Cascades at Riverwalk

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 3 out of 43 sampled residents, that the facility did not ensure all alleged violations of abuse, neglect, exploitation or mistreatment were reported immediately, but no later than 2 hours after the allegation was made. Specifically, the facility did not report a allegations of abuse within 2 hours of the allegation. Resident identifiers: 12, 20 and 157. Findings include: 1. Resident 12 was 9/2/22 and readmitted on [DATE] with diagnoses which included spinal stenosis, pneumonia, diabetes mellitus, and fusion of spine. A form titled Exhibit 358 revealed that the facility reported to the State Survey Agency on 8/18/23 at 5:54 PM that on 7/24/23 at 12:17 PM resident 12 was found lying on her left side, with right arm underneath her. Resident 12 sustained a 2 inch jagged laceration to the left side of her forehead. Resident was sent to the hospital. Resident 12's medical record was reviewed 10/3/23 through 10/10/23. A nursing progress note dated 7/24/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined for 1 or 43 sampled residents that the facility did not ensure the comprehensive care plan included the services needed to achieve the highest practicable physical, mental and psychosocial well-being. Specifically, a resident with pressure ulcers did not have a care plan that addressed the specific pressure ulcers. Resident identifier: 71. Findings include: Resident 71 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, type 2 diabetes mellitus, pressure ulcer of sacral region stage 4, pressure ulcer of right heel stage 3, pressure ulcer of left ankle stage 2. Resident 71's medical record was reviewed on 10/3/23. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 71 required two person physical assistance and was total dependence for bed mobility, toilet use, personal hygiene, dressing. In addition the MDS assessment documented that resident 71 was at risk of developing pressure ulcers 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 it was determined, for 1 of 43 sampled residents, the facility did not provide the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for residents who were unable to carry out the activities of daily living. Specifically, a resident was not showered twice weekly according to his preferences. Resident identifier: 77. Findings include: Resident 77 was admitted to the facility on [DATE] with diagnoses which included sepsis, diabetes mellitus, urinary tract infection, hereditary and idiopathic, spinal stenosis, generalized anxiety, and major depressive disorder. On 10/2/23 at 11:05 AM, an interview was conducted with resident 77. Resident 77 was observed to be laying in bed. Resident 77 stated he sometimes only received a bed bath once a week. Resident 77 stated that he would like at least 2 bed baths per week. Resident 77 stated there were not enough staff to provide a bed bath twice a week. Resident 77's medical record 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure for 1 of 43 sampled residents, that residents did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable; and the residents with pressure ulcers received necessary treatment and services. Specifically, a resident developed pressure ulcers during his stay and did not receive timely skin checks or wound treatments. Resident identifier: 71. Findings included: Resident 71 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, type 2 diabetes mellitus, pressure ulcer of sacral region stage 4, pressure ulcer of right heel stage 3, and pressure ulcer of left ankle stage 2. Resident 71's medical record was reviewed on 10/3/23. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 71 required two person physical assistance and was total dependence for bed mobility, toilet use, personal hygiene, and dressing. In addition, the MDS assessment…

