 2024, revealed that the facility shall ensure that residents who require outpatient hemodialysis treatment have appropriate arrangements made by the facility with an outpatient treatment center to provide such service as directed by the physician. Further review of this policy reveals the facility to complete pre-dialysis information on the communication form and send with resident to dialysis on treatment days, to ensure communication of resident information and coordinate care between Dialysis Center and facility. Review of Resident R47 's record revealed Resident R47 entered the facility on June 9, 2022 with the diagnosis of end stage renal disease (a medical condition in which a person's kidney ceases functioning on a permanent basis…

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 clinical record review, facility policy and interviews with staff, it was determined that the facility did not ensure that a physician assessment was completed related to unplanned weight loss for one of 32 residents reviewed (Resident R65). Findings include: Review of facility policy Nutritional Assessment dated March 18, 2024, revealed The Facility will follow current professional standards of practice that recommend weighing the Resident on admission or readmission, the day following admission (to establish a baseline Weight), weekly for the first 4 weeks after admission and at least monthly thereafter to help Identify and document trends such as slow and progressive weight loss. Weighing may also be Pertinent if there is a significant change in condition, food Intake has declined and persisted (e.g. For more than a week), or there is other evidence of altered nutritional status or fluid and Electrolyte imbalance. The facility may identify key individuals who could Participate in the assessment of nutritional status and related causes and consequences. For Example,…

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 observations, review of personnel files and interviews with staff, it was determined that the facility failed to ensure that agency licensed nurses had the specific competencies and skill sets necessary to care for residents' needs related to medication administration practices and infection control practices, for three of three agency staff reviewed (Employees E7, E8, and E10). Findings include: Observation of the morning medication pass on January 29, 2025, at 9:38 a.m. revealed that Employee E8, licensed nurse, prepared and administered medications for Resident R132. Employee E8, licensed nurse, administered two of the resident's insulin (medication used to lower blood sugar levels) doses after the breakfast meal, instead of before the meal. Employee E8, licensed nurse, also administered two lidocaine patches (medicated patch to relieve pain) without allowing sufficient time between doses. This resulted in four medication errors. Interview with Employee E8, licensed nurse, revealed that she was an agency nurse and only worked at the facility sporadically. Employee E8,…

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 clinical record reviews, interviews with staff, reviews of policies and procedures and the Department of Human Services assessments, it was determined that the facility failed to provide the necessary behavioral health care and services to attain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and care plan for one of four residents reviewed with mental illness (Residents R17). Findings include: Reviews of the facility policy titled Behavioral-Mental Healthcare Substance Use dated May 7, 2024 revealed that the facility was to provide an interdisciplinary approach for the care of residents who have a diagnosis of mental health disorder and decreased social interaction. The policy also indicated that the facility must provide the necessary Behavioral Health care and services to attain or maintain the highest practicable physical, mental and psychosocial well -being of the residents in accordance with their assessment and care plan. This…

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 observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for one of four medication carts reviewed (fourth floor south medication cart), and failed to ensure that medications were readily available for administration for three of 32 residents reviewed (Residents R132, R55, and R142). Findings include: Review of facility policy, Narcotic Management dated revised December 24, 2024, revealed, Control/Schedule II-V medication will be counted with two (2) professional nurses at the beginning and end of each shift. Documentation that a count was completed and accurate will be completed at the beginning and end of each shift. Control/Schedule II-V medications will be logged into a bound book or separate master index page once received from the pharmacy as well as individual countdown records. Observation on January 29, 2025, at 10:44 a.m. with Employee E7, licensed nurse, of…

