Lytle Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments person-centered care plan to reflect the current condition for 2 of 16 residents (Resident #4 and Resident #7) reviewed for care plan revisions. 1. The facility failed to ensure Resident #4's comprehensive care plan was updated to reflect she had a left hand contracture. 2. The facility failed to ensure Resident #7's comprehensive care plan was updated to reflect she was on Hospice services, was receiving oxygen and was receiving wound care. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included: 1. Review of Resident #4's annual assessment, dated 6/2/23, revealed she was admitted to the facility on [DATE] with diagnoses including Hypertension (high blood pressure 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 the physician reviewed the resident's total program of care, including medication and treatments, at each visit and wrote, signed and dated progress notes at each visit for 7 of 14 Residents (Resident #4, Resident #7, Resident #15, Resident #17, Resident #40, Resident #45 and Resident 200) reviewed for physician visits. The facility failed to ensure resident orders were signed by a physician, physician progress notes were available for Residents, were signed and dated by the physician(s) for each visit via the physical charts, and residents were seen by a physician at least once every 30 days for the first 90 days after admission, then at least once every 60 days thereafter. These failures could place residents at risk for not receiving appropriate care per physician orders and required oversight by the physician and could place the residents at risk for harm and overall physical health decline. Findings included: 1. Review of Resident #4'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 interviews and record reviews, the facility failed to maintain medical records on each resident that are-accurately documented for 3 of 12 residents (Resident #15, Resident #45, and Resident #200) reviewed for accurate medical records in that: 1. The facility failed to document Resident #15's refusal to attend medical appointments. 2. The facility failed to ensure nursing staff completed documentation for Resident #45's nephrostomy care in March and April of 2024. The facility failed to completed medication consent forms for Resident #45. 3. The facility failed to ensure nursing staff wrote a progress note reflecting when and what hospital Resident #200 was sent to after she fell on 5/4/24. These deficient practices could affect residents who have medical records and could result in misinformation about professional care provided. The findings included: 1. a. Record review of Resident #15's face sheet revealed a [AGE] year-old male was admitted on [DATE] and readmitted on [DATE] with diagnoses 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 observations, interviews, and record reviews, 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 disease and infection for 1 of 7 residents (Resident #45) reviewed for infection control, in that: The facility failed to ensure LVN A used sanitized scissors, followed hand hygiene, and followed procedure for sterile technique while providing nephrostomy care to Resident #45. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: 1. Record review of Resident #45's face sheet, dated 11/06/23, revealed Resident #45 was admitted to the facility on [DATE] with diagnoses of Diffuse traumatic brain injury with LOC of unspecified duration ( a brain injury that affects multiple areas of the brain. It is caused by the shearing of the brain's long connecting nerve fibers (axons) when 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, interviews, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 1 of 3 resident shower rooms (B Hallway) observed for resident environment. The facility failed to ensure the B hallway bathroom was clean. There was a black substance on the bathroom tile, a foul smell, and broken tiles on the floor. This failure could place residents at risk for an unsafe and unsanitary environment. The Findings included: During an observation and interview on 5/25/24 at 5:43 p.m. the B hallway shower had a strong odor of sulfur, the floor and shower wall had black stops all over it, approximately half foot hole in the shower floor with white cloudy water, and the trim plate was missing around the shower faucet. The DON stated she could not smell the bathroom. The DON stated she would not want her family to have to use that shower. The DON stated residents who were prone to infection and did not have their feet covered could get an infection from using the shower in that condition. During an interview on…

