Hollymead

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure the MDS assessment accurately reflected the resident status for 2 (Resident #71 and Resident #67) of 8 residents whose records were reviewed for assessment accuracy. 1. Resident #67's colostomy status was not coded on his 03/14/25 Quarterly MDS after readmission on [DATE]. 2. Resident #71's attention deficit hyperactivity disorder diagnosis was not listed on his 03/05/25 Quarterly MDS. This failure to ensure comprehensive and accurate assessments could affect residents by placing them at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services. Findings included: 1-Record review of Resident #67's 03/14/25 Quarterly MDS, reflected he was an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of heart failure, chronic kidney disease, acute respiratory failure (lung failure). He had intact cognition with a BIMS score of 14. 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.

Based on observation, interview, and record review the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for one (Resident #5) of two residents observed during a transfer. The Facility failed to ensure CNA K used a gait belt when transferring Resident #5 from her bed to the wheelchair on 04/22/2025. This failure could affect the residents by placing the residents at risk for falls, discomfort, pain, and/or injury. Findings included: Record review of Resident #5's Quarterly MDS assessment, dated 03/13/25, reflected an admission date of 11/29/23. Resident #5' active diagnoses included weakness and other abnormalities of gait and mobility. Resident #5 had a BIMS score of 06, meaning her cognition was severely impaired. she required maximal assist with transfers from a bed to a wheelchair. Record review of Resident #5's care plan, dated 03/19/25, reflected Focus .The resident has potential risk for injury due to unsafe independent transfers . Goal: The resident will be free from injury . Interventions included .to be transferred…

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 incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of two residents (Resident #1) reviewed for catheter care. 1. The facility failed to ensure CNA B provided catheter care and appropriate perineal care for Resident #1 when she failed to separate the labia and wash downward, failed to clean under the resident's skin folds and failed to clean around the suprapubic catheter (catheter that is inserted through the abdominal wall into the bladder) on 04/23/25. 2. The facility failed to ensure RN A maintained a sterile procedure while re-inserting Resident #1's suprapubic catheter on 04/23/25. This failure could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown. Findings included: Record review of resident #1s quarterly MDS assessment, dated 02/28/25, reflected a [AGE] year-old female with an admission…

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 for 2 of 21 residents (Resident #1 and Resident #5) observed for infection control. 1. The facility failed to ensure RN A used the required PPE for Resident #1, who was on enhanced barrier precautions due to her indwelling urinary catheter, while changing the indwelling urinary catheter on 04/23/25. 2. The facility failed to ensure CNA K changed her gloves and performed hand hygiene while providing incontinence care to Resident #5 on 04/22/25. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: 1. Record review of resident #1s quarterly MDS assessment, dated 02/28/25, reflected a [AGE] year-old female with an admission date of 08/01/24. She had a BIMS score of 15…

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 fed by enteral means received the appropriate treatment and services to prevent complications for 1 (Resident #1) of 2 residents reviewed for enteral nutrition. The facility failed to ensure Resident #1's correct G-tube feeding was administered as ordered by the physician on 2/19/25. This deficient practice could affect residents who receive tube feedings by not receiving the appropriate nutrition and hydration. Findings included: Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed that Resident #1 was an [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included Stroke ( interrupted blood flow to the brain) , Hypertension (high blood pressure), Diabetes Mellitus (high blood glucose), Hyperlipidemia (high blood lipids), Anxiety Disorder, Depression, Malnutrition. Resident #1 had a G-tube. Resident #1 had BIMS score of 11 suggesting moderate cognitive impairment. 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 observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 (Resident #1) of 2 residents observed for infection control. The facility failed to ensure LVN A donned the appropriate PPE (personal protective equipment) required for EBP (enhanced barrier precautions) during administering G-tube (external tube inserted in the stomach to provide nutrition and hydration) for Resident #1 who was on enhanced barriers precautions on 2/19/25. These failures could place residents at risk for infection and cross contamination of pathogens and illness. Findings included: Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed that Resident #1 was an [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included Stroke (interrupted blood flow to the brain), Hypertension (high blood pressure), Diabetes Mellitus (high blood glucose), Hyperlipidemia (high blood lipids),…

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 treat residents with respect and dignity for 1 of 4 (Resident #1) residents reviewed for dignity in that: The facility failed to ensure staff did not stand over Resident #1 while assisting the resident with her meal in her room on 11/13/2024. This failure could affect residents who require assistance with activities of daily living and place them at risk for psychosocial harm due to a diminished quality of life. The findings were: Record review of Resident #1's electronic face sheet, dated 12/31/24 reflected a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #1 had a diagnosis of Metabolic Encephalopathy (brain dysfunction caused by a chemical imbalance), Vascular Dementia (condition that affects memory, thinking, and behavior), Low Back Pain, Anorexia (eating disorder that causes people to obsess about weight and what they eat), Fracture of shaft of Right Humerus (upper arm bone), Fracture of Left Forearm (bone…

