Matlock Place Health & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and records review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 (Residents #16, #35, and #198) of 3 residents reviewed for pressure ulcers. 1. On 05/19/25, the facility failed to provide PRN wound care to Resident #16's right buttocks wound. 2. On 05/17/25 and 05/18/25, the facility failed to provide wound care to Resident #35's left foot. 3. On 05/09/25, the facility failed to provide wound care to Resident #198's sacrum wound. These failures placed residents at risk of developing new or worsening pressure ulcers. Findings included: 1. Record review of Resident #16's admission Record, dated 05/19/25, reflected the resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #16's Quarterly MDS Assessment,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who are fed by enteral means, received the appropriate treatment and services to prevent complications of enteral feeding, for 2 of 4 resident (Residents #16 and #58) reviewed for enteral nutrition. 1. The facility failed to follow physician orders for Resident 16's enteral feeding tube formula when it was not available and required a substitution. 2. The facility failed to follow Resident #58's physician orders for enteral feeding by not allowing Resident to have down time between the hours of 8:00 AM-12:00 PM. These failures could place residents who had gastrostomy tube at risk for weight loss, weight gain or stomach and digestion issues. Findings included: 1. Record review of Resident #16's admission Record, dated 05/19/25, revealed the resident was an [AGE] year-old who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #16's Quarterly MDS Assessment, dated 04/22/25,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Residents #23 and #33) reviewed for dialysis. 1. The facility failed to ensure dialysis communication forms were completed for Resident #23 after returning from dialysis treatment. 2. The facility failed to ensure Resident #33 had an order to complete dialysis treatment. This failure could place residents at risk of inadequate monitoring after returning to facility. Findings included: Record review of Resident #23's admission MDS assessment, dated 05/07/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #23 had a diagnosis of end-stage renal disease (the final stage of chronic kidney disease where the kidneys can no longer filter waste and fluids from the blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 medication carts (600,700 and 800 Halls cart) and 3 of 3 residents (Residents #68,#91 and #98) reviewed for pharmacy services. The facility failed to ensure the 600,700 and 800 Halls nurses' medication cart had accurate narcotic counts for Residents #68, #91 and #98. This failure could place residents at risk for medication errors, drug diversion, and delay in medication administration. Findings included: 1. Record review of Resident #68's comprehensive MDS Assessment, dated 05/07/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] . Resident #68 had diagnoses which included chronic obstructive pulmonary disease (a long-term lung disease that makes it difficult to breathe) and difficulty in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the medication error rate was not five percent (5%) or greater for 1 of 3 staff (LVN B) which resulted in a 43.9 % medication error rate after 41 opportunities with 18 errors for 1 of 4 residents (Resident #16) reviewed medication administration. LVN B failed to follow the physician orders for flushing Resident #16's gastrostomy tube with 5-10 mL (or prescribed amount) of water between medications, when she administered 13 medications to Resident #16. LVN B also failed to administer all the medications in medicatoin cups leading to 5 cups being left with residual medication. These failures could place residents at risk of physical and chemical incompatibilities leading to an altered therapeutic response and put residents who received medications via gastrostomy tube at risk for gastronomy tube blockage and medication interaction. Findings included: 1. Record review of Resident #16's quarterly MDS assessment, dated 04/22/25, 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 observations and interviews, the facility failed to ensure the menus were followed for 1 (the lunch meal on 05/20/25) of 2 meals reviewed for menus. The facility did not serve the correct portions of pureed broccoli and cauliflower, pureed pizza pasta bake, and pureed garlic bread for the lunch meal on 05/20/25. This failure could affect residents in the facility, who eat from the kitchen, by placing them at risk of being hungry or losing weight. Findings included: Observation on 05/20/25 at 11:45 AM of the kitchen revealed the steam table included the prepared pureed foods, including pureed broccoli and cauliflower, pureed garlic bread, and pureed pizza pasta bake. Interview and observation on 05/20/25 at 11:50 AM revealed the DM and [NAME] F were reviewing the recipe for the foods to be served and calling out the scoops required for each of the meal items. [NAME] F said she was using a 3-ounce scoop for the pureed broccoli and cauliflower, a 3-ounce scoop for the pureed pizza pasta bake, and a 2-ounce scoop for the pureed garlic bread. The DM provided [NAME] F with 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, the facility failed to ensure the facility provided food that was palatable, for one (the lunch meal on 05/20/25) of three observed meals reviewed for dietary services. The facility failed to serve food that had a smooth, pudding like texture during the lunch meal on 05/20/25. This failure could affect residents by placing them at risk of weight loss, altered nutritional status, and a diminished quality of life. Findings included: Observation on 05/20/25 