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

Based on observation, interview, and record review, it was determined that for 1 of 43 sampled residents, the facility did not ensure a resident receiving enteral feeding received appropriate care and services to prevent complications of enteral feeding. Specifically a resident's feeding tube bag had not been changed for 3 days. Resident identifier: 98 Findings Included: Resident 98 was admitted to the facility 7/12/23 with the following diagnosis that included dysphagia, aphasia, type 2 diabetes mellitus, hemiplegia, hemiparesis, and vascular dementia. On 10/2/23 at 2:12 PM, an observation was made of resident 98's feeding tube setup. A 1000 milliliter (ml) feeding bag was observed with the date of 9/29/23 and time of 1:54 PM. Resident 98's medical record was reviewed on 10/3/23. A physician enteral feed order with a start date of 9/11/23 documented one time a day for enteral care: Change syringe daily, feed supplies, and cylinder. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the months of September and October were reviewed 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 the review it was determined, for 1 of 43 sampled residents, that the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, a resident with documented pain had received pain medication recommendations from the pain clinic that were not implemented. Resident identifier: 160. Findings included: Resident 160 was admitted to the facility on [DATE] with diagnoses which included non-pressure chronic ulcer of unspecified part of left lower leg limited to breakdown of skin, methicillin susceptible staphylococcus aureus infection, major depressive disorder, resistance to multiple antimicrobial drugs, carrier of infections with a predominantly sexual mode of transmission, pain, chronic pain, and long term use of antibiotics. Resident 160's medical record was reviewed on 10/10/23. An admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 43 sampled residents, that the facility did not ensure that residents who received psychotropic drugs were not given these drugs unless the medication was to treat a specific condition as diagnosed and documented in the clinical record. Specifically, the facility continued to administer psychotropic medications after the recommendation to discontinued the psychotropic medications. Resident identifier 96. Findings include: Resident 96 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unsteadying on feet, anxiety disorder, type 2 diabetes mellitus with diabetic chronic kidney disease, insomnia, and cerebral edema. Resident 96's medical record was reviewed 10/3/23 through 10/10/23. A physician's order revealed orders dated 9/19/23 for the following: a. Lamotrigine Oral Tablet 25 milligrams (MG) to be given two times a day for anticonvulsant.…

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 it was determined, for 1 of 43 sampled residents, the facility did not provide each resident with food that accommodated resident allergies, intolerance's and preferences. Specifically, a resident with lactose intolerance was not provided food and a supplement that was lactose free. Resident identifier: 22. Findings include: Resident 22 was admitted to the facility on [DATE] with diagnoses which included muscle weakness, vitamin deficiency, rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement, pain, and severe protein-calorie malnutrition. On 10/02/23 at 2:36 PM, an interview was conducted with resident 22. Resident 22 stated that she was lactose intolerant. Resident 22 stated that the facility served cheese, milk and dairy foods to her for meals. Resident 22 stated that she had mashed potatoes served to her with butter and milk in them. Resident 22 stated that her family usually provided her breakfast. Resident 22…

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 it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, there were soiled areas in the kitchen and the vents above the food preparation area had dust on them. Findings include: 1. On 10/2/23 at 9:48 AM, the following observations were made: a. The preparation fridge handles were soiled. b. There was a container with pineapple in it in the refrigerator with a broken lid on it. c. The vents above the dry storage area and preparation area were soiled with dust. d. There was a yellow pipe behind the range that was soiled with black substance. e. A table with bases and hot plates soiled with crumbs and debris. f. The area under the dirty dish area in the dish machine room was soiled with food splatter and debris. The shelves had chemicals stored on it. g. There was food splatter on the ceiling in the dish machine room. h. There was food debris on a cart that clean cups were placed on. The cups were placed with rims down and 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 it was determined that the facility did not provide, for 1 of 43 sampled residents, specialized rehabilitative services such as physical therapy and occupational therapy that were required in the resident's comprehensive plan of care. Specifically, a resident was not provided specialized rehabilitation services after returning from the hospital with a physician's orders to be evaluated and treated. Resident identifier: 77. Findings include: Resident 77 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included sepsis, urinary tract infection (UTI), degenerative disc disease, hereditary and idiopathic neuropathy, spinal stenosis, generalized anxiety, and major depressive disorder. On 10/2/23 at 10:50 AM, an interview was conducted with resident 77. Resident 77 stated he went into the ER a couple months ago for a bad UTI that got into his blood stream. Resident 77 stated he was having pain in his feet and up his sides. Resident 77 stated he…

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, it was determined, that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 1 out of 43 sampled residents, a resident's urinal containing urine was stored on the bedside table next to and on the resident's food tray. Resident identifier: 92. Findings included: Resident 92 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, type 2 diabetes mellitus, spastic hemiplegia affecting left side, reduced mobility, cirrhosis of liver, vascular dementia, difficulty in walking, hemiplegia and hemiparesis, unsteadiness on feet, muscle spasm, mood disorder, and cognitive communication deficit. On 10/2/23 at 11:17 AM, an observation was conducted of resident 92's room. Resident 92's urinal was observed to be on resident 92's bed side table and…