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

Based on observation, interview and record review the facility failed to conduct an initial comprehensive assessment of each resident's functional capacity including the resident's needs, strengths, goals, life history and preferences for 1 of 5 Residents (Resident 200) reviewed for assessments. The MDS Coordinator failed to complete Resident #200's comprehensive assessment within 14 days after admission, 4/23/24 This deficient practice could affect newly admitted residents and result in residents not receiving the care and services as needed. The findings were: Review of Resident #200's face sheet, dated 5/23/24, revealed she was admitted into the facility on 4/23/24 with diagnoses including Fragile X Chromosome (genetic condition inherited from parents which results in various developmental problems like intellectual disabilities and cognitive impairment) and Severe Intellectual Disabilities. Review of Resident #200's admission nursing assessment, dated 4/23/24, revealed Resident #200 had severe cognitive impairment, she was never understood and did not understand others, required…

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 assessment accurately reflect the resident's status for 1 of 5 Resident's (Resident #4) whose records were reviewed for assessments. The MDS Coordinator failed to code that Resident #4 had a limited range of motion on her upper extremity related to left hand contracture for two, 2 assessment periods, 6/2/23 and 2/15/24 This deficient practice could affect residents and contribute to the resident's not receiving the necessary care and services as needed. The findings were: Review of Resident #4's annual assessment, dated 6/2/23, revealed she was admitted to the facility on [DATE] with diagnoses including Hypertension (high blood pressure and Alzheimer's Disease (a brain disorder that causes memory loss, thinking problems and behavior changes). Further review revealed Resident #4's limited range of motion of her upper extremity related to left hand contracture was not coded. Review of Resident #4's quarterly MDS assessment, 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 interview and record review the facility failed to refer all residents with possible serious mental disorder or a related condition for level II resident review upon a significant change in status assessment for 1 of 6 Residents (Resident #45) whose records were reviewed for mental disorders. The facility failed to refer Resident #45 for a PASARR evaluation based on mental disorder diagnoses including bipolar disorder and anxiety. The facility failed to refer Resident #45 for a PASARR evaluation based on mental disorder diagnoses including manic depression (bipolar disease), anxiety and depression. This deficient practice could affect residents with a mental illness and contribute to a delay in services needed. The findings were: Record review of Resident #45's face sheet, dated 11/06/23, revealed Resident #45 was admitted to the facility on [DATE] with diagnoses of Diffuse traumatic brain injury with LOC of unspecified duration, cerebral infarction, hypertension secondary to other renal disorders,…

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 5 Residents (Resident #7) reviewed for skin integrity. LVN H failed to use adequate hand hygiene during wound care; failed to clarify the order for wound care and failed to follow the order provided by Hospice services for Resident #7's wound on her left great toe. These deficient practices could affect residents who required pressure ulcer treatment and contribute to wounds becoming infected preventing the wounds from healing. The findings were: Review of Resident #7's face sheet, undated, revealed she was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure (long-term condition that happens when your heart cannot pump blood well enough to give your body a normal supply), Hypertension (high…

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 needs respiratory care was provided such care, consistent with professional standards of practice for 1 of 1 Resident (Resident #7) whose record was reviewed for oxygen therapy. Nursing staff failed to clean Resident #7's filter on the oxygen concentrator; it had a layer of lint covering the entire outside of the filter. This deficient practice could affect residents receiving oxygen therapy and could contribute to an upper respiratory infection and a resident's decline in physical health. The findings were: Review of Resident #7's face sheet, undated, revealed she was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure (long-term condition that happens when your heart can ' t pump blood well enough to give your body a normal supply), Hypertension (high blood pressure) and Arthritis (joint disorder). Review of Resident #7's annual MDS assessment, dated 3/6/24, 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 on interview and record review the facility failed to ensure that a physician was notified and provided orders for a resident's immediate care and needs for 2 of 14 residents (Resident #49 and Resident #200) reviewed for physician orders. The facility failed to ensure the Physician personally signed the initial admission orders for Resident #49 and Resident #200. This failure could affect the residents in the facility by placing them at risk for not receiving physician care for their immediate needs. Findings included: 1. Record review of Resident #49's face sheet dated [DATE] was an [AGE] year old female admitted to facility on [DATE]. Her diagnoses included fracture of unspecified part of neck of right femur (the bone that connects in the hip joint), Alzheimer's disease, and severe persistent asthma with status asthmaticus (severe asthma unresponsive to courses of therapy such as inhaled albuterol). Record review of admission Orders dated [DATE] revealed they were signed by a Nurse Practitioner. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 2 of 2 (LVN A and LVN H) nurses reviewed for competent nursing care. 1. The facility failed to ensure LVN A followed facility policy while providing nephrostomy care to Resident #45 when she used contaminated equipment, did not use sterile gloves, and contaminated her hands. 2. The facility failed to ensure LVN H was aware of how to calibrate a glucometer and ensured the glucometer she used to check residents blood glucose daily was calibrated. These deficient practices affect residents who depend on nursing care and could place residents at risk for injury, infection, and harm. The findings included: 1. Record review of Resident #45's face sheet, dated 11/06/23, revealed Resident #45 was admitted…

