Heritage House Of Marshall Health & Rehabilitation

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's status for 4 of 16 resident reviewed (Residents #30, #36, #45 and #212) for assessments. 1. The facility failed to ensure Resident #30's diagnosis of anxiety was coded on her MDS. 2. The facility failed to ensure Resident #36's dialysis (is a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) status was coded on his MDS. 3. The facility failed to ensure Resident #45's vision impairment was reflected on his MDS. 4. The facility failed to ensure Resident #212's fall on 04/03/24 was coded on her MDS. These failures could place residents at risk of not having individual needs met. Findings include: 1. Record review of Resident #30's face sheet, dated 06/24/24, reflected a [AGE] year-old, female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #30 had diagnoses which included Parkinson's disease (is a brain disorder 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 interview and record review, the facility failed to ensure dialysis service were provided consistently with professional standards of practice for 3 of 3 resident reviewed for dialysis services. (Resident #36, Resident #212, and Resident #112) 1. The facility failed to ensure post-dialysis assessments were completed and documented on Resident #36 and Resident #212's dialysis communication forms. 2. The facility failed to document Resident #112's dialysis communications. These failures could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: 1. Record review of Resident #36's face sheet, dated 06/25/24, indicated Resident #36 was a [AGE] year-old, male and was admitted to the facility on [DATE] and 05/02/24 with diagnosis including end stage renal disease (is the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their…

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 administering of all drugs and biologicals, to meet the needs of 1 of 16 residents reviewed for pharmacy services. (Residents #45) The facility failed to keep, in stock, medications for Resident #45. Resident #45 did not receive Levetiracetam (is a medicine used to treat epilepsy (seizures)), Hydrochlorothiazide (is commonly used to treat high blood pressure), or Scopolamine patch (helps prevent nausea and vomiting) on 06/04/24, 06/05/24 and 06/06/24. This failure could place residents at risk for inaccurate drug administration. Findings included: 1. Record review of Resident #45's face sheet, dated 06/24/24, indicated resident #45 was a [AGE] year-old, male and was admitted to the facility on [DATE] and 11/28/23 with diagnoses including nontraumatic intracerebral hemorrhage (bleeding into the brain tissue), hypertensive crisis (a sudden, severe increase in blood pressure),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 resident reviewed for infection control. (Resident #46 and Resident #50) The facility failed to isolate Resident #46 and Resident #50 after urine cultures (test checks urine for germs (microorganisms) that cause infections) revealed ESBL (enzymes break down and destroy some commonly used antibiotics) in their urine. This failure could place residents at risk for being exposed to health complications and infectious diseases. Find included: 1. Record review of Resident #46's face sheet, dated 06/26/24, indicated Resident #46 was a [AGE] year-old, female and was admitted to the facility on [DATE] and 12/06/22 with diagnoses including chronic kidney disease (means you have mild to moderate loss of kidney function) and Type 2 diabetes (a condition 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 interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 2 of 3 residents (Resident #31 and Resident #212) reviewed for Medicare/Medicaid coverage. 1. The facility failed to ensure Resident #31 and Resident #212 were given a NOMNC (is a notice that indicates when your care is set to end from a home health agency, skilled nursing facility, comprehensive outpatient rehabilitation facility, or hospice) when discharged from skilled services prior to his covered days being exhausted. 2. The facility failed to ensure Resident #31 and Resident #212 were given a SNF ABN (is document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services) when discharged from skilled services at 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 interview and record review the facility failed coordinate assessments with the Pre-admission Screening and Resident Review (PASRR) program under Medicaid for 1 of 5 residents (Resident #23) reviewed for PASRR screenings. The facility failed to conduct an accurate PASRR Level 1 and 2 screening for Resident #23. This failure could place residents at risk for not receiving appropriate services, depression, and decreased quality of life. Findings include: Record review of Resident #23's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: Hemiplegia affecting right dominant side (paralysis on the right side of the body due to damage to the brain or spinal cord) , Type II Diabetes (group of diseases that result in too much sugar in the blood) , Acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood) and PTSD (a disorder that develops when a person has experienced or witnessed a scary, shocking or…