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

Based on observations and interviews, it was determined the facility did not employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. If a qualified dietitian or other clinically qualified nutrition professional was not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who was a certified dietary manager. Specifically, the Dietary Manager (DM) for this facility had not yet completed certification to become a certified dietary manager. Findings included: On 10/27/21 at 9:16 AM, the DM was interviewed regarding her qualifications as a dietary manager. The DM provided documentation regarding course work that had been completed to become a certified dietary manager. The DM reported she had not yet taken her examination to become a certified dietary manager. The DM reported she had worked for this facility for 2 years and plans to take her examination to become a certified dietary manager in the near future. The DM stated the Registered Dietitian…

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 did not conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment as necessary, and at least annually. The facility must also review and update this assessment whenever there was, or the facility plans for, any change that would require a substantial modification to any part of this assessment. Specifically, the facility provided a data analysis that was not dated and incomplete of information regarding who completed the assessment and what actions were being taken to ensure necessary resources to care for its residents. Findings include: On 10/25/21 survey staff requested the facility assessment as part of required documentation from the facility. A binder marked State Survey was provided to the surveyors for review and subsequently scanned and sent on 10/26/21 at 5:13 PM. On 10/28/21 the facility assessment was reviewed. 1. The assessment provided 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 observations, interviews and record reviews it was determined, for 3 of 38 sample residents, that the facility did not ensure residents who were unable to carry out Activities of Daily Living (ADLs), received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, who were dependent on staff for ADL care, showers or bathes were not provided or offered per the assigned bathing schedule. Resident identifiers: 7, 44 and 46. Findings included: 1. Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE], with medical diagnoses that included irritable bowel syndrome, dysphagia following cerebrovascular disease, contracture to the left and right ankles, gastroparesis, protein-calorie malnutrition, type 2 diabetes mellitus, hypothyroidism, hemiplegia affecting right dominant side, aphasia, degenerative disease of the basal ganglia, cognitive communication deficit, anxiety disorder, muscle weakness, mood disorder, dysarthria, reduced mobility…

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 it was determined, for 8 of 38 residents, that the facility did not provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnosis of the facility's resident population in accordance with the facility assessment. Specifically, residents complained to the survey staff and in resident council meetings about the staffing level, residents were not receiving regularly scheduled showers, and resident call lights were not being answered in a timely manner. Resident identifiers: 15, 19, 22, 24, 44, 46, 53 and 71. Findings include: 1. On 10/26/21 at 11:59 AM, using his motorized wheelchair, resident 53 was observed to go to the nurses' station and ask for assistance getting into bed. Licensed Practical Nurse (LPN) 1 spoke to the resident asking him to go back to his room and place on his call light to recieve…

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 it was determined that for 6 of 38 sample residents, the facility did not ensure that the drug regimen of the residents were reviewed at least once a month by a licensed pharmacist. Specifically, residents did not have monthly pharmacy reviews completed and recommendations were not implemented in a timely manner. Residents: 6, 62, 65, 21, 28 and 56. Findings include: 1. Resident 56 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included polyneuropathy, heart failure, and atrial fibrillation. On 10/27/21 resident 56's medical record was reviewed. There were no pharmacy reviews in resident 56's medical record. A pharmacy review binder was provided. The binder revealed no pharmacy reviews for resident 56's for June 2021, July 2021, August 2021 and September 2021. 2. Resident 21 was admitted to the facility on [DATE] encephalopathy, systolic and diastolic heart failure, atrial fibrillation, leukemia, diabetes, and major depressive disorder.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that for 1 of 38 sampled residents, the facility did not ensure that resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, the facility did not administer medications according to parameters ordered by the physician. Resident identifier: 6. Findings include: Resident 6 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, Type 2 diabetes mellitus with diabetic neuropathy, essential (primary) hypertension, muscle weakness. Resident 6's medical record was reviewed on 10/27/21. 1. Resident 6's physician's orders dated 9/29/21, revealed Carvedilol 25 milligrams (mg) given 1 tablet by mouth two times a day 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.

