Mt. Olympus Rehabilitation Center

Based on observation and interview it was determined, 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 diseases and infections. Specifically, for 1 out of 38 sampled residents, a staff member was observed to touch a resident medications with bare hands with each medication administration. Also medications were dropped on and in the medication cart and then administered to the residents Findings include: On 5/8/24 at 8:20 AM, during morning medication pass the following was observed: a. At 8:32 AM Registered Nurse (RN) 2 was observed to not use hand hygiene prior to starting medication pass. RN 2 was observed to use her right index finger to retrieve a medication placed in the medication cup in error. After RN 2 had stuck her finger into the cup she was observed to then remove her finger and obtain a spoon to retrieve the medication from the cup. RN 2's finger was observed to have already touched the medications…

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 did not develop and implement a baseline care plan for 2 of 38 sample residents that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care, and be developed within 48 hours of the resident's admission. Specifically, a care plan was initiated 7 days after admission for two residents. Resident identifiers: 55 and 167. Findings include: 1. Resident 55 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's disease with dyskinesia, dysphagia, difficulty walking, reduced mobility, repeated falls, dementia, visual hallucinations, major depressive disorder and neuromuscular dysfunction of the bladder. Resident 55's medical record was reviewed on 5/6/24. The care plans developed for resident 55 were reviewed. The 48 hour care plan was not developed until 2/15/24, this was 7 days after admission. 2. Resident 167 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 that care plans for 2 of 38 sample residents were developed within 7 days after the completion of the comprehensive assessment, or revised by the interdisciplinary team after each assessment. Resident identifiers: 121 and 127. Findings include: 1. Resident 121 was admitted to the facility on [DATE] with diagnoses that included traumatic brain injury, vascular dementia, traumatic brain hemorrhage, cognitive communication deficit, and anxiety disorder. Resident 121's medical record was reviewed from 5/6/24 through 5/9/24. On 9/11/23, resident resident 121's BIMS on the admission MDS assessment was an 8, indicating moderate cognitive impairment. The MDS also indicated the the resident had wandered 1 to 3 days in the look back period. The MDS triggered behaviors on the Care Area Assessment Summary, however no wandering care plan was developed until 9/29/23. It should be noted that this was after the resident had eloped multiple times. Resident 121's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 38 sampled residents, that the facility did not ensure that each 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 indication for its use; or in the presence of adverse consequences which indicated that the dose should be reduced or discontinued. Specifically, a resident's blood pressure (B/P) medication was administered outside of physicians ordered parameters. Resident identifier: 4. Findings include: Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's disease with dyskinesia, traumatic subdural hemorrhage, severe protein calorie malnutrition, type II diabetes, dysphagia, chronic kidney disease stage 3, hypothyroidism, gastro-esophageal reflux disease and hypertension. Resident 4's medical record was reviewed on 5/6/24. Review…

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 interview, the facility did not label all drugs and biologicals used in the facility in accordance with currently accepted professional principles and included appropriate accessory instructions and the expiration date when applicable. Specifically, narcotics were repackaged into the narcotic medication cards. Findings include: On 5/8/24 at 8:35 AM, an observation was made of the facility medication cart for the Quail hallway serving rooms 31 - 42. The following medication was located inside: a. A medication card which held Tramadol 50 mg (milligrams) had the back of pockets numbered 10 and 20 taped, there was a white tablet observed to be in each of the pockets. On 5/8/24 at 8:45 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that 2 nurses are supposed to waste narcotics, and they are usually placed in the sharps container then both nurses sign the narcotic book. RN 2 stated the narcotics are not supposed to be taped back into the narcotic card. On 5/9/24 at 9:17 AM, an interview was conducted with the Director of Nursing (DON).…