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 review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness and intellectual disabilities were provided with a PASRR Evaluation assessment for 2 of 5 residents (Residents #32 and #58) reviewed for PASRR screening, in that: 1. The facility failed to coordinate with the Local Intellectual/Developmental Disability and/or Local Mental Health Authority (Local Authority) to ensure an accurate PASRR Level I Evaluation and a PASRR Level II Evaluations were conducted for Resident #32 who had a serious mental illness. 2. The facility failed to coordinate with the Local Intellectual/Developmental Disability and/or Local Mental Health Authority (Local Authority) to ensure an accurate PASRR Level I Evaluation and a PASRR Level II Evaluations were conducted for Resident #58 who had developmental disability and a mental illness. These failures could place residents at risk of not receiving needed assessments (PASRR…

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 a baseline care plan was developed and implemented for each resident that included the instructions for resident care needed to provide effective and person-centered care of the resident that met professional standards of quality of care for 2 of 4 residents (Residents #163 and #213) reviewed for baseline care plans. 1. The facility failed to complete a baseline care plan with Resident #163 and Resident #213 within 48 hours of admission. 2. The facility failed to provide Resident #213 or Resident #213's RP, a copy of the summary of the baseline care plan. These failures could place residents at risk of not receiving care and services to meet their needs. Findings include: 1. Record review of Resident #163's face sheet, dated 06/26/2024, reflected an 86- year-old- female who was admitted to the facility on [DATE]. Resident #163 had diagnoses which included chronic atrial fibrillation (an irregular and often very rapid heart rhythm. An irregular…

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 develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 16 residents (Resident #45) reviewed for care plans. The facility failed to ensure Resident #45 care plan was implemented when the resident did not have his abdominal binder (is a wide compression belt that encircles your abdomen) over his PEG feeding tube (Percutaneous endoscopic gastrostomy; is a tube inserted surgically into the stomach through the abdominal wall) on 06/24/24 which was a care plan intervention. This failure could place residents at risk of not having individual needs met and cause residents not to receive needed services. Findings include: Record review of Resident #45's face sheet, dated 06/24/24, reflected a [AGE] year-old…

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 residents had a discharge summary that included a recapitulation of the resident's stay that included, but was not limited to diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results for 1 of 2 residents (Resident #61) reviewed for discharge summaries. The facility failed to ensure Resident #61 had a discharge summary. This failure could place residents at risk for interruption of care after discharge, receiving the wrong care after discharge, and rehospitalization after discharge. Findings include: Record review of Resident #61's face sheet, dated 06/26/2024, reflected Resident #61 was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #61 had diagnoses which included sepsis (a serious condition in which the body responds improperly to an infection), hypertension (high blood pressure), and anxiety (uncontrolled nervousness). Record review of Resident #61's physician…

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 to maintain personal hygiene for 1 of 4 resident reviewed for quality of life. (Resident #213) The facility failed to remove Resident #213's unwanted facial hair. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, feelings of poor self-esteem, lack of dignity and health. Findings included: Record review of Resident #213's face sheet, dated 06/25/24, indicated Resident #213 was an [AGE] year-old, female and was admitted to the facility on [DATE] with diagnosis including Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior). Record review of the MDS assessment indicated Resident #213 was admitted to the facility less than 21 days ago. No MDS for Resident #213 was completed prior to exit. Record review of a care plan, dated 06/24/24, indicated Resident #213…

