Maple Ridge Rehabilitation and Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not allow the resident the right to formulate an advance directive. Specifically, for 1 out of 14 sampled residents, a resident that did not have a Physician Orders for Life-Sustaining Treatment (POLST) or Advance Directive was documented as full code in their medical record. Resident identifier: 32. Findings included: Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, acute respiratory failure with hypoxia, chest pain, pleural effusion, chronic obstructive pulmonary disease, asthma, atrial fibrillation, type 2 diabetes mellitus with complications, secondary hypertension, and shortness of breath. Resident 32's medical record was reviewed. A physician's order dated 10/8/24, documented that resident 32 was a full code, full treatment, and a trial period of artificial nutrition. On 10/8/24 at 5:16 PM, an admission Progress Note documented . POLST status: . was blank. An Advanced…

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 out of 14 sampled residents, the facility did not make prompt efforts to resolve grievances the resident may have or maintain evidence demonstrating the results of all grievances. Specifically, a resident reported that his wallet and all personal documents were missing and requested assistance with obtaining new identification (ID) cards and the facility did not maintain evidence demonstrating the grievance investigation and decision. Resident identifier: 18. Findings included: Resident 18 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included schizophrenia, tremor, stimulant abuse, chronic obstructive pulmonary disease, peripheral vascular disease, and hypertension. On 5/27/25 at 8:54 AM, an interview was conducted with resident 18. Resident 18 stated that his wallet was missing with his identification and Medicaid card. Resident 18 stated that he informed the Resident Advocate (RA) and was told that she would…

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 14 sampled residents, the facility did not ensure that residents who use psychotropic drugs received a gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, a resident did not have an attempted GDR for Depakote and the Trazodone did not have a rationale for the clinical contraindication. Resident identifier: 26. Findings included: Resident 26 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, cognitive communication deficit, hemiplegia and hemiparesis of left side, dysphagia, aphasia, and hypertension. Resident 26's medical record was reviewed. Resident 26's physician orders revealed the following: a. On 2/6/24, an order was initiated for Trazodone Oral Tablet 50 milligram (mg), give 50 mg by mouth at bedtime related to insomnia. b. On 2/6/24, an order was initiated for Divalproex Sodium Oral Tablet Delayed…

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 14 sampled residents, the facility did not ensure that all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegation was made to the administrator, the State Survey Agency (SSA), and Adult Protective Services (APS). Specifically, the facility investigations for a residents allegation of sexual abuse and an elopement did not have a documented date that APS was notified. Resident identifier: 1. Findings included: Resident 1 was admitted to the facility on [DATE] with diagnoses which included anoxic brain damage, unspecified convulsions, diabetes mellitus, asthma, hypothyroidism, restless leg syndrome, and dysphagia. Resident 1's facility abuse investigations were reviewed. On 5/2/24 at 2:47 PM, the facility Form 358 documented that the local Police Department (PD) notified the facility that they found resident 1 wandering one street north of the facility and he seemed confused. 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, for 2 of 14 resident's sampled, the facility did not ensure that the resident's transfer or discharge was documented in the resident's medical record and the information was communicated to the receiving provider included contact information for the practitioner responsible for the care of the resident; resident representative contact information; Advanced Directive information; all special instructions or precautions for ongoing care; a comprehensive care plan goals; and all other necessary information to ensure a safe and effective transition of care. Specifically, the resident's medical record did not contain documentation of what information was sent to the receiving provider for a transition of care. Resident identifiers: 7 and 15. 1. Resident 7 was admitted to the facility on [DATE] and was re-admitted to the facility on [DATE] with diagnoses which included Human Immunodeficiency Virus, generalized anxiety disorder, paranoid schizophrenia, and viral…

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 14 sampled 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 the resident's medical, nursing, and psychosocial needs that were identified in the comprehensive assessment. Specifically, the resident's care plan did not address the resident's bowel elimination pattern. Resident identifier: 4. Findings included: Resident 4 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which consisted of schizophrenia, Parkinsonism, generalized anxiety disorder, obsessive-compulsive disorder, major depressive disorder, congestive heart failure, peripheral vascular disease. On 5/27/25 at 9:35 AM, an interview was conducted with resident 4. Resident 4 stated that within the last two months he had experienced some constipation and went a long time without a bowel movement (BM). Resident 4'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, it was determined, for 1 of 14 sampled residents, the facility did not ensure that all residents received the treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, a resident had complaints of constipation that were not treated with the facility bowel protocol. Resident identifier: 4. Findings included: Resident 4 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which consisted of schizophrenia, Parkinsonism, generalized anxiety disorder, obsessive-compulsive disorder, major depressive disorder, congestive heart failure, peripheral vascular disease. On 5/27/25 at 9:35 AM, an interview was conducted with resident 4. Resident 4 stated that within the last two months he had experienced some constipation and went a long time without a bowel movement (BM). Resident 4 stated that he used to take Milk of Magnesia (MOM) for constipation.…

