Wedgewood Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 5 residents (Residents #10) reviewed for ADL care. The facility failed to ensure Resident #10's fingernails were kept trimmed. These failures could place the residents at risk of infections or injuries. Findings included: Record review of Resident #10's undated admission Record reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included myopathy (muscle weakness and involuntary muscle movement), reflux, unsteadiness on feet, and failure to thrive. Record review of Resident #10's annual MDS Assessment, dated 12/16/24, reflected a BIMS score of 6 indicating severe cognitive impairment. Her Functional Abilities assessment indicated she required assistance for her personal hygiene. Record review of Resident #10'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 ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 1 of 3 residents (Resident #25) reviewed for contracture management The facility failed to provide equipment/services for Resident #25's right hand contracture (a permanent tightening of the muscles). This failure could place residents at risk for a decline in range of motion, decreased mobility, worsening of contractures, and a decline in physical capabilities. Findings included: Record review of Resident #25's MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included aphasia (language disorder that affects a person's ability to communicate), hemiplegia (muscle weakness or partial paralysis on one side of the body). The MDS further reflected Resident #25 has memory problems. Record 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 that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 6 residents (Resident #67) reviewed for respiratory care. The facility failed to ensure there was a physician order for Resident #67's tracheostomy care, suction tubing, and emergency trach kit. This failure could place residents with a tracheostomy requiring tracheostomy care at risk for respiratory distress, hospitalizations, and a decline in their quality of life. Findings included: Record review of Resident #67's admission Record dated 01/16/25 reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #67's quarterly MDS assessment dated [DATE] reflected his diagnoses included cerebral…

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 prepared in a form designed to meet individual needs for 1 or 2 meals (lunch) reviewed for food meeting residents' needs. The facility failed to prepare and serve pureed mash potatoes as a pudding consistency for residents who required pureed diets during the lunch meal on 01/15/25. This deficient practice could affect residents and place them at risk of not receiving meals that meet their needs Findings included: Record review of Week-At-A-Glance Texas 4 Week 4 menu revealed the menu for the lunch service was . Boiled Potato . Observation on 01/15/25 at 11:16 AM of the Dietary Manager pureed mashed potatoes with a hand whisk, was observed removing the potato skins and then proceeded to place it on the steam table. The Dietary Manager did not check the consistency or ensure it was all blended to have a pudding consistency. Observation of the test tray on 01/15/25 beginning at 12:55 PM with the Dietary Manager, the test tray included the regular textured menu items and the pureed menu items.…

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 and interviews 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 (Residents #5 and #60) of five residents reviewed for infection control. MA D failed to sanitize a re-useable blood pressure cuff between uses on Resident #5 and Resident #60. This failure could place the residents at risk of exposure to infections. Findings included: Record review of Resident #5's undated admission Record reflected he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included kidney disease, diabetes, high blood pressure, and heart failure. Record review of Resident #5's quarterly MDS assessment, dated 11/20/24, reflected a BIMS score of 12 indicating he was cognitively intact. His Functional Assessment indicated he required assistance with all of his ADLs. Record 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 a safe, functional, sanitary, and comfortable environment for 4 of 5 rooms (Rooms 221, 225, 229, and 231) reviewed for environmental conditions. The facility failed to maintain Rooms 221, 225, 229, and 231 in a safe and sanitary condition. The failure placed residents at risk for infection and decreased quality of life. Findings included: Observation on 10/01/24 at 10:56 AM of room [ROOM NUMBER] revealed a vent cover measuring approximately 10 inches by 10 inches on the ceiling was covered with dark debris. When looking through the vent, it appeared to have thick black dust and debris. room [ROOM NUMBER] had a silver ceiling rail hanging from the ceiling. Observation on 10/01/24 at 11:21 AM of room [ROOM NUMBER] revealed a vent cover measuring approximately 10 inches by 10 inches on the ceiling over resident bed revealed the vent was completely covered with black debris identical to mold, dust and dirt. When looking through 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 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 1 of 5 residents (Resident #1) reviewed for ADL care. The facility failed to provide Resident #1 assistance with timely incontinence care. This failure could place the residents at risk for decreased feelings of self-worth, skin breakdown, and infection. Findings included: Record review of Resident #1's face sheet, dated 10/01/24, reflected the resident was a [AGE] year-old female, admitted to the facility on [DATE], and readmitted on [DATE]. Resident #1's diagnoses included stroke, hypertension (high blood pressure), peripheral artery disease (disorder that causes abnormal narrowing of the arteries), hemiplegia (loss of the ability to move one entire side of the body), dementia (general decline in ability to perform everyday tasks), seizure disorder (uncontrolled…