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, the facility did not provide a clean, comfortable homelike environment. Specifically, for 5 out of 41 sampled residents, resident rooms were dirty, a sit to stand lift was dirty, resident wheelchairs were dirty, and furniture was broken. Resident identifiers: 10, 15, 36, 54, and 72. Findings included: 1. On 2/6/23 at 10:04 AM, an observation was made of resident 36's room. Resident 36 had gashes behind the bed in the dry wall. Resident 36 stated the gashes had been in the wall since she had moved to the room. 2. On 2/6/23 at 10:14 AM, an observation was made of resident 54's room. Resident 54's room had laundry on the floor, a ripped gift bag on the floor, and a can of soda on the floor. Resident 54 stated sometimes her room was cleaned but she would like to have her room cleaned more often. 3. On 2/6/23 at 12:13 PM, an observation was made of a sit to stand lift in the hallway across from resident room [ROOM NUMBER]. There was dust and debris observed 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 4 out of 41 sampled residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, 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 administrator of the facility and to other officials. Specifically, an accident in which a resident sustained second degree burns when his oxygen ignited while smoking a cigarette unsupervised was not reported to the State Survey Agency (SSA) or Adult Protective Services (APS). Two allegations of resident abuse were not reported to the SSA or APS. Lastly, a Silver Alert was issued for a missing resident and this was not reported to the SSA or APS. Resident identifiers: 3, 17, 31, and 131. Findings included: 1. Resident 17 was admitted on [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 3. Resident 3 was admitted to the facility on [DATE] with diagnoses that included but not limited to schizoaffective disorder, Parkinson's disease, major depressive disorder, insomnia, cognitive communication deficit, and type 2 diabetes mellitus. Resident 3's medical records were reviewed on 2/7/23 Resident 3's progress notes revealed the following: a. Nursing note dated 12/6/22 documented as followed: rec'd [received] call from 911 dispatch stating resident called saying that she had been strangled. upon entering room, res [resident] was noted to be laying on bed, talking on the phone w/ [with] 911 dispatch. res handed phone to this nurse, confirmed that emergency response not needed. asked resident what happened, res then responded stating 'I only have 1/4 of a brain', res redirected to statement to dispatch that 'someone strangled her'. res said she was and showed this nurse her neck saying 'look at the marks'. neck assessed w/no marks/discolorations/wounds to be found. told res no marks are visible. res…

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, the Minimum Data Set (MDS) assessments did not accurately reflect the resident's status. Specifically, for 5 out of 41 sampled residents, residents that had Preadmission Screening and Resident Review (PASRR) level II's completed did not have the PASRR indicated on the MDS assessments. Resident identifiers: 11, 10, 16, 20, and 36. Findings included: 1. Resident 11 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, hemiplegia and hemiparesis, schizoeffective disorder, major depressive disorder, anxiety, and post-traumatic stress disorder. Resident 11's medical record was reviewed on 2/8/23. An admission MDS assessment dated [DATE], revealed that resident 11 did not have a PASRR level II. A PASRR screening dated 5/12/22, revealed that resident 11 required a PASRR level II to be completed. 2. Resident 10 was admitted to the facility on [DATE] with diagnoses which included acquired absence of right leg above knee,…

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 3 out of 41 sampled residents, that the facility did not develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care to meet professional standards of quality care. Specifically, residents did not have a baseline care plan developed within 48 hours of admission, and the baseline care plan did not include the minimum healthcare information necessary to properly care for the residents. Resident identifiers: 32, 64, and 78. Findings included: 1. Resident 64 was admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses that included dementia with behavioral disturbances, fracture of right femur, orthopedic aftercare, history of falls, long term use of anticoagulants, anxiety disorder, type 1 diabetes mellitus with neuropathy, hyperglycemia, neuralgia and neuritis, muscle weakness, mood disorder, long term use of insulin, hypertension, nicotine…