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 ensure that each resident received adequate supervision and assistance devices to prevent accidents for 3 of 10 residents (Resident #54, Resident #16, Resident #52) reviewed for quality of care. 1. The facility failed to distribute Residents #54, #16, and #52 protective smoking aprons. Residents #54, #16, and #52 were observed smoking without a protective smoking apron on 06/24/2024 at the 9:00 a.m., smoke break. This failure could place residents at the facility who smoked at risk for contributing to burns or serious injuries. Findings Included: 1.Record review of Resident #54's undated face sheet revealed he was a 63- year-old male, admitted to the facility on [DATE] with the diagnoses of heart failure (your heart can not supply enough blood to meet your body's needs), tremors( nervous system condition, also known as a neurological condition, that causes involuntary and rhythmic shaking), and psychosis (condition of the mind or psyche…

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 was incontinent of bladder received appropriate treatment and services, and an indwelling catheter is not used unless there is valid medical justification for catheterization and the catheter is discontinued as soon as clinically warranted for 1 of 3 residents (Resident #213) reviewed for quality of care. 1. The facility failed to ensure LVN L placed an order by MD K, to consult MD J, a local urologist (is a doctor who specializes in diagnosing and treating diseases of the urinary system), about removal of Resident #213 indwelling catheter and bladder retraining. 2. The facility failed to ensure LVN L successfully contact MD J's office to for consultation of removal of Resident #213 indwelling catheter and possible bladder retraining. These failures could place residents who had urinary catheters at risk of not receiving care needed. Findings included: Record review of Resident #213's face sheet, dated 06/25/24,…

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 was free from unnecessary medications (a medication used in excessive doses and including duplicate therapy or for excessive duration; or without adequate monitoring, or without adequate indications for its use; or in the presence of adverse consequences which indicated the dose should be reduced or discontinued) for 1 of 3 residents reviewed for pharmacy services. (Resident #30) The facility failed to ensure Resident #30 antibiotic was discontinued after her urine culture (checks urine for germs (microorganisms) that cause infections) results showed no organism growth. This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections (happens when germs like bacteria and fungi develop the ability to defeat the drugs designed to kill them). Findings include: Record review of Resident #30's face sheet, 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 ensure residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record and PRN orders for psychotropic drugs are limited to 14 days. Except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for 1 (Resident #4) of 16 residents reviewed for pharmacy services. The facility failed to ensure Resident # 4's prn lorazepam was discontinued or reviewed by a physician to extend usage after 14 days. This failure could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications. Findings included:…

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 were free of significant medication errors for 1 of 5 residents (Residents #45) reviewed for pharmacy services. The facility failed to ensure Residents #45 received his prescribed Levetiracetam (is a medicine used to treat epilepsy (seizures)) as scheduled for 06/05/24 and 06/06/24. This failure could place residents at risk of medical complications and not receiving the therapeutic effects of their medications. Findings included: Record review of Resident #45's face sheet, dated 06/24/24, indicated resident #45 was a [AGE] year-old, male and was admitted to the facility on [DATE] and 11/28/23 with diagnoses including nontraumatic intracerebral hemorrhage (bleeding into the brain tissue) and convulsions (a condition in which muscles contract and relax quickly and cause uncontrolled shaking of the body). Record review of Resident #45's quarterly MDS assessment, dated 04/05/24, indicated Resident #45 was usually…

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 implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation, or mistreatment of residents for 1 of 4 residents (Resident #1) reviewed for abuse and neglect. The facility failed to suspend an alleged perpetrator immediately following an accusation of abuse. This failure could place residents at risk for continued abuse and neglect due to inappropriate interventions and failure to report the allegations of abuse timely. The findings included: Record review of the facility's policy and procedure, titled Reporting Abuse and Neglect Policy, revision date March 2018, .'With an allegation of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, the employee will immediately be suspended pending an investigation' .'The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 .a. If the allegations involve…