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

Based on observations, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to ensure that the medication error rate was less than five percent for one of three residents observed during medication administration (Resident R132). Findings include: The facility's medication error rate was 12.5% based on observation of 32 medication administration opportunities with four errors observed. Review of facility policy, Medication Administration/Disposition dated reviewed December 2024, revealed, Medications shall be administered in a safe and timely manner, and as prescribed by the physician. Facility staff involved in the administration of resident care will be knowledgeable of the policies and procedures regarding pharmacy services including medication administration. Medications, both prescription and non-prescription, shall be administered under the orders of the attending physician. Continued review revealed, Medications must be administered with one (1) hour of their prescribed time, unless otherwise specified (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 observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that insulin pens and vials were labeled in accordance with currently accepted professional principles for one of four medication carts reviewed (fourth floor north medication cart). Findings include: Review of facility policy, Medication Administration/Disposition dated reviewed December 2024, revealed, When opening a multi-dose container, the date opened is recorded on the container. Observation on January 29, 2025, at 10:14 a.m. of the fourth floor north medication cart with Employee E8, licensed nurse, revealed the following: A lantus (long acting) insulin (medication used to lower blood sugar levels) pen for Resident R17 that was opened and undated; A lantus insulin vial for Resident R132 that was opened and undated; A lispro (rapid acting) insulin vial for Resident R95 that was opened and undated; and An admelog (rapid acting) insulin vial for Resident R83 that was opened and undated. Interview, at the time of the observation, Employee E8, licensed…

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 the review of facility documents and resident clinical record and staff interviews, it was determined that the facility failed to ensure a resident had the capacity to understand the terms of a binding arbitration agreement for two of three residents reviewed (Resident R147 and Resident R151). Findings Include: Review of Resident R147's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated May 6, 2024, revealed the resident was admitted to the facility on [DATE], and had a diagnosis of non-traumatic brain dysfunction and cognitive communication deficit. Further review of the MDS, Section C - Cognitive Patterns (items in this section are intended to determine the resident's attention, orientation, and ability to register and recall new information - these items are crucial factors in many care-planning decisions), indicated that Resident R147 scored a 12 on the Brief Interview for Mental Status (BIMS), which indicated the resident had moderate cognitive…

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 observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to maintain enhanced barrier precautions during wound care for one of one observations of wound care performed (Resident R271). Findings include: Review of facility policy, Transmission Based Precautions dated revised July 11, 2024, revealed, Enhanced barrier precautions (EBP) are designed to reduce the transmission of multidrug-resistant organisms (MDRO) in facilities. Continued review revealed that, EBP consists of the use of gowns and gloves for high-contact care activities which include . changing briefs and wound care. Review of Resident R271's care plan, dated initiated January 29, 2025, revealed that the resident had a sacral wound and to maintain enhanced barrier precautions. Observation on January 29, 2025, at 11:31 a.m. revealed that a sign was posted on Resident R271's door indicating that he required EBP. The sign instructed staff to wear a gown and gloves while providing high-contact care activities, such as wound and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to obtain and follow physician orders related to medications, wound care and dietary recommendations for three of five residents reviewed (Residents R1, R2 and R3). Findings include: Review of facility policy, Medication Management - Unavailable Meds dated April 22, 2024, revealed, If a medication shortage is noted during normal pharmacy hours, a licensed nurse notifies the pharmacy and speaks to a registered pharmacist to determine the status of the order . if the next available delivery results in a delay or missed dose in the customer's medication schedule, take the medication from the emergency stock supply to administer the dose. If ordered medication is not available in the emergency stock, notify pharmacist that an emergency delivery is required . if an emergency delivery is not feasible, a licensed nurse contacts the attending physician to obtain…

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 observations, review of facility policies, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure that residents were treated in a dignified manner for one of five residents reviewed (Resident R1). Findings include: Review of facility policy, Transmission Based Precautions dated revised April 6, 2024, revealed, Enhanced Barrier Precautions are designed to reduce the transmission of multidrug resistant organisms in facilities. Continued review revealed that Enhanced Barrier Precautions are indicated for residents with wounds and/or indwelling medical devices (such as central lines, foley catheters and feeding tubes). Further review revealed, Residents may share rooms with other residents who are not on Enhanced Barrier Precautions and residents may leave their rooms. Interview on September 11, 2024, at 10:00 a.m. Resident R1 stated that a few weeks ago she overheard staff outside of her room saying, I'm not going in there, I don't know what…