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, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments for 1 of 4 (Medication Cart 1) medication carts reviewed for storage of medication. The facility failed to ensure that medications were secured inside the medication cart on 100 halls on 04/30/24. This failure could place residents at risk of overdosing and drug diversions by staff and visitors. Findings included: In an observation on 04/30/24 at 9:20 AM, the medication cart on the 100 halls was unlocked and unattended. Resident #3 was observed sitting in her wheelchair next to the unlocked medication cart, and Resident # 1 was observed independently propelling in his wheelchair a total of 3 times within 12 inches of the unlocked medication cart at 9:25 AM. The surveyor supervised the medication cart until assigned staff returned. At 9:28 AM the assigned medication person had not returned. The surveyor called for CNA L 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 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 3 residents (Resident #1) reviewed for Care Plans. The facility failed to ensure Resident #1's Care Plan was reviewed and updated quarterly, based on record reviews made on 04/30/24. This failure could place residents at risk of their needs not being met. Findings included: Record review of Resident #1's face sheet, dated 04/30/24, revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: Cerebral infarction (stroke), age related nuclear cataract (age related condition affects the lens of the eye), Depression (mental state of low mood), anxiety (fearful, worrying). Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 15, indicating the resident was cognitively…

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 establish and implement policies addressing resident admission to the facility for one (Resident #1) of three residents reviewed for admissions. The facility failed to provide Resident #1 with an admission packet upon admission. This failure could affect residents by placing them at risk for not being aware of what services the facility is providing. Findings included: Review of Resident #1's facesheet printed on 03/14/24 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (heart attack), aphagia (difficulty speaking), muscle weakness, dysphagia (difficulty swallowing), need for assistance for personal care, and seizures. Review of Resident #1's progress notes revealed she was discharged from the facility on 02/05/24. Interview on 03/13/24 at 10:25 AM with Resident #1's family revealed when Resident #1 was admitted to the facility, they were not asked to fill out any type 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 maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 4 residents (Residents #1 and #2) reviewed for accuracy of records. 1. The facility failed to ensure Resident #1's wound care was documented on the TAR for 01/13/24, 01/14/24, and 01/21/24. 2. The facility failed to ensure Resident #2's wound care was documented on the TAR for 01/15/24 and 01/29/24. This deficient practice could result in misinformation about professional care provided. The findings included: Resident #1 A record review of Resident #1's electronic face sheet, dated 01/31/24, reflected he was an [AGE] year-old man, who admitted to the facility on [DATE]. Resident #1's diagnosis included unsteadiness on feet, muscle weakness, diabetes, rheumatoid arthritis (a chronic (long-lasting) autoimmune disease that mostly affects joints), and osteoarthritis (a degenerative joint disease, in which 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 reveiw, the facility failed to ensure residents were provided a safe, clean, and comfortable and homelike environment for 13 of 25 rooms (Rooms #120, 121, 123, 125, 127, 130, 131, 216, 219, 220, 221, 223, and 231) reviewed for homelike environment. 1.The facility failed to ensure Rooms #120, 121, 123, 125, 127, 130, and 131 were supplied with warm water to the resident's sinks. 2. The facility failed to ensure Rooms #216, 219, 220, 221, 223, and 231 were provided with clean air vents. These failures could place the residents at risk of discomfort from not having warm water to wash their hands. Findings included: 1. Observation on 12/18/23 at 9:10 AM of room [ROOM NUMBER] revealed the resident's sink hot water tap supplied lukewarm water after the water ran for 3 minutes. Observation on 12/18/23 at 9:15 AM of room [ROOM NUMBER] revealed the resident's sink hot water tap had no water flow, and water was only available from the cold water tap. Observation on 12/18/23 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, revealed the facility failed to refer all level II residents and all residents with new evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 2 (Residents #20 and #68) of 5 residents reviewed for PASARR requirements. 1. The facility failed to refer Resident #20 who had a diagnosis of PTSD to the local authority. 2. The facility failed to refer Resident #68 who had a positive PASRR Level I to the local authority. These failures could place the residents at risk of not receiving possible specialized services available to them. Findings included: Review of Resident #20's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including traumatic brain injury, PTSD, mild cognitive impairment, and anxiety. Review of Resident #20's quarterly MDS assessment, dated 11/21/23, revealed a BIMS score…