at 10:30 AM of the kitchen revealed the DM had taken a tray out of the oven that had prepared pizza pasta bake that included ground meat, pasta, and a sauce. The DM added several scoops of the prepared food to the machine to puree the food. The DM pureed the prepared food, but it still had bits of pasta in it and was not smooth or pudding like. A sample tray was requested and tasted on 05/20/25 at 12:55 PM with three surveyors and the DM. The tray that was tasted included pureed pizza pasta bake, pureed garlic bread, and pureed broccoli and cauliflower. The pureed pizza pasta bake…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 20 residents (Resident #36) reviewed for clinical records. The facility failed to have complete records for Resident #36's wound care for April and May 2025 This failure could place residents at risk for incomplete and inaccurately documented medical records that included their progress treatment, services, and interventions. Findings include: Review of Resident #36's MDS dated [DATE] reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included heart disease and Alzheimer's disease. The resident had a BIMS of 1, indicating her cognition was severely impaired. The MDS reflected the resident had a chronic disease that may result in a life expectancy of less than 6 months and was on hospice care. The MDS further reflected the resident had a stage 4 pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 of 2 residents (Residents #2 and #16) observed for infection control. 1. CNA P and C N A Q failed to perform hand hygiene while providing incontinence care to Resident #16. 2. The facility failed to ensure Wound Care Nurse performed hand hygiene and change gloves during the wound care for Residents #2 and #16. This failure could affect the residents, by placing them at risk for worsening conditions and cross contamination. Findings included: Record review of Resident #2's quarterly MDS assessment, dated 02/12/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had a diagnosis of Respiratory Failure (a serious condition that makes it difficult to breathe on your own). She had a BIMS score of 02, which indicated her cognition was severely impaired. The MDS reflected 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 observation, interview, and record review, the facility failed to ensure the resident had a right to a safe, clean, comfortable, and home-like environment for 1 of 5 residents (Resident #73) reviewed for environment. The facility failed to ensure Resident #73 had a home-like environment when she was relocated temporarily to another room leaving her without any of her belongings or entertainment. These failures could place residents at risk of an uncomfortable environment, depression and feeling lonely. Findings included: Record review of Resident #73's face sheet dated 05/20/25 reflected the resident was an [AGE] year-old female admitted on [DATE] and readmitted [DATE]. Record review of Resident #73's Quarterly MDS assessment dated [DATE] reflected the resident was usually understood and understood others. The MDS indicated a BIMS score of 09 indicating Resident #73 had a moderate cognitive impairment with diagnoses including Depression (persistent feeling of sadness), paralysis or severe weakness 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, the facility failed to ensure nurse aides received required training which included dementia management training for 1 of 16 (CNA V) staff reviewed for in-service training requirements. The facility failed to ensure CNA V received dementia management training. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings included: Record review of personnel records provided by the HR Manager revealed CNA V with hire date of 04/17/23 did not have any documented evidence in the facility for annual trainings taken on Residents with Dementia which was consistent with her expected role. During an interview and record review on 05/20/25 at 10:12 AM with Human Resource Specialist revealed she was responsible for new hire orientation. Human Resource Specialist stated that new hires did not have dementia training during orientation with her. Human Resource Specialist stated she did not review job description responsibilities with newly hired staff. Human Resource Specialist stated the DON was over…

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 maintain an infection control program designed to prevent the development and transmission of disease and infection for 7 of 7 rooms (Rooms #605, #607, #608, #703, #704, #801, and #805) reviewed for infection control. The facility failed to ensure that staff had appropriate Personal Protective Equipment (PPE) readily available to wear when entering rooms (Rooms #605, #607, #608, #703, #704, #801, and #805) on droplet precautions to prevent the spread of infection. This failure placed all residents, as well as employees and visitors, at risk of communicable diseases. Findings included: Observation of Hall 600 on 03/01/25 at 11:15 AM revealed Rooms #605 and #608 were on droplet precautions. Both rooms had PPE bins outside of the door, but there were no face shields or goggles available. Observation of Hall 700 on 03/01/25 at 11:18 AM revealed Rooms #703 and #704 were on droplet precautions. Both rooms had PPE bins outside of the door, but there were no face shields or goggles available. Observation of Hall 800…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for one of five residents (Resident #1) reviewed for accuracy of assessments. The facility failed to ensure Resident #1's medications were correctly documented on his quarterly and annual MDS assessments. This failure could place residents at risk of inadequate care due to inaccurate assessments. Findings included: Record review of Resident #1's face sheet, printed