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 review of facility policy, review of facility records, observations, and interviews with residents and staff it was determined that the facility failed to provide a safe, homelike environment for one of four resident units observed. (Unit Three) Findings Include: Review of facility policy titled, Temperature Extremes dated September 2017 states, The policy of [NAME] Terrace is to provide comfortable and safe temperature levels. The temperature throughout this facility shall be maintained at between 71 degrees and 81 degrees Fahrenheit. Any temperatures outside of this range requires specific intervention(s) to avoid potential negative impact on the residents' well-being. Should the A/C or heating system fail, specific monitoring and safety measures should be activated. Additional responses listed as, 1. Maintain a log of temperature monitoring. An initial tour was taken with the Director of Maintenance Employee E3 on July 17, 2024 at 9:40 a.m. A tour of the third-floor unit revealed several rooms above 81 degrees on the southside hall. The temperatures were taken 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 review of clinical record and interview with staff, it was determined that the facility failed to inform residents of tests results and the facility failed to follow-up on the result of test results resulting in a delay in providing resident of the test results for one of seven residents reviewed (Resident R1) Findings include: Review of Resident R1's annual MDS (Minimum Data Set- a federally required resident assessment completed at a specific interval) dated April 3, 2024, section C0500 BIMS (brief interview for mental status) revealed that Resident R1 scored 15 suggesting that Resident R1 was cognitively intact. Review of resident diagnoses list revealed that resident had diagnoses of but not limited to Diabetes Mellitus (a group of diseases that result in too much sugar in the blood), Anxiety Disorder, Depression Further review of Resident R1's clinical record revealed that a test for Hemoglobin A1C (HbA1C-a blood test that shows the average blood sugar during the past two to three months) was done on February 6, 2024. Further review of Resident R1's clinical record…

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 review of resident clinical records, it was determined that the facility failed to ensure proper accommodation of needs for one of 32 residents reviewed regarding appropriate bed size and mattress (Resident R17). Findings include: Review of Resident R17 annual MDS (an assessment of resident needs) dated January 22, 2024, indicated the resident was cognitively intact, diagnosed with a history of a cerebrovascular accident (stroke), arthritis, and quadriplegia. The MDS indicated the resident was impaired on one side of his upper body, both sides of his lower body, and was completely dependent on staff for bed mobility and all activities of daily living (ADL). The MDS indicated the resident was on a scheduled pain management regimen and reported the pain would frequently affect his sleep, and frequently interfere with his day-to-day activities, including therapy. The resident rated the intensity of his pain, an 8 out of 10 (ten being the worst level of pain). Further review of Resident R17's clinical record revealed a plan of care for chronic pain related from…