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 9 of 41 sampled residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident. Specifically, residents care plans did not address care areas such as pain, falls, smoking, and activities of daily living (ADL) assistance. Resident identifiers: 3, 4, 6, 17, 18, 24, 54, 78, and 134. Findings Included: 1. Resident 3 was admitted to the facility on [DATE] with diagnoses that included but not limited to schizoaffective disorder, Parkinson's disease, major depressive disorder (MDD), insomnia, cognitive communication deficit, and type 2 diabetes mellitus (DMII). Resident 3's medical records were reviewed on 2/7/23 An Annual Minimum Data Set (MDS) dated [DATE] documented Resident 3 required a one person limited assist while ambulating throughout the facility. Resident 3's balance and transitions while walking was identified as not steady, but able to stabilize without staff assistance. It 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 4 of 41 residents sampled, that the facility did not ensure that each 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 indication for its use; or in the presence of adverse consequences which indicated that the dose should be reduced or discontinued. Specifically, residents' medications were not administered or held per the physician ordered parameters. Resident identifier: 11, 31, 32, and 47. Findings included: 1. Resident 11 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, hemiplegia and hemiparesis, type 2 diabetes mellitus, alcoholic cirrhosis, schizoaffective disorder bipolar type, major depressive disorder, alcohol induced pancreatitis, paranoid schizophrenia, Post-Traumatic Stress Disorder (PTSD), anxiety disorder, insomnia, hyperlipidemia, atrial fibrillation,…

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, the facility did not file in the resident's clinical record laboratory (lab) reports that were dated and contained the name and address of the testing laboratory. Specifically, for 3 out of 41 sampled residents, a resident that had a UA completed did not have the sensitivity report at the facility or filed in their medical record. In addition, a resident that had a Troponin and Creatine Kinase (CK) ordered for chest pain did not have the report at the facility or filed in their medical record, and a resident that had an influenza nasal swab ordered did not have the report at the facility or filed in their medical record. Resident identifiers: 11, 20, and 68. Findings included: 1. Resident 68 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, paraplegia incomplete, fracture of neck, spinal stenosis, extradural and subdural abscess, surgical aftercare, moderate protein-calorie malnutrition, pressure ulcer of left…

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 maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized. Specifically, for 3 out of 41 sampled residents, a resident with an arteriovenous (AV) fistula in his left arm had multiple blood pressure readings that were inaccurately documented as being taken with his left arm, a resident who was sent to the emergency room (ER) was missing documentation from the ER visit, and a resident that was sent to the hospital was missing hospital documentation and the tests and imaging from their medical record. Resident identifiers: 50, 64, and 78. Findings Included: 1. Resident 50 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included end stage renal disease, encounter for palliative care, holiday relief care, chronic viral hepatitis C, chronic obstructive pulmonary disease, dysphagia, memory deficit…

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 41 sampled residents, 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, a Certified Nurse Assistant (CNA)was observed to pick up the oxygen tubing and nasal cannula from the floor and then offered it to the resident to place on their nose and face. Resident identifier 32. Findings included: Resident 32 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), heart failure, hypertension, cerebral infarction, dysphagia, unsteadiness on feet, cognitive communication deficit, asthma, dorsalgia, pain in bilateral knees, and encounter for palliative care. On 2/06/23 at 12:46 PM, an interview was conducted with resident 32. CNA 7 picked resident 32's oxygen tubing up off the floor,…

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 2 out of 41 sampled residents, that the facility did not ensure that the resident right to self-administer medications was determined by the interdisciplinary team (IDT) as clinically appropriate and safe. Specifically, residents reported self administration of medications and no evaluation was completed to determine if this was a safe practice. Resident identifiers: 32 and 79. Findings included: 1. Resident 32 was admitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), heart failure, hypertension, cerebral infarction, dysphagia, unsteadiness on feet, cognitive communication deficit, asthma, dorsalgia, pain in bilateral knees, and encounter for palliative care. On 2/6/23 at 12:29 PM, an interview was conducted with resident 32. Resident 32 was observed to have a Wiexla Metered Dose Inhaler (MDI) and Spiriva MDI located at bedside. Resident 32 stated that at first the nurse kept the inhalers, but…

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, the facility did not immediately consult with the resident's physician when there was need to alter the residents treatment. Specifically, for 1 out of 41 sampled residents, the facility nursing staff did not notify the provider when a resident's blood sugar (BS) was greater than the indicated amount as per the physician order. Resident identifier: 47. Finding Included: Resident 47 was admitted to the facility on [DATE] with diagnoses that included but not limited to spina bifida, type two diabetes mellitus with hyperglycemia, muscle weakness, bladder disorder, anxiety disorder, chronic pain, essential hypertension, and a colostomy. Resident 47's medical record was reviewed on 2/7/23 Resident 47's care plan was reviewed and revealed a care area with a focus area stating resident has diabetes mellitus type 2 with hyperglycemia. Interventions were identified and included as follows: 1. Diabetes medication as ordered by doctor. Monitor/document for side…