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 each resident's drug regimen must be free from unnecessary drugs without adequate indications for its use for 1 of 3 Residents (Resident #17) whose record were reviewed for drug regimen. Nursing staff did not obtain a consent from Resident #17's family representative for the use of Depakote (anticonvulsant) used for mood disorder and did not indicate the medication classification on the consent form. These deficient practices could affect residents who received medications for mood disorder and could contribute to the use of unnecessary medications. The findings were: Review of Resident #17's face sheet, undated, revealed he was admitted to the facility on [DATE] with diagnosis including Mood disorder due to known physiological condition. Further review revealed Resident #17 had a family representative who served as his responsible party. Review of Resident #17's quarterly MDS assessment, dated 4/10/24 revealed his BIMS was 11 out 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.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 2 medication carts and 1 of 2 supply storage rooms (C hall and nursing supply room) reviewed for storage of drugs. 1 The facility failed to ensure the nurse supply room patient nourishment refrigerator did not contain staff food, expired products, unlabeled food products, and unsealed food products. 2. The facility failed to ensure the crash cart did not contain expired products. 3. The facility failed to ensure C hall medication cart did not contain loose pills and expired medications in it This deficient practice could place residents at risk of medication misuse and diversion. The findings were: 1. During an observation and interview on 5/24/24 at 10:35 a.m. revealed a refrigerator in the nursing supply room that contained unlabeled food container with a tan color food, a half empty liter of soda, condiment bottles with no labels, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to provide a therapeutic diet, in the appropriate form as prescribed by a physician for 1 of 6 residents (Resident #15) observed for therapeutic diets. The facility failed to provide Resident #15 a mechanical soft diet, as ordered by the physician. This failure could affect residents with physician orders for therapeutic diets and could result in consumption of inappropriate textured food items which could cause choking or aspiration and a decline in health. The findings were: Record review of Resident #15's face sheet revealed a [AGE] year-old male was admitted on [DATE] and readmitted on [DATE] with diagnoses that included acute cerebrovascular insufficiency, major depressive disorder, chronic disease of tonsils and adenoids, other disorders of teeth and supporting structures, and hemiplegia affecting left nondominant side, Record review of Resident #15's Quarterly MDS assessment, dated 3/29/24, indicated Resident #15's cognition was…

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

Based on interview and record review the facility failed to establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The facility did not have a QAPI plan, policies or procedures in place for program systematic analysis and systemic action. This deficient practice could affect all residents' overall quality of life and quality of care they received as a result of not having systems in place to improve direct care nursing staff provided. The findings were: Interview on 05/24/24 at 02:24 PM with the DON revealed they had a Quality Assurance Committee but did not have a Quality Assurance and Performance Improvement Program because they did not utilize PIPS (Performance Improvement Projects. She stated they did not have a written plan, policies or procedures in place. The DON stated all department heads along with the MD met once a month to discuss effective systems in the facility. She stated direct care staff was not involved in the process. She stated they did not complete written comparative…