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 observations, clinical record reviews, review of facility policy and interviews with residents and staff, it was determined that the facility failed to provide assistance with showers for three of five residents reviewed (Residents R96). Findings include: Review of facility policy, Refusal of Care, revised March 2024, indicated that the nurse will monitor for recurring refusals of medication, treatments, care and services. Further review revealed that the IDT team will meet with the resident/resident representative to ascertain the reasons why they are refusing care and services and will review and offer alternative interventions as appropriate. Interview with Resident R96's power of attorney on March 27, 2024, at approximately 2:00 p.m. revealed that Resident R96 was not provided assistance with showers. Review of physician orders for Resident R96 revealed that the resident was to receive showers on Mondays and Thursdays on the 7-3 shift. Review of Resident R96's current care plan, date-initiated September 7, 2023, revealed that the resident requires assist of 1 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, interviews with staff and review of facility policy, it was determined that the facility failed to ensure a resident who required respiratory care received the necessary care and services in accordance with professional standards of practice, and resident's plan of care for one of 32 resident records reviewed (Resident R96) Findings included: Review of the facility's policy titled, BIPAP CPAP revised May 2021 states, BIPAP and CPAP is administered by Licensed Nurses with a Physician's order . prescribed for some residents to augment resident breathing when they have difficulty maintaining adequate ventilation due to obstructive sleep apnea, central sleep apnea and complex sleep apnea. Review of Resident R96's clincial record revealed that the resident was admitted to the facility on [DATE], diagnosed with Obstructive Sleep Apnea (intermittent airflow blockage during sleep). Review of physician orders dated June 1, 2023, instructed to use the C-pap machine at bedtime and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of clinical records and interviews with staff, it was determined that the facility failed to ensure each resident received the necessary behavioral health services in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being for two of 32 resident records reviewed (Resident 18 and R61). Findings include: Review of Resident R18 clinical record revealed the resident was initially admitted to the facility on [DATE] diagnosis included Traumatic Brain Injury, Major Depressive Disorder, recurrent, severe with psychotic symptoms, Unspecified Dementia, unspecified severity, with other behavioral disturbances, Vascular Dementia, unspecified severity, with other behavioral disturbance, Schizoaffective disorder, unspecified, Mood Disorder due to unknown physiological condition with depressive features, and unspecified Symbolic Dysfunctions, Review of Resident R18 psychiatric consultation dated August 9, 2023, indicated the physician recommendations were to monitor…

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 review of clinical records and interview with staff and review of facility policy, it was determined that the facility failed to provide services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of a resident by failing to assist in community placement options until completion for one of 32 resident records reviewed (Resident R61). Findings include: Review of facility policy titled, Discharge Planning Process dated March 2021, last reviewed April 2023 stated, The policy is to ensure that the resident has a planned program of post-discharge continuing care that takes his/her needs into account for a safe discharge. Discharge planning is interdisciplinary and is initiated preadmission, admission and continues through continum of care. Review of Resident R61's clinical record revealed the resident was initially admitted to the facility September 17, 2020, diagnosis included, Unspecified Dementia, Anxiety disorder, Major Depressive disorder, and insomnia. Review of Resident R61's Social Service note dated June 29, 2023, revealed Social…

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 review of facility policy, review of clinical records, and interview with staff, it was determined that the facility failed to provide pharmaceutical services to meet resident's needs including acquiring, receiving, and administering medications for two of 32 residents reviewed (Resident R17 and R96). Findings include: Review of the facility policy titled, Medication Storage/Unavailable Medications not dated, states when medications are not available the nurse will urgently initiate action. If delivery of the medication will be late or missed, take the medication from the emergency stock supply. If the medication is unavailable the nurse will call the physician for further orders. The policy further instructs to document missed doses on the EMAR (electronic medical record), document explanation for missed , See nurses notes for explanation. Document explanation of missed dose in the nurses note, describing the circumstance of medication shortage, notification of pharmacy and response and action(s) taken. Review of Resident R17 annual MDS (an assessment of resident needs)…