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 the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #3) of 8 residents reviewed for ADLs. The facility failed to ensure Resident #3 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: A record review of Resident #3's Quarterly MDS assessment dated [DATE] reflected Resident #3 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included cerebral infarction (a loss of blood flow to part of the brain, which damages brain tissue), hemiplegia (paralysis of one side of the body), and other lack of coordination. Resident #3 had a BIMS score of 15 which indicated Resident #3's cognition was intact. He required extensive assistance with personal hygiene.…

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 needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 2 Residents (Resident #1) reviewed for respiratory care. The facility failed to ensure Resident #1's nasal cannula tubing was labeled or dated. This failure could place residents at risk of respiratory infections. The finding were: Record review of Resident #1's admission MDS assessment, dated 06/24/2024, reflected Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's relevant diagnoses included Chronic Obstructive pulmonary disease (lung disease that block airflow and make it difficult to breathe), Diabetes mellitus (high blood sugar levels) and Hyperlipidemia (high levels of lipid in blood) and Hypertension (high blood pressure). Resident#1 had BIMS of 9 , which indicated moderate…

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 The facility failed to provide Resident #2 a divided plate to assist her with eating independently. This failure could affect residents who depended on assistive devices and infringe on the resident's dignity and feeding independence. Findings included: Record Review of Resident #2 Annual's MDS assessment dated [DATE] revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE]. Her relevant diagnoses included: Hypertension (high blood pressure), Hyperlipidemia (high blood lipid levels), Hemiplegia (paralysis of half side of the body related to brain damage), Chronic Obstructive Pulmonary disorder (lung disease that block airflow and make it difficult to breathe), and Respiratory failure. Resident #2 had BIMS score of 12 which reflected Resident #2 had moderately impaired cognition. Resident #2 was independent with use of suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. Record review of Resident #2's…

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 one of one resident (Resident #4) observed for infection control. The facility failed to ensure CNA D and CNA E performed hand hygiene while providing incontinence care to Resident # 4. This failure could place the residents at risk for infection. Findings include: A record review of Resident #4's Quarterly MDS assessment, dated 06/28/2024, reflected Resident #4 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included hemiplegia (paralysis of one side of the body) following cerebral infarction (a loss of blood flow to part of the brain, which damages brain tissue) affecting left side. Resident #4 had a BIMS score of 06 which indicated Resident #4's cognition was severely impaired. Resident#4 required extensive assistance of 2-person physical assistance with toileting hygiene and bathing. In an…

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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of five residents reviewed for medications. -The facility failed to have Resident #1's Hydromorphone (used to manage pain) available for administration, which caused the resident to miss two doses. This failure could place residents at risk of not receiving their medication treatment(s) as ordered by the physician to receive the full therapeutic benefit. Findings included: Record review of Resident #1's face sheet, dated 4/30/24, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: unspecified pain, schizoaffective disorder (mood disorder), type II diabetes, epilepsy (seizure disorder), kidney failure, hypertension (high blood pressure), edema (swelling caused by trapped fluid…

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 and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed to label and date food in the walk-in freezer. 2. The facility failed to date food stored in the walk-in refrigerator that should no longer be consumed. 3. Cook B failed to wear effective hair restraint while serving food. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed, and food contamination. Findings included: Observations on 03/19/24 at 9:45 AM revealed Pie shells in the walk-in freezer were not labeled or dated. Observations on 03/19/24 at 9:49 AM revealed several sausage patties in the walk-in refrigerator were left opened in a plastic bag. Observations on 03/19/24 at 12:22 PM revealed that [NAME] B was wearing a hat with a bun and hair exposed below the hat line while serving food in the kitchen. He was not wearing a hair net 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 develop and implement a comprehensive person-centered care plan for each Resident, consistent with Resident rights, that include measurable objectives and time frames to meet Residents' mental and psychosocial needs for 1 of 4 (Resident #51) residents reviewed for care plans. The facility did not develop and implement a comprehensive person-centered care plan to address Resident # 51's use of dietary preferences and food intolerance. This failure could place resident at risk of not having a plan developed to address care needs. Findings include: Record review of Resident #51 Quarterly MDS dated [DATE] revealed that Resident #51 was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included Deep vein thrombosis (occurs when a blood clot forms in one or more deep veins in the body) , cerebrospinal fluid leak ( fluid leaking through a tear or hole surrounding the brain), and depression (common mental disorder).…

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 assist residents in obtaining routine and 24-hour emergency dental care for one of 5 residents (Residents #29) reviewed for dental services. The facility failed to provide a timely dental service referral for Resident #29. This failure could place residents at risk of oral infection, dental pain, and diminished quality of life. Findings include: Record review of Resident #29 MDS dated [DATE] revealed she was an [AGE] year-old female admitted on [DATE] diagnoses of major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), type-2 diabetes (high blood sugar levels), reduced mobility, lack of coordination, hypertension (high blood pressure), hyperlipidemia (fats in blood) and a BIMS score of 13 (cognition intact). Observation on 03/20/2024 at 2:00 PM of Resident #29 revealed she had multiple missing teeth to both sides of her jaw and on the upper and lower portion of her jaw with dark, black,…