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 14 sampled residents, the facility did not ensure that the resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not provide adequate supervision to prevent a resident elopement from the facility on two occasions. Resident identifier: 1. Findings included: Resident 1 was admitted to the facility on [DATE] with diagnoses which included anoxic brain damage, unspecified convulsions, diabetes mellitus, asthma, hypothyroidism, restless leg syndrome, and dysphagia. On 5/27/25 at 9:18 AM, an interview was conducted with the resident 1. Resident 1 stated that he tried to go outside once in a while but he was not supposed to go out by himself. Resident 1 stated that the doors to the facility were locked. Resident 1's facility abuse investigations were reviewed. On 5/2/24 at 2:47 PM, the facility Form 358 documented that the local Police Department (PD) notified the facility 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 observation, interview, and record review, the facility did not ensure that pain management was provided to residents who required such services. Specifically, for 1 out of 14 sampled residents, a resident complaining of pain and requesting to go to the hospital was not provided pain medications, an alternative pain reliever, or nonpharmaceutical pain interventions. Resident identifier: 14. Findings included: Resident 14 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, atherosclerotic heart disease of native coronary artery without angina pectoris. On 5/27/25 at 11:14 AM, resident 14 was observed to tell a Certified Nursing Assistant (CNA) that he was in a lot of pain right now. The CNA stated to resident 14 that she would talk to the nurse. The CNA was observed to tell the nurse that resident 14 was having pain. The nurse stated to the CNA that she would send a message to the Medical Director (MD). Resident 14 was observed to tell the nurse the pain was in…

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, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, and included the expiration date when applicable. Specifically, for 1 out of 14 sampled residents, an opened multi use vial of Humalog had expired and a multi use vial of aplisol was not labeled with an open or a discard date. Resident identifier: 15 Findings included: On [DATE] at 10:33 AM, an observation was conducted of the medication fridge located at the nurses station with Licensed Practical Nurse (LPN) 1. There was an open multi use vial of Humalog with a date on the box of [DATE]. LPN 1 stated that she was unsure if the date was an open date or a discard date. The Humalog was available for use and belonged to resident 15. The medication fridge also included an open multi use vial of aplisol that was available for use and did not include an open or discard date. On [DATE] at 11:25 AM, an interview was conducted with the Director…

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 14 sampled residents, the facility did not maintain medical records on each resident that was complete and accurately documented. Specifically, a resident's medication order was entered incorrectly in the medical record. Resident identifier: 15. Findings included: Resident 15 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included type 1 diabetes mellitus, generalized anxiety disorder, chronic kidney disease stage 3, complete traumatic amputation of two or more left toes, bipolar disorder, and suicidal ideations. Review of resident 15's record was completed on 5/27/25 through 6/2/25. On 5/25/25 at 11:22 AM, a physician's order revealed Hydroxyurea Oral Tablet (Hydroxyurea Sickle Cell Disease) Give 25 milligrams (mg) by mouth every 12 hours as needed for Anti-anxiety. On 5/26/25 at 11:24 AM, a nursing progress note revealed that a verbal order was received from the in-house provider to restart hydroxyzine 25 mg by…

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 out of 14 sampled residents, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Specifically, a resident with a peripherally inserted central catheter (PICC) line and open wounds did not have enhanced barrier precautions (EBP) initiated and a plate guard that dropped to the floor was used on the resident's lunch plate. Resident identifier: 22 Findings included: Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included intracranial injury without loss of consciousness, type 2 diabetes mellitus, mixed receptive-expressive language disorder, dementia with mood disturbance and agitation, and major depressive disorder with psychotic symptoms. Review of resident 22's record was completed on 5/27/25…