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 review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food that was palatable, attractive, and served at the proper temperature for one of five nursing units observed (third floor nursing unit) Findings include: Review of undated facility policy titled, Meal Tray Accuracy Audit Report Policy, indicated that for satisfactory result, all got items must be 135 degrees or higher and all cold items must be 45 degrees or below at point of service. Interview with Resident R119 on March 26, 2024, at 12:04 p.m. revealed that food is always cold and coffee is never hot. Observations during a test tray conducted with The Food Service Director, Employee E3, on March 27, 2024, at 12:58 p.m. revealed that the hot coffee registered at 133.7 degrees Fahrenheit (F); macaroni and cheese at 135.7 degrees F; green beans at 138.4 degrees F; mashed potato at 124.9 degrees F; milk at 56 degrees F; rice pudding at 62.8 degrees F; and cranberry juice at 61 degrees F. An interview with the FSD, on March 27, 2024, 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 review of facility policy, review of clinical record, observations, and staff and resident interviews, it was determined that the facility failed provide food items consistent with the prescribed diet order for one of four residents reviewed for nutrition (Resident R149). Findings Include: Review of facility diet guide sheet revealed Tuesday lunch offerings on March 25, 2024, was Herb Rubbed Pork, Parley New Potatoes, Braised Cabbage, and Chilled Peas. Per the diet guide sheet, a resident on a mechanically soft diet (consisting of food that have been bended, mashed, pureed, or chopped, making them soft and easy to eat without biting or chewing), should receive ground herb rubbed pork, mashed potatoes, and pureed braised cabbage. Review of Resident R149's physician orders revealed the resident was ordered a Mechanically Soft Textured diet dated January 25, 2024. Dining observation conducted on March 26, 2024, at 1:16 p.m. revealed Resident R149's meal ticket confirmed that the resident was ordered a Mechanical Soft Diet. Further review of the meal ticket indicated 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 observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: Review of facility policy titled, Uniform Policy, revised May 27, 2023, indicated that facial hair coverings will be worn to cover any and all facial hair. Review policy titled, Dating and Labeling Policy revised January 24, 2023, indicated that the kitchen will assure food safety by maintaining proper dated and labels to all goods and ready to eat food products . An initial tour of the main kitchen was conducted on March 25, 2024, at approximately 10:19 a.m. with the Food Service Director (FSD), Employee E3. Observations revealed that two kitchen staff were not wearing a facial hair covering. Observations in the reach in refrigerator in the main cooking area revealed that gravy and macaroni and cheese was unlabeled and undated; hashbrowns and peas were inappropriately dated with the month 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 interviews with residents and staff and review of clinical records, it was determined that the facility failed to ensure timely provision of professional services furnished by outside providers, for one of 32 residents reviewed (Residents R17). Findings include: Review of Resident R17 annual MDS (an assessment of resident needs) dated January 22, 2024, indicated the resident was cognitively intact, diagnosed with a history of a cerebrovascular accident (stroke), arthritis, and quadriplegia. The MDS indicated the resident had an impairment on one side of his upper body, both sides of his lower body, and was completely dependent on staff for bed mobility and all activities of daily living (ADL). During an interview on March 27, 2024, Resident R17 stated he had a cardiologist appointment in July but couldn't get a ride to his appointment, so the facility cancelled it but did not reschedule another visit. Review of the nursing progress notes dated July 17, 2023, stated, Cardiology appointment cancelled. This was confirmed on March 27, 2024, at 4:00 p.m. with the Nursing Home…

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 observations of the food and nutrition department, review of facility policy and interviews with staff, it was determined that the facility failed to maintain essential food service equipment in safe operating condition. Findings Include: Review of facility policy titled, Dish Machine Usage Policy, revised November 15, 2023, revealed that dishwasher staff will monitor and record dish machine temperatures to assure compliance for wash and rinse cycles . FSD (food service director) or Designee will monitor temperature log and PPM readings prior to each usage for compliance. An initial tour of the main kitchen was conducted on March 25, 2024, at approximately 10:19 a.m. with the Food Service Director (FSD), Employee E3. Observations of the dish room revealed Dietary Aide, Employee E4, was utilizing the dish machine. Further observations revealed that the dish machine thermometers were not operating; FSD confirmed that the dish machine was not functioning properly. Review of the dish machine temperature log titled, Dish Machine Ware Washing- Low Temperature, revealed missing…