Based on observations, interviews, and record review it was determined, for 14 of 38 sample residents, the facility did not ensure each resident received and provided, food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, residents had complaints regarding the overall palatability of the food, grievances and resident council minutes revealed complaints about the food, and the test tray was not attractive and palatable. Resident identifiers: 7, 9, 15, 18, 21, 23, 24, 40, 44, 46, 49, 55, 63, and 70. Findings included: 1. On 10/25/21 at 9:42 AM, an interview was conducted with resident 21. Resident 21 stated there were to many spices and the food was cold. Resident 21 stated that she did not hardly eat dinner the night before because she was not sure if it was beef or something else. 2. On 10/25/21 at 10:19 AM, an interview was conducted with resident 44. Resident 44 stated that lunch and dinners were not good. Resident 44 stated that sometimes the food just doesn't taste good. Resident 44 stated that the food usually lukewarm. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined that the facility failed to maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including COVID-19. Specifically, staff were observed without Personal Protective Equipment (PPE), a vital signs machine was disinfected in the hallway without the appropriate solution, a laundry aide was not observed performing hand hygiene after touching surfaces in resident rooms, staff did not know where visitors should doff PPE and food was transported uncovered through the hallway. Findings include: 1. The following observations were made of staff: a. On 10/27/21 at 12:18 PM, an observation was made of the Activities Director (AD). The AD was observed in the hallway and in the conference room with surveyors without a mask or eye protection. The AD was within 6 feet of surveyors and other staff without the mask…

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 it was determined, for 1 of 38 sample residents, that the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, a resident was not provided with interpretive services, her call light was not responded to in a manner that promoted quality of life, and she was spoken of by staff in a manner that did not promote dignity. Resident identifier: 19. Findings include: Resident 19 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia without behavioral disturbances, hyperlipidemia, and muscle weakness. On 10/25/21 at 9:09 AM, an observation was made of Registered Nurse (RN) 4 entering resident 19's room. RN 4 stated Resident 19 doesn't speak English so good luck trying to talk to her. Resident 19 was in the room when RN 4 made the statement.…

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 observation, it was determined that for 1 or 38 sample residents the facility did not provide reasonable accommodation of the needs and preferences. Specifically, a resident had expressed concerns as well as completed a grievance form regarding a certain staff member. The staff member was still working with the resident. Resident identifier: 322. Findings include: On 10/26/21 at 2:55 PM, an interview was conducted with resident 322. Resident 322 stated that she had made multiple complaints regarding Certified Nursing Assistant (CNA) 8. Resident 322 stated she did not get along with CNA 8 and felt that CNA 8 was unkind to her. Resident 322 stated that she had complained to multiple nurses, the schedule coordinator, as well as completing a formal grievance. Resident 322 said that nothing has been resolved with this issue. Resident 322 stated that today she had CNA 8 caring for her. On 10/26/21 at 2:59 PM, an observation made of CNA 8. CNA 8 was observed to be working in the assigned area that resident 322 resided in. On 10/27/21 at approximately 10:30 AM, 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 interview and record review it was determined, for 2 of 38 sample residents, that the facility did not ensure that resident's had the right to request, refuse, and /or discontinue treatment and to formulate an advance directive. Specifically, resident's advanced directives were not accurately documented in the medical records. Resident identifiers: 44 and 62. Findings include: 1. Resident 44 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included arthritis, cerebellar ataxia, aphasia, embolism and thrombosis, and depressive episodes. Resident 44's medical record was reviewed on 10/27/21. Resident 44's Provider Order for Life-Sustaining Treatment (POLST) form dated 4/20/2020 and signed by the physician on 4/28/2020 revealed resident 44's desire was to attempt to resuscitate and provide full treatment for medical interventions. A physicians' order dated 4/20/2020 revealed Code Status: DNR (Do Not Resuscitate). On 10/26/21 at approximately 1:00 PM, an interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, it was determined, for 2 of 38 sample residents, the facility did not develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. The facility did not ensure the comprehensive care plans described the services that were furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Specifically, resident's care plan interventions were not implemented, in regards to the use of hearing devices and the use of interpretive services . Resident identifiers: 7 and 19. Findings included: 1. Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with medical diagnoses that included irritable bowel syndrome, dysphagia following cerebrovascular disease, contracture to the left and right ankles,…