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 all alleged violations involving abuse, neglect, exploitation or mistreatment, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 6 residents (Resident #1) reviewed for abuse and neglect. The facility failed to report Resident #1's abuse allegation within 24 hours to the state agency. This failure could place residents at risk for continued abuse and neglect due to inappropriate interventions and failure to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #2) reviewed for accidents and supervision, in that: Resident #2 was transferred with only (1) staff member using a mechanical hydraulic lift by CNA D causing her foley catheter to become dislodged spilling urine on the resident and causing pain to Resident #2 by not supporting her right fractured leg that was non-weight bearing on 06/10/2024. This failure could place residents who are transferred by mechanical hydraulic lift at risk for avoidable accidents and could result in a decline in physical condition. The findings included: Record review of Resident #2's face sheet, dated 06/12/2024, revealed Resident #2 was admitted to the facility on [DATE] with the diagnoses of fracture of right tibia (broken bone in the lower part of right leg), pneumonia (lung infection), and urinary retention (inability to empty 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 interview, and record review, the facility failed to provide Pharmaceutical Services that accuratly ensured the facility met the needs of each Resident for 1 of 29 residents reviewed for pharmacy services. (Resident #1) 1. The facility failed to ensure LVN A followed the facility's policy to reconcile medications for Resident #1 when admitted on [DATE]. 2. The facility failed to ensure LVN B followed the facility's policy to reconcile medications for Resident #1 when discharging on 09/26/23. This failure could place residents at risk of drug diversion and misuse of medication. Findings included: Review of Resident #1's on face sheet dated 05/25/24 showed Resident #1 was an [AGE] year-old female admitted on [DATE] with diagnoses of Mycoplasma Pneumonia (Walking Pneumonia), Sepsis (Infection), Hypertension (High blood pressure), and Chronic Kidney disease, Stage 4 (Severe). Resident #1 was discharged on 09/26/23. Review of Resident #1's physician orders dated 05/25/24 showed on 09/23/23 Resident #1 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 demonstrate a response and rationale for resident council concerns and requests for 9 of 9 residents in a confidential interview. The facility did not provide a response or rationale to the resident council on their concerns regarding employee cell phone usage, privacy in the shower area, call lights being answered timely, laundry smelling of urine after being laundered, and the dining area not being cleaned between meals. This failure could place residents at risk for not having their needs met, diminished resident rights, and diminished feelings of self-worth. Findings include: In a confidential interview on 05/09/2023 at 10:05 a.m. nine alert and oriented residents stated there were recurring concerns discussed in Resident Council meetings with no resolution provided to the group regarding their concerns. The residents stated the recurring concerns were: Staff using cell phones in resident care areas and while performing care No shower curtain in the 200-hall shower Call lights not being answered for greater than 1 hour…

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 develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' mental and psychosocial needs; and, services that were to be furnished to attain or maintain the residents' highest practicable physical, mental and psychosocial well-being for 7 (Residents #06, #07, #11, #15, #26, #33, and #48) of 16 residents reviewed for care plans. 1.The facility failed to develop a care plan for Resident #07's falls. 2.The facility failed to develop a care plan for Resident #15's PASRR diagnoses and goals. 3.The facility failed to follow a comprehensive person-centered care plan for Resident #26 by not monitoring or properly documenting skin changes. 4. The facility failed to implement Resident #6 and Resident #11's intervention of provide oxygen per MD order 5. The facility failed to develop a care plan for Resident #33's CAAs such…