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 clinical record review, observation of medication administration and staff interview, it was determined that the faciltiy failed to ensure that medications were administered timely for one of nine residents reviewed. (Resident R1) Findings include: Review of Resident R1's clinical record revealed that the resident had the diagnosis of aphasia (a disorder that results from damage to portions of the brain that are responsible for language). Continued review of the resident's clinical record revealed an order dated January 5, 2024 May crush medications unless contraindicated. Review of Resident R1's January 2024 physician's orders revealed an order obtained January 8, 2024 for Multivitamin-Minerals Oral Tablet (Multiple Vitamins w/ Minerals), give 1 tablet by mouth one time a day for nutritional needs, wound healing, crush and serve with applesauce/fluids; Aspirin 81 milligrams oral tablet chewable (Aspirin), give 1 tablet by mouth one time a day for Cerebral Vascular Accident (order date 1/5/2024); Amlodipine Besylate oral tablet 5 mg, 1 tablet by mouth one time a day 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to provide care and services to meet the accepted standards of practice for one of five residents (Resident R1). Findings include: Review of facility policy Wound Vac Guidelines last reviewed October 2023, indicated, The Facility will utilize Negative Pressure Wound Therapy for specifically identified residents who meet criteria for use. A physician order is necessary to provide this treatment. There are numerous types of Wound VACs on the market; the Facility will utilize the equipment ordered by the physician. Nurses will be trained on the specific Wound VAC that the Facility is utilizing. Specific information regarding the equipment will be maintained and provided as a resource for the nurses. 1. Precautions for use: a. Precautions should be taken with active bleeding b. Difficult wound hemostasis c. Resident's on anticoagulant therapy d. Follow standard precautions e. When placing 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 observations, review of facility policy and interviews with staff and residents it was determined the facility failed to provide food that was palatable, attractive, and served at appetizing temperatures for one of four units reviewed. (Unit four) Findings Include: Review of the facility policy titled, Recording Food Temperatures Policy last revised 8/16/18 states, Purpose: To ensure the quality and safety of food are met by providing and maintaining proper food temperatures during meal service. 6. Hot food will be maintained at 135 degrees or higher. The facility failed to ensure all food was maintained at 135 degrees Fahrenheit or higher. Interview with Resident R2 on September 28, 2023 at stated that the food comes cold, they let it sit twenty to thirty minutes. The resident stated he eats all his meals in his room and the meals are cold. Interview with Resident R4 on September 28, 2023 at 10:20 a.m. revealed the resident stated that the meals here are cold. When asked which meals come cold the resident stated all of them. Interview on September 28, 2023 at 11:52 a.m.…

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 observations, review of facility policies and documentation, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to provide an ongoing program to support residents in their choice of activities for two of 42 residents reviewed (Residents R268, R76) Findings include: Review of facility policy, Activity Manual dated reviewed April 2023, revealed that, The facility will provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. Observation of the fourth floor nursing unit on May 30, 2023, at 10:38 a.m. revealed an activities calendar posted prominently in the hallway. An activity…

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 observations, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to provide appropriate serving equipment to dietary staff during dining services to ensure that menu portions were properly served, on one of four nursing units observed (Fourth Floor nursing unit). Findings include: Interview on May 30, 2023, at 11:34 a.m. Resident R268 stated that food portions were too small. Interview on May 30, 2023, at 11:47 a.m. Resident R76 stated that not enough food was served during meals and that foods had poor presentation. Review of the posted menu on the fourth floor nursing unit on May 30, 2023, revealed that BBQ chicken, vegetarian baked beans, corn and chilled peaches were to be served at the luncheon meal. The alternate meal posted was beef hot dog on a bun, macaroni salad and cauliflower. Review of the facility's Diet Guide Sheet revealed that portion sizes to be served for the luncheon meal were: three ounces of BBQ chicken, four ounces of vegetarian baked beans, one ear of corn and four ounces of chilled…