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 incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning and transitions of care for 1 of 2 residents (Resident #1) reviewed for PASRR. The facility failed to submit NFSS forms timely for Resident #1. This failure could place residents at risk for not receiving specialized services in a timely manner. Findings included: Record review of Resident #1's admission record, dated 11/06/2023, revealed a [AGE] year-old female who admitted on [DATE] with diagnosis that included dementia, pain, schizophrenia, major depressive disorder, and bradycardia (slow heart rate). Record review of Resident #1's Annual MDS assessment, dated 12/01/2023, reflected a BIMS score of 5, indicating severe cognitive impairment. Record review of Resident #1's care plan, date initiated 08/30/2023, revealed Resident #1's was PASRR positive and was entitled to services recommended by PASRR with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #1) reviewed for comprehensive care plans in that: Resident #1's comprehensive care plan did not address refusal for select PASRR services. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and having personalized plans developed and accessible to address their specific needs. The findings included: Record review of Resident #1's admission record, dated 11/06/2023, revealed a [AGE] year-old female who admitted on [DATE] with diagnosis that included dementia, pain, schizophrenia, major depressive disorder, and bradycardia (slow heart rate). Record review of Resident #1'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 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 (Resident #1 and #2) reviewed for accuracy of medical records in that: Resident #1 and Resident #2 comprehensive care plan was not accessible to all staff in the medical records system. This deficient practice could affect residents whose records were maintained by the facility and place them at risk for errors in care and treatment. The findings included: 1. Record review of Resident #1's admission record, dated 11/06/2023, revealed a [AGE] year-old female who admitted on [DATE] with diagnosis that included dementia, pain, schizophrenia, major depressive disorder, and bradycardia (slow heart rate). Record review of Resident #1's Annual MDS assessment, dated 12/01/2023, reflected a BIMS score of 5, indicating severe cognitive impairment. Record review of Resident #2's admission record, 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 maintain medical records, in accordance with accepted professional standards and practices, which were complete and accurate for 1 of 6 residents (Resident #1) reviewed for accuracy of records. The facility did not document in Resident #1's medical record that resident suffered a second fall in early September 2023. This failure could place residents at risk of not having accurate medical records and could create confusion in services provided or needed to be provided. The findings were: Record review of Resident #1's face sheet, dated 10/03/23, and EMR (electronic medical record) revealed a 53-year- old male admitted to the facility on [DATE] with diagnoses which included: (current) diabetes 2, nausea with vomiting, unspecified; other: hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness one side of the body), and cerebral infarction (stoke). Resident #1's Advanced Directive was Full Code. RP (responsible…

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 interview the facility failed to develop and implement a baseline care plan which includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 3 of 5 residents (Resident #27, Resident #31, and Resident #52) reviewed for baseline care plans. The facility failed to develop a baseline care plan for Resident #27, Resident #31, and Resident #52. This failure could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met. The findings included: Record review of Resident #27's face sheet revealed Resident #27 was admitted to the facility on [DATE] with diagnoses of unspecified dementia (symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), unspecified severity, low vision (vision loss that cannot be corrected by medical or surgical…

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 that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 7 of 15 residents (Residents #1, #3, #8, #10, #13, #27, #31, and #56) reviewed for care plans in that: 1. Resident #1's diagnosis of schizophrenia was not addressed in the care plan. 2. Resident #3 received pain medications with pain not addressed in the care plan. 3. Resident #8's care plan goals and interventions were contradictory and not individualized. 4. Resident #10's diagnosis for schizophrenia was not addressed in the care plan. 5. Resident #13's care plan did not address the use of bilateral prosthesis. 6. Resident #27's received skeletal muscle relaxant with muscle spasms/pain not addressed in care plan. 7. Resident #31's care plan did not address Resident #31 being a smoker. 8. Resident # 56's care plan did not address the need for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for 1 of 15 residents reviewed for call light: Resident # 1's call light was not placed within reach of her . This failure could place residents who used call lights for assistance in maintaining and/or achieving independent functioning, dignity, and well-being. Findings included: Record review of Resident's #1's face sheet, undated, revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included: [Schizophrenia] (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation).[ rheumatoid arthritis] (is an autoimmune and inflammatory disease, which means that your immune system attacks healthy cells in your body by mistake, causing…