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 3 of 8 residents (Residents #23, #40, and #53) reviewed for comprehensive care plans. 1. The DON failed to ensure Resident #23's care plan was updated to include her use of an indwelling catheter. 2. The Treatment Nurse failed to ensure Resident #40's care plan was updated to include his wound and wound care. 3. The Treatment Nurse failed to ensure Resident #53's care plan was updated to include his wounds and wound care. These failures could place the residents at risk of deterioration of their wounds and not receiving proper care with indwelling catheters. Findings included: Review of Resident #23's undated admission Record revealed Resident #23 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic kidney disease (stage 4), urethrocele (urethra pushed down into the vaginal canal), presence of urogenital implants (devices that support 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 that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for 2 of 6 residents (Resident #75 and Resident #72) reviewed for respiratory care, in that: 1. The facility failed to date the oxygen tubing and humidifier bottle when not in use for Resident #75 as ordered by the physician. 2. The facility failed to ensure Residents #72 orders for oxygen administration were being accurately provided. This deficient practice placed residents that received oxygen therapy at risk for inadequate care and respiratory infection. Findings included: 1. Review of Resident #75's face sheet dated 12/21/23 revealed the resident was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #75's active diagnoses included tracheostomy status (a procedure to help air and oxygen reach the lungs by creating an opening into 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 maintain an effective pest control program to ensure the facility was free of pests for 2 (North and South Stations) of 2 stations, 1 of 1 conference room and 1 of 1 dining 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 foodborne illness and/or disease spread by pests. Findings included: Multiple observations between 12/18/23 at 9:15 AM and 12/20/23 at 4:00 PM revealed gnats in the North Station and South Station, Conference Room and Common Dining Rooms. Observation and interview on 12/18/23 at 2:04 PM revealed Resident #3 lying in her bed. Resident #3 stated she was doing well. She stated her room was cleaned almost every day; however, she had been having issues with gnats in her room. Observed about 3-4 gnats in Resident #3's room. Resident #3 stated the gnats annoyed her. She…

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 was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 of 8 residents (Residents #23) reviewed for dignity. The facility failed to promote Resident #23's dignity by not covering her urinary catheter collection bag with a privacy bag. This failure could place residents with catheters at risk for a loss of dignity, decreased self-worth and decreased self-esteem. Findings included: Review of Resident #23's undated admission Record revealed she was a [AGE] year old female, admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic kidney disease (stage 4), urethrocele (urethra pushed down into the vaginal canal), presence of urogenital implants (devices that support the urethra and bladder neck when you exert pressure) , retention of urine, calculus of kidney (kidney…

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 for the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 5 residents (Resident #11) reviewed for call lights. The facility failed to ensure Resident #11's call light was accessible. This failure placed the resident at risk of falling, further injury, and unnecessary pain from not being able to call for help. Findings included: Review of Resident #11's face sheet revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] and 01/26/20 with diagnoses that included dementia, schizoaffective disorder, muscle weakness, lack of coordination, unsteadiness on feet, history of falls, unspecified incontinence and unspecified convulsions and seizures. Review of Resident #11's MDS, dated [DATE], revealed the resident had intact…

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 at the time each resident was admitted , the facilty had a physician order for the resident's immediate care for 2 of 8 residents (Resident #23 and Resident #60) reviewed for residents receiving necessar care and services upon admission. 1. The facility failed to ensure that Resident #23 had a current order for use of indwelling catheter after readmission to the facility. 2. The facility failed to ensure that Resident #60 had a current order for dialysis after readmission to the facility. This failure could place residents at risk of not receiving the appropriate care as ordered by the physician. Findings included: 1. Review of Resident #23's undated admission Record revealed the resident was a [AGE] year-old female, admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic kidney disease (Stage 4), urethrocele (urethra pushed down into the vaginal canal), presence of urogenital implants…