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 each resident received food that accommodated their preferences for one (Resident #51) of four residents reviewed for dietary services. The facility failed to honor Resident #1's preferences which stated no pork, no fish, no eggs, and no lettuce. This failure could place residents at risk for not having their choices and food preferences accommodated, and a diminished quality of life. Findings include: Record review of Resident #51 Quarterly MDS dated [DATE] revealed that Resident #51 was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included Deep vein thrombosis (occurs when a blood clot forms in one or more deep veins in the body) , cerebrospinal fluid leak ( fluid leaking through a tear or hole surrounding the brain), and depression (common mental disorder). Record review revealed that Resident #51 did not have a care plan for food preferences and food intolerances. Record review of Resident #51…

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 for two (Resident #17, and Resident #63) of seven residents reviewed for infection control. - RN A failed to sanitize the blood pressure cuff between uses on Resident # 17 and Resident # 63. Theses failures could place residents at risk for infection and cross contamination. Findings include: -Record review of Resident #17's face sheet, dated 03/21/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #17 had diagnoses which included hypertension, type 2 diabetes mellitus, dementia (dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). -Record review of Resident #63's…

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 the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for one (Resident #1) of five residents reviewed for ADLs. The facility failed to ensure Resident #1 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for infections, and a decreased quality of life. Findings include: Record review of Resident #1's face sheet, printed on 02/27/24, reflected a 89-year-ild male who admitted to the facility on [DATE], with diagnoses of cognitive communication deficit, heart failure, generalized muscle weakness, vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain), age-related physical debility, hypokalemia (low potassium ); dementia(the loss of cognitive functioning), lack of coordination; spondylosis (abnormal…

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 that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 4 of 4 residents (Resident #2, Resident #5, Resident #12, and Resident #31) reviewed for respiratory care. The facility failed to ensure Resident #2, Resident #5, Resident #12, and Resident #31 had oxygen concentrator filters free of sediment and debris. This failure could place residents at risk of not receiving proper delivery of oxygen, cross contamination, respiratory compromise and/or infection and residents not having their respiratory needs met. Findings included: 1. Record review of Resident #2's face sheet, dated 02/08/23, revealed an [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had diagnoses which included Lung Disease (disease of the lung which may lead to respiratory failure), Parkinson's…

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 was stored, prepared, distributed and served in accordance with professional standards for food service safety for one of the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure foods were dated and labeled in the refrigerator and dry storage rooms. 2. The facility failed to ensure expired foods were discarded. 3. The facility failed to ensure food in the food preparation area was covered. These failures could place residents at risk for cross contamination and other bacteria illnesses. Findings include: An Observation on 2/7/2023 at 10:25 AM of the facility cooler revealed the following: -1 large container of Italian Dressing, dated January 4th. The year was not listed. -1 Large opened container of Mayo, dated January 12, 2022. -1 bottle of half used Teriyaki Sauce, dated January 16. The year was not listed. -1 bottle of, undated, Soy Sauce. -1 Worchester expired November 8, 2021. -2 Gallons of prepared tea, dated expiration date 10/22. -1 cardboard box 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 interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident right, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 1 residents reviewed for care plans. The facility failed to ensure Resident #12's Care Plan was comprehensively developed and implemented to meet the residents needs. This failure could place residents at risk of their needs not being met. Findings include: Record review of Resident #12's face sheet, dated 02/09/23, revealed an [AGE] year-old female admitted to the facility on [DATE]. Resident #12 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and mental functions), Dementia (loss of memory, language , or problem solving skills) , Hypotension(low blood pressure), and Stroke(damage to the brain resulting 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, which included both the comprehensive and quarterly review assessments for 1 of 6 residents (Resident #49) reviewed for Care Plans. The facility failed to ensure Resident #49's Care Plan was reviewed quarterly. This failure could place residents at risk of their needs not being met. Findings include: Record review of Resident #49's face sheet, dated 02/09/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Chronic Bladder Pain, Shortness of breath, Type 2 Diabetes, and Major Depressive Disorder. Record review of Resident #49's Minimum Data Set (MDS), dated [DATE], revealed she required a two -person physical assist for all Activities of daily Living Assistance (ADL), and the use of a wheelchair. Record review of Resident #49's Care Plan, dated 02/09/2023, revealed the resident's last…

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 that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of one residents (Residents #20) reviewed for urinary catheters. The facility failed to ensure Resident #20's urinary catheter bag was off the floor. These failures could place residents at risk of cross-contamination and infections. Finding include: Record review of Resident #20's face sheet, dated 2/9/2023, revealed an [AGE] year-old female who was initially admitted to the facility on [DATE]. Resident #20 had diagnoses which included Pressure ulcer of sacral region, stage 4, Long term current use of antibiotics, dehydration, Record review of Resident #20's quarterly MDS assessment revealed Section H was incomplete and did not address Resident #20's catheter. Record review of Resident #20's Nursing Admission/readmission Assessment, dated 06/24/22, revealed This Section Not Applicable Section 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.