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, for 4 of 6 sampled residents, the facility failed to provide the residents the right to participate in the development and implementation of a person-centered care plan, the right to attend meetings regarding the person-centered plan of care, the right to attend meetings regarding the person-centered plan of care, and the right to request revisions to the person-centered plan of care. Specifically, resident's representatives were not informed or included in care planning meetings in which concerns regarding the resident's plan of care could be discussed. Resident identifiers: 1, 2, 4 and 6. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses that included schizotypal disorder, type 2 diabetes, hypertension, and hyperlipidemia. Resident 1's medical records were reviewed on 3/5/24. An annual Minimum Data Set (MDS) assessment dated [DATE] revealed resident 1 had a Brief Interview of Mental Status (BIMS) score of 8 which suggested moderate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 2 of 6 sampled resident, the facility did not ensure residents were free of any significant medication errors. Specifically, a resident was administered another residents medications. In addition, there was no documented monitoring after the medications were administered. Resident Identifiers: 3 and 6. Findings include: Resident 6 was admitted to the facility on [DATE] with diagnoses which included personal history of transient ischemic attack, cerebral infarction, type 2 diabetes mellitus, and dementia. Resident 6's medical record was reviewed 3/5/24. A quarterly Minimum Data Set (MDS) dated [DATE] revealed resident 6 had a Brief Interview of Mental Status (BIMS) of 5 which suggested severe cognitive impairment. Resident 3 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, dementia, mood disorder, hemiplegia and hemiparesis, generalized idiopathic epilepsy and epileptic syndromes and hypertension. Resident 3's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, it was determined, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 18 sampled residents, a resident that required a cigarette smoking extender was not provided one during observed smoking sessions. In addition, chemicals on the cleaning cart were unlocked and stored in the resident television (TV) room. Resident identifier: 25. Findings included: 1. On 9/10/23 at 10:06 AM, an observation of resident 25 was conducted. A staff member was observed to assist resident 25 with the lighter to light the cigarette. The staff member was observed to stay in the smoking area while the residents smoked. Resident 25 did not have a cigarette extender present. On 9/10/23 at 11:24 AM, an observation of resident 25 was conducted. Resident 25 was in the smoking area smoking a cigarette without 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 3 of 28 sample residents, that the facility did not conduct a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. Specifically, annual Minimum Data Set's (MDS) was not completed timely. Resident identifier: 1, 15 and 24. Findings include: 1. Resident 24 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure, dementia with behavioral disturbances and anemia. Resident 24's medical record was reviewed on 11/15/21. Resident 24's annual MDS had an Assessment Reference Date (ARD) of 9/22/21. The MDS was completed on 11/10/21. 2. Resident 1 was admitted to the facility on [DATE] with diagnoses which included hypotension, dementia with behavioral disturbances, mood disorder, anemia, hypertension, prebyopia, disorder of brain, and astigmatism and psychosis. Resident 1's medical record was reviewed on 11/15/21. Resident 1's annual MDS had an ARD of 9/27/21. The MDS 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 it was determined, for 7 of 28 sample residents, that the facility did not assess each resident using the quarterly review instrument specified by the State and approved by Center for Medicare services not less frequently than once every 3 months. Specifically, residents quarterly Minimum Data Set (MDS) were not completed timely. Resident identifiers: 5, 6, 7, 10, 16, 17 and 18. Findings include: 1. Resident 6 was admitted to the facility on [DATE] with diagnoses which included anemia, cerebrovascular disease, adjustment disorder with depressed mood, hemiplegia, and hepatitis C. Resident 6's medical record was reviewed on 11/10/21. A quarterly MDS with an Assessment Reference Date (ARD) 9/9/21 was completed on 11/9/21. 2. Resident 18 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, mood disorder due to known physiological condition, dementia with behavioral disturbance and hemiplegia. Resident 18's medical record was reviewed 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 interview and record review it was determined, for 3 out of 28 sampled residents, that the facility assessment did not accurately reflect the resident's status. Specifically, a resident's Brief Interview for Mental Status (BIMS) and Patient Health Questionnaire (PHQ-9) were not completed on the admission and Quarterly Minimum Data Set (MDS) assessments. Resident identifiers 1, 11, and 30. Findings included: 1. Resident 11 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of cirrhosis of liver, disorder of urea cycle metabolism, schizoaffective disorder, dementia, alcohol dependence, stimulant dependence, viral hepatitis C, hypertension, benign prostatic hyperplasia, hyperlipidemia, gastro-esophageal reflux disease, myopia, and anemia. On 11/9/21 resident 11's medical record was reviewed. Review of resident 11's admission Minimum Data Set (MDS) Assessment on 8/17/21 revealed that resident 11's Brief Interview Mental Status (BIMS) under Section C for Cognitive…