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 respiratory care was provided consistent with professional standards of practice for 3 of 6 residents reviewed for respiratory care. (Resident #6, Resident #11, Resident #50). The facility failed to properly store Resident #50's respiratory equipment. The facility failed to clean the oxygen concentrator filter of Resident #6, Resident #11, and Resident #50. These failures could place residents at risk of respiratory infections. Findings included: 1. Record review of face sheet dated 05/08/23 revealed Resident #6 was a [AGE] year-old female admitted on [DATE] with diagnoses including respiratory failure (is a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), chronic obstructive pulmonary disease (is a chronic inflammatory lung disease that causes obstructed airflow from the lungs), atelectasis (is a complete or partial collapse of the entire lung or area (lobe) of the lung), and shortness…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 4 of 16 residents reviewed for pharmacy services. (Residents #6, #11, #16, and #42) The facility failed to keep in stock all medications for Resident #6, #11, #16, and #42. This failure could place residents at risk for inaccurate drug administration and cause Resident #11 and #42 increased pain. Findings included: 1. Record review of face sheet dated 05/08/23 revealed Resident #6 was a [AGE] year-old female admitted on [DATE] with diagnosis including convulsions (are rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement) and atherosclerotic heart disease (is a common condition that develops when a sticky substance called plaque builds up inside your arteries). Record review of an admission MDS assessment dated [DATE] revealed Resident #6 was understood 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 promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate the use of an antibiotic for 5 of 8 residents reviewed antibiotic use. (Resident #27, Resident #28, Resident #33, Resident #40, Resident #214) The facility failed to ensure Resident #33, Resident #40, and Resident #214 had lab work to support use of antibiotics. The facility failed to ensure physician order had diagnosis to support antibiotic therapy for Resident # 27, Resident #28, Resident #33, and Resident #40. The facility failed to ensure Resident #28 received the appropriate antibiotic to treat his urinary tract infection. These failures could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. Findings included: 1. Record review of a face…

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 treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 16 residents (Resident #07 and Resident #36) reviewed for resident rights in that: The facility failed to provide a shower curtain for Residents #07 and #36 while bathing in a multi-stall shower room while being observed by CNAs. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth. Findings included: 1.Record review of a face sheet for Resident #07 dated 05/11/2023, indicated Resident #07 was a [AGE] year-old female and admitted on [DATE] with the diagnoses of hypertension (blood pressure that is higher than normal), kyphosis (a spinal disorder in which an excessive curve of the spine results in an abnormal rounding of the upper back), and hypoglycemia (a condition in which your blood sugar (glucose) level is lower than the standard…

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 the residents had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 2 of 13 residents ( Resident #35, Resident #38) reviewed for resident rights . The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available from Resident #35 prior to administering Lorazepam (is used to treat anxiety disorders) The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available from Resident #38 prior to administering Seroquel (is an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia 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 each resident was informed before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 2 of 3 residents (Resident #50, and Resident #54) reviewed for beneficiary notice. The facility failed to ensure Resident #50, and Resident #54 were given a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place the residents who were discharged at risk of not having knowledge of changes to services in a timely manner to allow the resident or their representative the option of appealing the denial of services. Findings: Record review of facility face sheet dated 05/11/2023 indicated Resident # 50 an [AGE] year-old female admitted [DATE]…

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 right of the residents to be free from abuse for 2 of 9 residents reviewed for abuse and neglect. (Resident #6, Resident #47) The facility failed to ensure Resident #6, and Resident #47 did not experience abuse from CNA M. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of face sheet dated 05/08/23 revealed Resident #6 was a [AGE] year-old female admitted on [DATE] with diagnoses including respiratory failure (is a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), chronic obstructive pulmonary disease (is a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and muscle weakness. The face sheet revealed Resident #6 resided in room [ROOM NUMBER] A. Record review of an admission MDS assessment dated [DATE] revealed Resident #6 was understood and understood others. The MDS revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, including injuries of unknown source are reported immediately or not later than 24 hours for 1 of 16 residents reviewed for abuse and neglect. Resident #26 sustained an injury of unknown source that was not reported timely as required. This failure could place residents at risk for abuse and neglect . Findings included: Record review of a face sheet dated 05/10/23 revealed Resident #26 was [AGE] years old and was admitted on [DATE] with diagnoses including multiple sclerosis (a potentially disabling disease of the brain and spinal cord (central nervous system). In multiple sclerosis, the immune system attacks the protective sheath (myelin) that covers nerve fibers and causes communication problems between your brain and the rest of your body), high blood pressure, and convulsions (seizures). Record review of a quarterly MDS dated [DATE] indicated Resident #26…