on 01/08/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included metabolic encephalopathy (brain dysfunction caused by an imbalance of chemicals in the blood), chronic embolism and thrombosis of other specified veins (blood clots), end stage renal disease (a permanent condition where the kidneys can no longer function properly), acute and chronic respiratory failure with hypoxia (condition where the lungs are not effectively delivering oxygen 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 5 residents (Residents #1 and #2) reviewed for ADL care. The facility failed to provide Residents #1 and #2 assistance with timely incontinence care on 10/31/24. This failure could place the residents at risk for decreased feelings of self-worth, skin breakdown, and infection. Findings included: 1. Record review of Resident #1's admission Record, dated 10/31/24, reflected the resident was a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's Annual MDS Assessment, dated 10/04/24, reflected there was not a BIMS score calculated. Further review reflected a Staff Assessment for Mental Status was completed which revealed Resident #1 had a memory problem resulting in inattention that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to immediately notify the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #1) reviewed for physician notification of changes. 1. The facility failed to consult with Resident #1's physician and provide all necessary details, when MA A failed to inform LVN A that Resident #1 refused to take her Lactulose medication on Saturday, 10/05/2024 (12:00 PM) and again on Sunday, 10/06/2024 (12:00 PM and 5:00 PM) for a total of 3 doses. 2. The facility failed to follow their policy on medication administration on 10/05/2024 and 10/06/2024 by MA A not immediately detailing any refusals by Resident #1 of her Lactulose medication to LVN A. Resident #1's MAR revealed she missed three doses over a two-day period on Saturday, 10/5/2024 (12:00 PM) and on Sunday, 10/6/2024 (12:00 PM and 5:00 PM). 3. The facility failed to follow their policy on change 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 observation, interview, and record review, the facility failed to ensure food, subject to spoilage and removed from its original container, was kept sealed, labeled, and dated in the facility's only kitchen. 1. The facility failed to ensure food items stored in the freezer were properly labeled with the contents after being removed from the original packages and not dated to reflect when the food items were opened. 2. The facility failed to ensure the freezer was maintained in a sanitary manner free from dark substances. This failure could place all residents at risk for food contamination and food borne illness. Findings included: Observation of the freezer and interview on 03/24/24 beginning at 9:00 AM revealed the following: - a grey tub in the bottom of the freezer, - 6 clear plastic bags with frozen chicken parts, undated and unlabeled, - 1 clear bag with breaded patties, undated and unlabeled. At the bottom of the freezer underneath the grey tub and to the left of the tub appeared to be a dark substance that was spilled and frozen. According to [NAME] Q, the spillage…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 2 (Residents #21 and #54) of 5 residents reviewed for quality of care. 1. The facility failed to follow physician orders for weekly weights on Resident #21 resulting in a weight gain. 2. The facility failed to obtained physician orders for Resident #54 use of hinged knee brace. This failure could place the resident at risk of not receiving the care intended by the physician. Findings included: 1. Review of Resident #21's undated admission Record reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia, depression, heart disease, and diabetes. Review of Resident #21's quarterly MDS assessment, dated 01/26/24, revealed a BIMS score of 7, indicating severe cognitive impairment. Her Functional Status assessment revealed she required minimal assistance with her ADLs. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the system for identifying and reporting infections and communicable diseases for all resident was followed for 1 (Resident #63) of 2 residents reviewed for infection control. The staff failed to notify the physician of Resident #63's urine culture being positive for an infectious agent, resulting in a delay in starting antibiotics and contact isolation. This failure could place residents at risk of being exposed to an infectious agent. Findings included: Review of Resident #63's undated admission Record revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included difficulty swallowing, dementia, muscle weakness and diabetes. Review of Resident #63's quarterly MDS assessment, dated 03/21/24, revealed a BIMS score of 13, indicating intact cognition. Review of Resident #63's care plan, dated 01/26/24, indicated she had impaired nutrition, impaired decision making, and she had bowel 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, the facility failed to maintain an effective pest control program to ensure the facility was free of pests for 3 (100, 200 and 400 Hall) of 6 Halls, and 1 of 1 conference room reviewed for pests. The facility failed to ensure an effective pest control program was implemented to prevent the presence of gnats throughout the facility. This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life. Findings included: Observations between 03/24/24 at 9:30 AM through 03/26/24 at 5:00PM revealed 2-3 gnats in the facility Conference room. Observations between 03/24/24 at 10:30 AM through 03/26/24 at 5:00 PM revealed gnats flying in 100, 200, and 400 Hall. Observation and interview on 03/24/24 at 10:44 AM revealed Resident #35 lying in her bed. Resident #35 room was in the 100 Hall. Resident #35 stated she was doing well. She stated her room was cleaned every day; however, she had been having issues with gnats in her room. Observed about 4-5 gnats in Resident #35's room.