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 it was determined, for 1 of 38 sample residents, that the facility did not provide appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living which included bathing. Specifically, a resident complained they were not showered according to their shower schedules. Resident identifiers: 5. Findings Include: Resident 5 was admitted to facility on 9/26/2020 with diagnoses which included Multiple sclerosis, atazia, polyneuopathy and epilepsy. On 10/25/21 at 9:55 AM, an interview was conducted with resident 5. Resident 5 stated the last shower he received was on 10/20/21. Resident 5 stated that he was scheduled to have showers Tuesdays and Saturday in the afternoon. Resident 5 stated that he would like to have showers on these days but that he was only showered 1 time a week. Resident 5 stated that he occasionally had to remind staff to shower him. On 10/27/21 at 8:20 AM, a follow-up interview with resident 5. Resident 5…

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 it was determined, for 1 of 38 sample residents, that the facility did not ensure that residents received proper treatment and assistive devices to maintain vision and hearing abilities. Specifically, the facility did not provide a resident with assistance in maintaining hearing ability through coordination in obtaining hearing aides. In addition, the staff continued to document utilization of hearing aides after the resident's hearing aides had been missing. Resident identifier: 7. Findings included: Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included irritable bowel syndrome, dysphagia following cerebrovascular disease, contracture to the left and right ankles, gastroparesis, protein-calorie malnutrition, type 2 diabetes mellitus, hypothyroidism, hemiplegia affecting right dominant side, aphasia, degenerative disease of the basal ganglia, cognitive communication deficit, anxiety disorder, muscle weakness,…

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 it was determined that the facility did not ensure that the environment remained as free of accident hazards as was possible. Specifically, a public restroom that residents had access to had elevated water temperatures in the hand washing sink. Findings include: On 10/28/21 at 8:54 AM, an observation was made of the hand washing sink in a public restroom in the lobby. The restroom was not locked and was across from the facility dining room. The women's restroom water temperature of the sink was 131.4 degrees Fahrenheit within 30 seconds. The men's restroom water temperature of the sink was 135.0 degrees Fahrenheit. On 10/28/21 at 9:08 AM, an interview was conducted with the Receptionist. The Receptionist stated that residents would be able to get into the restrooms. The Receptionist stated there was a resident that was blind and wandered. The Receptionist stated that the resident would have access the restroom. The Receptionist stated that another resident had used the bathroom about a month prior. On 10/28/21 at 11:20 AM, an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 1 of 38 sample residents, the facility did not ensure that residents maintained acceptable parameters of nutritional status unless the resident's clinical condition demonstrated that this was not possible. Specifically, one resident who had significant weight loss was not provided interventions to prevent further weight loss. Resident identifier: 6. Findings Include: Resident 6 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus type two, diabetic neuropathy, dementia without behavioral disturbance, chronic kidney disease stage three, cognitive communication deficit, reduced mobility, retention of urine and essential hypertension. On 10/25/21 at 1:57 PM, an interview was conducted with a family member of resident 6. The family member stated he was concerned about the resident's food intake. He stated he and another family member came each day to assist the resident with eating. The family member stated…

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 and interviews, it was determined, for 1 of 38 sample residents, that the facility did not adequately equip each resident with a communication system that was relaying calls directly to staff or a centralized work area. Specifically, a resident's call light was not functioning properly. Resident Identifier 322. Findings Include: On 10/27/21 at approximately 10:30 AM, an interview was conducted with resident 322. Resident 322 stated that occasionally the wait for a call light to be answered had been hours but had since discovered the call light will not work occasionally. Resident 322 stated that in order to get the call light to turn on. Resident 322 stated she pressed the hand held call light multiple times. Resident 322 stated that if that did not work then resident 322 placed the bed in a relined position to press the call light button on the wall until it lit up. Resident 322 stated if it still did not illuminate, then she called a family member to express needs and the family member will then call the facility. On 10/28/21 at 10:19 AM, a follow up interview…

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.