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 review of facility polices, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to provide a resident the right to participate in the care planning process, of 42 residents reviewed (Resident R63). Findings include: Review of facility policy, Care Planning Process and Care Conference dated last reviewed May 2023, revealed, Care conference invitations will be given/sent to the resident/patient and resident representative if applicable, with date and time. Evidence of invitation should be maintained by the facility. The resident/patient should be encouraged to attend and participate. Resident R63 stated during interview on May 30, 2023 at 11:01 a.m. that he has not been invited to or involved in his care planning process and that he would like to be. Review of Resident R63's quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated March 10, 2023, revealed that the resident was admitted to the facility on [DATE], and had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a resident council meeting, resident interview, review of facility policy and procedures and staff interview, it was determined that the facility failed to ensure that the grievance forms were available and accessible to residents' locations on the nursing units for 4 of 4 nursing units observed. (Floor 3, 4, 5, 6) Findings include: A review of the facility policy and procedure, titled, Grievance indicated under the Procedure section The facility will post information on how to file a grievance and information on the name, phone Number and contact information (including mail and email) for the facility grievance officer. Grievances may be received in writing, orally or anonymously. On May 31, 2023 at 10:23 a.m. an interview was held with Resident R319 who was admitted to the facility on [DATE] and had expressed several concerns about dietary, housekeeping, and pest control. When questioned her if she knew the grievance procedure she reported no I don't. She also did not know about grievance forms being…

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 clinical record review, review of facility policies and staff interviews, it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed according to the resident assessment for two of three residents reviewed (Residents R58 and R268). Findings include: The PASRR (Preadmission Screening Resident Review) was created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA) and it has three goals: to identify individuals with mental illness and/or intellectual disability, to ensure they are placed appropriately, whether in the community or in a nursing facility, and to ensure they receive the services they require for their mental illness or intellectual disability. The PASRR Level 1 must be completed on all persons who are considering admission to a Medicaid certified nursing facility. A Level II PASRR evaluation must be completed if the Level 1 PASRR determined that the person is a targeted person with mental illness or an intellectual…

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 observations, clinical record review, and staff interviews, it was determined that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for two of eight residents reviewed (Resident R54 and R3) Findings include: Review of Resident R54's clinical record revealed the diagnosis of chronic obstructive pulmonary disease (disease process that causes decreased ability of the lungs to perform). Review of Resident R54's May 2023 physicians orders revealed an active order for Budesonide - Formoterol Fumarate Inhalation Aerosol 160-4.5 mcg/act (Budesonide-Formoterol Fumarate Dihydrate, corticosteroid) to be administered twice daily; and Albuterol Sulfate Inhalation Aerosol Powder Breath Activated 108 (90 base) mcg/act (Albuterol Sulfate, bronchodilator) to be administered as needed for wheezing. During medication administration observations on May 31, 2023 at 9:30 a.m. Licenced nurse, Employee E12, was unsure if Albuterol was the same as Budesonide. Employee E12, prepared to administer Albuterol inhaler as needed…

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 observations, clinical record review and interviews with staff, it was determined that the facility failed to ensure that a resident received appropriate treatment and services for contracture management as prescribed for one of one residents reviewed for contracture management (R62). Findings include: Observation on May 31, 2023, at 10:10 a.m. revealed Resident R62 resting in bed. The resident was noted with contractures (permanent shortening of a muscle or joint) in his hands, arms and legs. The resident was not wearing any devices for contracture management, such as splints, hand rolls or braces. Review of an occupational therapy discharge summary for Resident R62, dated April 13, 2023, revealed that the resident received therapy services for bilateral wrist splints and bilateral elbow extension splints for contracture management. The therapist recommended to continue using the splints upon discharge. Review of a physical therapy discharge summary for Resident R62, dated November 2, 2022, revealed that the resident received therapy services for bilateral lower extremity…

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 clinical record review, facility policy and interviews with staff, it was determined that the facility did not ensure that a physician assessment was completed related to unplanned weight loss for two of 33 residents with weight loss reviewed (Resident R21, R89). Findings include: Facility policy titled Nutrition Assessment indicates in the Procedure section #d. Physicians and non-Physician practitioners help identify relevant diagnoses, identify causes of weight changes and monitor the continued relevance of those interventions Review of clinical documentation for Resident R21 revealed that that the resident was admitted to the facility on [DATE], with diagnoses of Astro-esophageal reflux (acid reflux when stomach acid repeatedly flows back into the tube connecting your mouth and stomach) and severe protein-calorie malnutrition. Review of the resident's weight documentation revealed that on October 20, 2022, Resident R21 weighed 153.5 pounds and on November 21, 2022, the resident weighed 127.8 pounds…