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent neglect for one (09/12/23) of one incidents reviewed for reporting. The facility failed to follow their policy to report to the State Survey Agency when Resident #302 tilted in her wheelchair while being transported to an appointment in the facility van. This failure could place the residents in the facility at risk of lacking timely reporting of incidents. Findings included: Review of the facility's Abuse, Neglect, and Exploitation policy, revised 01/01/23, reflected the following Policy It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures and that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. VII. Reporting/Response 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services 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 interview and record review, the facility failed to ensure all alleged violations involving abuse and neglect were reported immediately but not later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency for one of one incidents reviewed for reporting. The facility failed to report to the State Survey Agency when Resident #302 tilted in her wheelchair while being transported to an appointment in the facility van. This failure could affect residents by resulting in a delay of identification of abuse or neglect and lack of timely follow-up on recommended interventions to prevent harm, or impairment. Findings included: Review of Resident #302's MDS assessment, dated 08/23/23, reflected the resident was [AGE] year-old female admitted to the facility 08/16/23. The resident's diagnoses included hypertension (high blood pressure), diabetes, arthritis, presence of left artificial shoulder joint, and bicipital tendinitis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility admitted a resident with a mental disorder before the State mental health authority had determined he was appropriately placed for 1 of 7 residents (Resident #95) reviewed for Preadmission Screening and Resident Review (PASARR) screening. The MDS Coordinator failed to complete the PASARR screening process accurately for Resident #95. This failure could place residents at risk of not receiving specialized services. Findings included: Review of Resident #95's undated face sheet revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia (decline in cognitive abilities), severe, with psychotic disturbance (mental health disorders), cognitive communication deficit (communication impairment), and Schizophrenia (general misperception of reality). Review of Resident #95's quarterly MDS assessment, dated 01/12/24, revealed a BIMS score of 00, indicating the score was not able to be completed.…

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, interviews, and record reviews the facility failed to develop a comprehensive care plan for 1 (Resident #54) of 5 residents reviewed for comprehensive care plans. The facility failed to update Resident #54's care plan to address the use of his hinged knee brace. This failure could result in the resident not receiving appropriate care for his fracture. Findings included: Review of Resident #54's face sheet dated 03/26/24 indicated Resident #54 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #54 had a diagnosis of hyperkalemia (high potassium), end stage renal disease (renal failure), type 2 diabetes mellitus, unspecified fracture of shaft (middle bone) of left tibia (shinbone), subsequent encounter for closed fracture with routine healing and other reduced mobility. Review of Resident #54's quarterly MDS assessment dated [DATE] revealed Resident #54 had a BIMS score of 14 which indicated cognition was intact. MDS Assessment further 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide residents who were unable to carry out activities of daily living the necessary services to maintain grooming and personal hygiene for two (Residents #35 and #83) of eight residents reviewed for facial hair. The facility failed to remove Resident #35 and Resident #83's facial hair. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: Review of Resident #35's face sheet revealed Resident #35 was admitted to the facility on [DATE] with diagnoses of reduce mobility, dysphagia (difficulty swallowing), major depressive disorder, essential hypertension (high blood pressure), unsteadiness of feet, and muscle weakness. Review of Resident #35's quarterly MDS assessment, dated 03/04/24, revealed Resident #35 had a BIMS score of 06, which indicated severe cognitive impairment. Section GG - Functional Abilities and Goals, Question GG0130. Self-Care revealed 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 observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for two (Resident #40 and #302) of six residents reviewed for accidents. 1. The Van Driver failed to properly restrain Resident #302's wheelchair in the facility transportation van to prevent the wheelchair from tipping over on its side on the way to dialysis on 09/12/23. 