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 assessments accurately reflected the resident status for 1 of 12 residents (Resident #36) reviewed for MDS assessment accuracy. Resident #36's quarterly MDS assessment dated [DATE] was coded incorrectly for dialysis treatment when she was not receiving dialysis treatment. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Review of Resident #36's face sheet dated 12/21/2023 indicated Resident #36 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #36 had a diagnoses of essential hypertension (high blood pressure), chronic pain, muscle wasting and atrophy and stiffness of unspecified joint. Review of Resident #36's quarterly MDS dated [DATE] revealed Resident #36 had a BIMS score of 15 which indicated cognition was intact. The MDS Assessment for Resident #36 revealed Special Treatment for Dialysis. Review of Resident #36's care plan,…

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 pain management was provided to residents who require such services, consistent with professional standards of practice for 1 of 7 residents (Resident #10) reviewed for pain management. The facility failed to ensure Resident #10's pain control was maintained at a level acceptable to the resident. This failure could place the resident at risk of a decrease in quality of life due to pain. Findings included: Review of Resident #10's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included paraplegia, decreased mental cognition, and chronic pain related to osteoarthritis. Review of Resident #10's quarterly MDS assessment, dated 10/25/23, revealed a BIMS score of 15, indicating he was cognitively intact. His Functional Status indicated his mobility was via electric wheelchair, he required maximal assistance with his ADLs. Review of Resident #10's care plan, dated…

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 be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area, for 2 of 83 residents (Residents #45 and #65) reviewed for call lights. The facility did not adequately equip Resident #45 and Resident #65 with a call light to allow residents to call for assistance. This failure could place residents who rely on the call light system to have a delayed response or no way contact staff to meet their needs. Findings included: Review of Resident #45s Face sheet, dated 12/21/23, revealed the resident was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of essential hypertension (high blood pressure), muscle weakness, type 2 diabetes mellitus and lack of coordination. Review of Resident #45's quarterly MDS assessment, dated 11/15/23, revealed a BIMS score of 14 which indicated the resident's cognition was intact. 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 residents received services in the facility with reasonable accommodation of each resident's needs, for one Resident (Resident #1), of 12 residents reviewed for services and needs in that: The facility did not assist Resident #1 to get out of bed when multiple requests were made due to not having a wheelchair available for her. This failure could place all residents who are bedfast at risk of not having their needs and preferences met and a decreased quality of life. Findings included: Record review of Resident #1's face sheet, dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: disruption of external operation surgical wound. Record review revealed Resident #1 did not have a completed admission MDS assessment. Record review revealed Resident #1 did not have a completed care plan. Record review of Resident #1's Progress Note by LVN C, dated [DATE] at 10:35…

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 have physician orders for the resident's immediate care for one (Resident #1) of twelve residents reviewed for admission physician orders. The facility failed to have complete and accurate admission physician order for Resident #1. This failure could affect all residents by placing them at risk for not receiving the appropriate care, medication, and treatment services. Findings included: Record review of Resident #1's face sheet, dated 10/23/23, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: disruption of external operation surgical wound. Record review of the EHR revealed Resident #1 did not have a completed admission MDS assessment. Record review of the EHR revealed Resident #1 did not have a completed care plan. Record review of Resident #1's Progress Note by LVN R, dated 10/16/23 at 9:35 PM, revealed The resident is diabetic and requires monitoring and management 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 establish and 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 one of four staff (CNA A) reviewed for infection control practices. 1. The facility failed to ensure Resident #1's door was closed while being on isolation for COVID-19. 2. CNA A failed to don proper PPE prior to entering Resident #1's room, who was on isolation for COVID-19. 3. CNA A failed to perform hand hygiene when passing out lunch trays for residents on the North Hall. These failures could place residents at risk of cross-contamination and infections such as COVID-19. Findings included: Record review of Resident #1's face sheet, dated 09/08/23, revealed a [AGE] year-old-male who was admitted to the facility on [DATE]. The resident had diagnoses which included Wernicke's encephalopathy (memory 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 ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #2) of three residents reviewed for accidents. Hospitality Aide D failed to transfer Resident #2 with the assistance of another staff person during a Hoyer transfer. This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life. Findings included: Review of Resident #2's MDS, dated [DATE], revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included end stage renal disease, non-Alzheimers dementia, chronic obstructive pulmonary disease, obesity, dependence on renal dialysis, and chronic pain. The MDS further reflected Resident #2 required total assistance of two or more staff. Review of Resident #2's, undated, care plan revealed the resident had a performance deficit related to cognitive impairment, functional…

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.