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 assess each resident quarterly (every 3 months) using the MDS (minimum data set) form specified by the state and approved by CMS for 2 of 5 residents (Resident # 51, and Resident # 52) reviewed for quarterly assessments. The facility failed to ensure Residents # 51, and # 52 had a quarterly MDS assessment completed within 3 months from the previous assessment. This failure could place residents at risk of not receiving necessary care or receiving inappropriate care for their conditions. Findings: Record review of facility face sheet dated 05/11/2023 indicated Resident #51 an [AGE] year-old male admitted to the facility on [DATE] with diagnoses nontraumatic intracerebral hemorrhage (stroke), depression (mood disorder), anxiety (mental disorder). Record review of Resident #51's medical record revealed a quarterly MDS with an assessment reference date of 12/28/2022 and was completed and submitted on 01/09/2023. Resident #51 has not had another MDS…

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 baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 2 of 16 residents reviewed for new admissions (Resident #11 and Resident #44). 1. The facility did not provide a summary of the baseline care plan to Resident #11. 2. The facility failed to address Resident #11's social service needs and resident preference for being notified of updates to plan of care 3. The facility failed to complete a baseline care plan for Resident #44. These failures could place residents at risk of not receiving care and services to meet their needs. Findings included: 1. Record review of a face sheet dated 05/08/23 revealed Resident #11 a was [AGE] year-old female admitted on [DATE] with diagnoses including heart failure (is a condition that develops when your heart doesn't pump enough blood for your body's needs), chronic…

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 act upon the recommendations of the pharmacist report of irregularities for 2 of 5 residents (Resident #35 and #38) reviewed for (DRR) Drug Regimen Review. 1. The facility failed to clarify PRN use of Lorazepam (antianxiety) for Resident #35 and Resident #38 after pharmacist recommendations on 03/07/23. 2. The facility failed to clarify Resident #38's diagnosis and rationale for antipsychotic use after pharmacist recommendation on 03/07/23. 3. The facility failed to confirm correct diagnosis was included on the Form 3713 Antipsychotic consent for Resident #38 after pharmacist recommendation on 03/07/23. These failures could place residents at risk from maintaining their highest practicable level of physical, mental, and psychosocial well-being, and could place them at risk for adverse consequences related to medication therapy. Findings include: 1. Record review of a face sheet dated 05/09/23 revealed Resident #35 was [AGE] year-old female 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, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 2 of 5 residents (Resident #35, Resident #38) reviewed for unnecessary psychotropic medications. The facility failed to have an appropriate diagnosis or indication of use for Resident #38's Seroquel (antipsychotic). The facility failed to limit Resident #35's and Resident #38's Lorazepam (anti-anxiety) prn medications to 14 days and the prescribing practitioner did not provide a rationale for extended use. These failures could put residents at risk of receiving unnecessary psychotropic medications. Findings included: 1. Record review of a face sheet dated 05/09/23 revealed Resident #35 was a [AGE] year-old female admitted on [DATE] with diagnoses including dementia (impaired ability to remember, think,…

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 resident's medical record included documentation that indicates the resident received education on the influenza and the pneumococcal immunizations of 2 of 16 residents (Residents #6, Resident #11) reviewed for immunizations. The facility failed to ensure Resident #6 received education on influenza and the pneumococcal immunization. The facility failed to offer and administer the influenza and pneumococcal vaccination to Resident #6. The facility failed to offer and administer the pneumococcal vaccination to Resident #11. These failures could place residents at risk for contracting a viral disease and cause respiratory complications, and potential adverse health outcomes. Findings included: 1. Record review of face sheet dated 05/08/23 revealed Resident #6 was a [AGE] year-old female admitted on [DATE] with diagnoses including respiratory failure (is a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide),…

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.