2. The facility failed to provide adequate supervision for Resident #40 when she was stuck outside in the courtyard and she was not able to call the facility because their phone lines were down. This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life. Findings included: 1. Review of Resident #302's MDS assessment dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility 08/16/23. The resident's diagnoses included hypertension (high blood pressure), diabetes, arthritis, presence of left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was fed by enteral means received appropriate treatment and services to prevent complications for one (Resident #46) of four residents reviewed for feeding tubes. The nursing staff failed to ensure Resident #46's water flushes were correct on the feeding pump per the physician orders. The failure placed residents, who received nutrition via g-tube, at risk for decreased nutritional intake and weight loss complications. Findings included: Review of Resident #46's MDS assessment dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included hypertension (high blood pressure), Cerebrovascular Accident (stroke), non-Alzheimer's dementia, hemiplegia (Muscle weakness or partial paralysis on one side of the body). The MDS further reflected Resident #46 did not have a BIMS due to having severely impaired cognition and he had a feeding tube. 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 record review and interviews the facility failed to provide or obtain laboratory services to meet the needs of its residents in a timely manor for 1 (Resident #77) of 5 residents reviewed for laboratory services in that The facility failed to follow physician orders for routine lab work for Resident #77, resulting in the lab not being performed. This failure could result in missing resident's medical conditions getting worse. Findings included: Review of Resident # 77's undated admission Record revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia, diabetes, vitamin deficiency, high cholesterol, and bipolar disorder. Review of Resident #77's annual MDS assessment, dated 2/02/24, revealed a BIMS score not calculated due to the resident's dementia. Her Functional Status assessment indicated she required substantial assistance with her ADLs. Review of Resident #77's care plan, dated 2/23/24, revealed she had a self-care deficit, limited 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 observation, interview, and record review, the facility failed to provide food prepared by methods, which conserved nutritive value, flavor, and appearance for one of one pureed meal observed for nutrition. The Dietary Manager failed to ensure the pureed lunch meal on 03/24/24 was prepared according to the recipe to conserved nutritive value and flavor. The failure could place residents, who were on a pureed diet, at risk for a decrease in nutritive status, loss of appetite, decreased intake and unwanted weight loss. Findings included: Observation on 03/24/24 at 10:55 AM of the Dietary Manager preparing the pureed lunches revealed she put shredded turkey pieces, hot water, and thickener into a blender. She then blended the mixture. The pureed meat appeared to have a pudding consistency. The Dietary Manager then mixed stuffing which included the stuffing, thickener, and hot water. Interview on 03/24/24 at 11:11 AM with the Dietary Manager revealed she was notified by her morning cook that surveyors were in the building, and she was nervous. She stated she came in to assist.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for one (Resident #6) of five residents reviewed for radiology services. The facility failed to properly enter a request for an x-ray on 01/27/24 after Resident #6's spouse report swelling at the right hip and that he had pain when he was being changed or repositioned. This failure placed residents at risk of a delay in medical evaluation and treatment, pain, and a decrease in quality of care. Findings included: Review of Resident #6's face sheet dated 02/15/24 revealed the resident was an [AGE] year-old-male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #6's diagnosis included aftercare following joint replacement surgery,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for one (Resident #6) of five residents reviewed for radiology services. The facility failed to retrieve results of an x-ray order of Resident #6's right hip in a timely manner. This failure placed residents at risk of a delay in medical evaluation and treatment, pain, and a decrease in quality of care. Findings included: Review of Resident #6's face sheet dated 02/15/24 revealed the resident was an [AGE] year-old-male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #6's diagnosis included aftercare following joint replacement surgery, other reduced mobility, unspecified dementia, hypertension (high blood pressure), unsteadiness…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections of 4 (ADON B, CNA C, Medical Records and Dietary Supervisor) of 6 staff members reviewed for infection control practices. The facility failed to ensure ADON B, CNA C, Medical Records and Dietary Supervisor donned proper PPE prior to entering the COVID Unit. This failure could place residents at risk of cross-contamination and infections such as COVID-19. Findings included: Review of the facility's line list COVID positive Residents/Staff List revealed Resident #1 and Resident #2 tested positive for COVID on 02/04/24, Resident #3 tested positive for COVID on 02/06/24, Resident #4 tested positive for COVID on 02/07/24 and Resident #5 on 02/13/24. Interview on 02/15/24 at 9:02 AM with the Administrator and DON revealed the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 4 residents (Resident #1) reviewed for pressure ulcers. The facility failed to ensure the pressure ulcer on Resident #1's sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis) was covered with a dressing as ordered, and failed to ensure the dressings on both heels and on the right hip were dated. This failure could affect the residents, who received pressure ulcer care, by placing them at risk for contamination of their wounds and causing unnecessary infections and worsening of pressure ulcers. Findings included: Record review of Resident #1's face sheet dated 11/29/23 revealed the resident was a [AGE] year-old male who was admitted into the facility 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.