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, interviews, and record reviews, the facility failed to ensure the assessment accurately reflected the resident status for 1 (Resident #56) of 15 residents reviewed for assessments in that: Resident #56's thick nectar liquids were not reflected on the MDS. This failure could affect residents at the facility who had been assessed and could contribute to inadequate care. The findings were: Record review of Resident # 56's face sheet, undated, revealed a [AGE] year-old male admitted on [DATE] with a diagnoses that included [cerebral infarction] (the pathologic process that results in an area tissue in the brain that is disrupted blood supply); [dysphagia] takes more time and effort to move food or liquid from your mouth to your stomach);[ hyperlipidemia] (high cholesterol, means too many lipids in your blood). Record review of Resident # 56's quarterly MDS dated [DATE] revealed a BIMS score of 99, suggesting the resident could not complete the interview. Record review of physicians' orders for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on in Interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASARR) to the maximum extent practicable to avoid duplicate testing and effort for 2 of 15 resident's ( Resident #1 and Resident #10), reviewed for PASARR in that : 1. Resident #1 had a serious mental disorder that was not referred for level II review. 2. Resident #10 had a serious mental disorder and was not referred for level II review. This failure could place residents with serious mental disorders by not receiving support services. The findings were: 1. Record review of Resident #1's face sheet, undated, revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included: [Schizophrenia] (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, 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 observation, interview, and record review, the facility failed to ensure that residents received appropriate treatment and services to prevent urinary tract infections for 1 of 15 residents (Resident #51) who were reviewed for indwelling urinary catheter care, in that: a. Resident #51's indwelling urinary catheter (suprapubic urinary catheter) tubing touched the floor. b. Resident #51's catheter anchor was not placed on the leg These failures could affect residents with indwelling urinary catheters and place them at risk of urinary tract infections. The findings were: Record review of Resident #51's face sheet, undated, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: [Benign prostatic hyperplasia] (is also called an enlarged prostate; symptoms include blocking urine flow from the bladder). [Hyperthyroidism] (happens when the thyroid gland makes too much thyroid hormone symptoms include weight loss, hand tremors, and rapid or irregular heartbeat).…

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, observation and interview, the facility failed to provide 3 of 35 double occupancy resident rooms (rooms [ROOM NUMBER]) with at least 80 square feet per resident in that: Rooms 27, 28 and 34 did not have the required minimum of 80 square feet per resident. This failure could affect residents placed in these multiple occupancy rooms by reducing their living space. The findings included: Observation on 03/21/2023 by life safety code revealed the following measurements of resident room dimensions for the room size waiver: 1. room [ROOM NUMBER] (two-person room) had a total of 157.34 square feet and 78.67 square feet per resident. 2. room [ROOM NUMBER] (two-person room) had a total of 156.79 square feet and 78.40 square feet per resident. 3. room [ROOM NUMBER] (two-person room) had a total of 141.94 square feet and 70.97 square feet per resident. Review of the Bed Classifications form 3740, dated 03/20/2023 revealed each room had two beds. room [ROOM NUMBER]a was occupied, room [ROOM NUMBER]b…

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 establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, and smoking safety for 1 (Resident's #31) of 6 residents reviewed did not have their smoking assessment. The facility failed to ensure Resident #31 was assessed for safe smoking per the facility policy. This failure could affect smoking residents and could result in harm if policies were not followed. The findings included: Record review of Resident #31's face sheet revealed Resident #31 was admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure), type 2 diabetes mellitus, schizoaffective disorder, bipolar type (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), generalized anxiety, and hyperlipidemia (blood has too many lipids (or fats), such as cholesterol 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.