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 3 of 28 sampled residents, that 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 the resident's medical, nursing, and mental and psychosocial needs. Specifically, care plans were not developed or updated for resident's after sustaining falls, an elopement, new medical diagnosis and resident to resident altercations. Resident identifiers 4, 15 and 30. Findings included: 1. Resident 15 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses of epilepsy, contracture, brachial plexus disorder, mood disorder, neuralgic amyotrophy, and dementia. Resident 15's medical records were reviewed. Review of resident 15's Minimum Data Set (MDS) Assessments revealed the following: a. On 11/22/20 the Annual MDS assessed resident 15's Functional Status for bed mobility as Supervision with set up help; Limited 1 person assist for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 2 of 28 sample residents, that the resident was not able to make choices about aspects of their life, in the facility, that were significant to the resident. Specifically, a resident requested to leave the facility and was not permitted to leave and two residents' televisions were not functioning. Resident identifiers: 13 and 22 . Findings include: 1. Resident 13 was admitted to the facility on [DATE] with diagnoses which included traumatic hemorrhage of cerebrum, mood disorder, unspecified abnormal involuntary movements, and vascular dementia with behavioral disturbance. On 11/8/21 at 10:20 AM, resident 13 was observed in his room, laying on his bed. Resident 13 had no pictures or other personal objects. Resident 13 was interviewed. Resident 13 stated that the only things he needed was a reading light and a working television. Resident 13 stated that his television was broken for months and he had reported it to staff but nothing had happened. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 out of 28 sample residents, that the facility did not notify the physician immediately when there was a significant change in the resident's physical, mental, or psychosocial status, or the need to alter treatment. Specifically, a resident had several doses of insulin held without physician ordered parameters to hold and the physician was not notified. Resident identifier 20. Findings included: Resident 20 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus, mental disorder, unspecified psychosis, hypertension, and mild intellectual disabilities. Resident 20's medical records were reviewed. Review of resident 20's physician orders revealed an order for Basaglar KwikPen Solution Pen-injector 100 units/milliliter (insulin glargine), inject 48 units subcutaneously one time a day related to type 2 diabetes mellitus. Review of resident 20's Medication Administration Record (MAR) revealed the following: a. In October 2021 the…

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

Based on observation and interviews it was determined, for 3 of 28 sample residents, that the facility did not provide a safe, clean, comfortable and homelike environment. Specifically, the door leading to the residents' smoking area was in disrepair and had a elevated threshold to get into the facility. Additionally, the sofa in the east television room was in disrepair. Resident identifier: 9, 10 and 28. Findings include: 1. On 11/8/21 at 12:57 PM, an observation was made of resident 10. Resident 10 was observed to have a four wheeled walker. Resident 10 was observed to walk into the facility from the smoking area. Resident 10 was observed to lift up her four wheeled walker onto the threshold. Resident 10 was immediately interviewed. Resident 10 stated stated that she had tripped over the threshold but had not fallen. The handle on the door was observed to be missing a rod and had duct tape on it. 2. On 11/9/2021 at 11:39 AM, an observation was made of resident 28, resident 10, and resident 9 exiting the facility through the east door leading to the resident smoking area. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 4 of 28 sampled residents, that the facility did not ensure that all alleged violations involving abuse 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 to the State Survey Agency (SSA), Adult Protective Services (APS), and the results of all investigations were reported to the SSA within 5 working days of the incident. Specifically, an in incident of sexual abuse was not reported to the SSA or APS within 2 hours of the incident occurring and the final investigation report was not submitted to the SSA, and an incident of physical abuse was not reported to the SSA within 2 hours of the incident occurring. Resident identifiers: 1, 11, 15, and 20. Findings included: 1. Resident 11 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included cirrhosis of liver, disorder of urea cycle metabolism,…