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 observations, staff and resident interview, and clinical record review, it was determined that the facility did not ensure that a resident who was incontinent of bowel received care in a timely manner for one out of eight residents reviewed (Resident R4) Findings include: Review of Resident R4's clinical records revealed that the diagnoses of chronic kidney disease, chronic idiopathic constipation, urethral stricture, calculus of kidney, chronic obstructive pyelonephritis, acute kidney failure, other artificial openings of urinary tract status, urethral fistula. Review of R4's current care plan revealed a care plan for bowel incontinence 2/2 hx (history) of chronic bowel and impaired mobility. Interventions included: Check resident every two hours and assist with toileting as needed, provide pericare after each incontinent episode, observe pattern of incontinenc, and initiate toileting schedule if indicated. During interview with Resident R4 on May 30, 2023 at 12:20 p.m., the resident stated that facility has poor track record with answering call bells. The resident 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 review of facility policy, clinical record review and interview with staff, it was determined that the facility did not ensure that adequate activities were provided, that medications utilized for the management of dementia were appropriately prescribed, and that an individualized, person-centered care plan was developed and implemented to address a resident's dementia care needs for one of 33 records reviewed (R102). Findings include: Review of facility policy titled Care Planning, dated May 6, 2023, revealed that the facility will develop a comprehensive, resident centered care plan for each resident. Care plan development, renewal and revision will be based upon the results of the resident assessment. Observation of Resident R102 on May 30, 2023, at 11:57 a.m. revealed the resident to be alone in his room wearing only an incontinent brief and no other clothing. The resident was laying in his bed and unable to engage in meaningful conversation with the surveyor. No opportunities for engaging independent activities were found in the room other than a small radio playing…

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, review of facility policies and interviews with staff, it was determined that the facility failed to provide appropriately textured foods to meet the needs of residents on a mechanically altered diet, on two of four nursing units observed (Fourth and Fifth Floor nursing units). Findings include: Review of facility diet and nutrition care manual related to puree diets, dated 2019, revealed that, All foods must be the consistency of moist mashed potatoes or pudding. Continued review revealed, It is important to make the diet look appealing. Review of the posted menu on the fourth floor nursing unit on May 30, 2023, revealed that BBQ chicken, vegetarian baked beans, corn and chilled peaches were to be served at the luncheon meal. Observations of the luncheon meal on the fourth floor nursing unit on May 30, 2023, from 12:32 p.m. through 1:49 p.m. revealed Employee E15, dietary aide, prepare the steam table in the dining room and began plating resident lunches at 12:59 p.m. Employee E15, dietary aide, was observed pouring pureed foods directly from containers onto…

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 review of clinical records and interviews with staff, it was determined that the failed to maintain legible clinical records for 2 of 42 residents reviewed (Residents R21 and R268). Findings include: Review of Resident R268's psychiatric (mental health) consultation, dated May 22, 2023, revealed that the handwritten consultation note was not legible. Multiple lines in the Findings section of the note, including the physician's assessment and key notes during the consultation, were unable to be deciphered. Interview on June 1, 2023, at 10:39 a.m. revealed that Employee E11, unit manager, E18, licensed nurse, and the Nursing Home Administrator were unable to read all portions of the note and confirmed that Resident R268's psychiatric consultation was not legible. Review of clinical documentation for Resident R21 revealed that that the resident was admitted to the facility on [DATE] and had unplanned weight loss on November 21, 2022 and needed to have a physician evaluation. On June 1, 2023, at 12:28 p.m.…

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.