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 out of 28 sampled residents, that the facility did not ensure timely transmission and completion of the Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid Services (CMS). Within 14 days after a facility completed a resident's assessment, the facility must electronically transmit encoded, accurate and completed MDS data to the CMS system including reentry, discharge and death. Specifically, two resident's MDS data was not transmitted. Resident identifiers: 6 and 11. Findings included: 1. Resident 11 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of cirrhosis of liver, disorder of urea cycle metabolism, schizoaffective disorder, dementia, alcohol dependence, stimulant dependence, viral hepatitis C, hypertension, benign prostatic hyperplasia, hyperlipidemia, gastro-esophageal reflux disease, myopia, and anemia. On 6/6/21 at 4:45 AM, resident 11's progress note documented that resident 11…

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 28 sampled residents, that the facility did not ensure that a resident that had urinary incontinence, based on the resident's comprehensive assessment, received appropriate treatment and services to prevent urinary tract infections. Specifically, a resident was observed saturated with urine for 2 hours without incontinence cares. Resident identifier: 1. Findings include: Resident 1 was admitted to the facility on [DATE] with diagnoses which included hypotension, dementia with behavioral disturbances, mood disorder, anemia, hypertension, prebyopia, disorder of brain, and astigmatism and psychosis. On 11/8/21 from 11:47 AM until 1:54 PM, a continual observation was conducted of resident 1. Resident 1 was observed to walk behind his wheelchair from the hallway. At 11:47 AM, resident 1 was observed to have a discolored area in his lap area and his brief was observed to be sagging. At 11:56 AM, resident 1 was observed to go to his room. 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 of 28 sampled residents, that the facility did not ensure that the resident received the necessary behavioral health care and services to maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, a resident had complaints of feeling depressed and no care and services were provided to address these complaints of depression. Resident identifier 30. Findings included: Resident 30 was admitted to the facility on [DATE] with diagnoses which consisted of dementia, traumatic brain injury, schizophrenia, muscle wasting and atrophy, foot drop, low back pain, and gastro-esophageal reflux disease. On 11/9/21 resident 30's medical records were reviewed. On 11/08/21 at 9:20 AM, an interview was conducted with resident 30. Resident 30 stated he was depressed, he was locked up, and he wanted to go home. Resident 30 stated he had not talked to anyone about his feelings of depression, and he did not take any medications for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 28 sample residents, that the facility did not ensure that the 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 indicated the dose should be reduced or discontinued; or any combination of the reasons above. Specifically, a resident had their insulin held without any physician ordered parameters to hold the medication. Resident identifier 20. Findings included: Resident 20 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes, mental disorder, unspecified psychosis, hypertension, mild intellectual disabilities, and pedophilia. Review of resident 20's physician orders revealed the following: a. Basaglar KwikPen Solution Pen-injector 100 units/milliliters (Insulin Glargine), Inject 48 unit subcutaneously one time…

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 2 out of 4 sample residents, that the facility did not ensure that its medication error rate was not 5 percent or greater. Specifically, the facility was observed to have 2 medication errors out of 25 observations for an error rate of 8 %. Resident identifiers: 5 and 19. Findings included: On 11/9/21 at 7:53 AM, an observation was made of Registered Nurse (RN) 1 administering medication to resident 19. Resident 19 had just finished breakfast in the main dining room and was returning to his bedroom. RN 1 was observed to administer a Levothyroxine 75 micrograms (mcg) tablet to resident 19. Resident 19's physician orders were reviewed. The order for Levothyroxine 75 mcg by mouth one time a day related to hypothyroidism, stated to administer during morning medication pass per the resident's preference. The time ranges entered into the order were between 6:00 AM and 8:00 AM. On 11/9/21 at 8:09 AM, an observation was made of RN 1 administering medication to resident 5. RN 1 was observed to administer Calcium-Vitamin…

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 28 sampled residents, that the facility did not maintain medical records on each resident that were complete; accurately documented; readily accessible; and systematically organized. Specifically, the facility could not locate a resident's medication administration record (MAR) for a month. Resident identifier 11. Findings included: Resident 11 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included of cirrhosis of liver, disorder of urea cycle metabolism, schizoaffective disorder, dementia, alcohol dependence, stimulant dependence, viral hepatitis C and benign prostatic hyperplasia. On 11/9/21 resident 11's medical records were reviewed. Review of resident 11's electronic Medication Administration Record (MAR) for June 2021 revealed a blank form. On 11/10/21 resident 11's paper chart was reviewed. No documentation could be found of resident 11's June 2021 MAR. The record was requested from the Director of…

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