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 41 sampled residents, that the facility did not ensure that residents had the right to be free from abuse, neglect, and misappropriation of property. Specifically, the facility did not protect two residents from abuse by another resident. Resident identifier 2, 3, and 183. Findings included: 1. Resident 31 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included but were not limited to chronic obstructive pulmonary disease (COPD), sepsis, dementia, type 2 diabetes mellitus, anxiety disorder, unspecified disorder of personality and behavior, schizoaffective disorder, viral hepatitis C, glaucoma, delirium, history of malignant neoplasm, chronic pain syndrome On 2/6/23 at 10:55 AM, an interview was conducted with resident 31. Resident 31 reported having fallen on a couple of occasions while attempting to use the toilet. On 2/7/23 resident 31's medical records were reviewed. Review of resident 31's progress…

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 41 sampled residents, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this to the maximum extent practicable to avoid duplicative testing and effort. Specifically, a resident who was assessed as needing a PASARR Level II evaluation did not have a PASARR Level II evaluation. Resident identifier: 50 Findings Include: Resident 50 was initially admitted to the facility on [DATE] and again on 12/21/22 with diagnoses which included end stage renal disease, encounter for palliative care, holiday relief care, chronic viral hepatitis C, chronic obstructive pulmonary disease, dysphagia, memory deficit following other cerebrovascular disease, dependence on renal dialysis, atherosclerotic heart disease, restless legs syndrome, nicotine dependence, panic disorder, delusional disorders, general anxiety disorder, bipolar disorder, essential hypertension, dysphagia,…

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, the facility did not provide the necessary services to maintain good nutrition, grooming, and personal and oral hygiene to residents who were unable to carry out activities of daily living (ADLs). Specifically, for 2 of 41 sampled residents, two dependent residents did not receive showers or bathing assistance in a timely manner and according to the facility schedule for showers. Resident identifiers: 24 and 133. Findings included: 1. Resident 24 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included peripheral vascular disease, type 2 diabetes mellitus with neuropathy, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, chronic pain, hypothyroidism, obesity, benign prostatic hyperplasia with lower urinary tract symptoms, adjustment disorder with mixed anxiety and depressed mood. On 2/6/23 at 1:56 PM, an interview was conducted with resident 24. Resident 24 stated he was getting at least…

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 41 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices. Specifically, hospice communication notes were not contained within the resident's medical records and staff reported difficulty with communication between the hospice providers. Resident identifier 32. Findings included: Resident 32 was admitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), heart failure, hypertension, cerebral infarction, dysphagia, unsteadiness on feet, cognitive communication deficit, asthma, dorsalgia, pain in bilateral knees, and encounter for palliative care. On 2/06/23 at 12:21 PM, an interview was conducted with resident 32. Resident 32 stated that his hospice nurse came into the facility 2 times a week and the hospice Certified Nurse Assistant (CNA) came 3…

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 41 sampled residents, that the facility did not ensure that residents who have not used a psychotropic drug were not given the drug unless the medication was necessary to treat a specific condition diagnosed and documented in the clinical record, and residents do not receive psychotropic drugs pursuant to a as needed (PRN) order for greater than 14 days unless the prescribing practitioner has documented a rationale to extend the use with a documented duration for the PRN order. Specifically, a resident received psychotropic medications and monitoring was not documented and another resident had a PRN order for Ativan that extended past 14 days without a documented rationale to extend the use and monitoring was not documented. Resident identifiers: 6 and 11. Findings Included: 1. Resident 6 was admitted to the facility on [DATE] with diagnoses that included but no limited to moderate protein-calorie malnutrition, dementia, history of falling, 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 it was determined, for 1 of 41 sampled residents, that the facility did not file in the resident's clinical record signed and dated reports of radiological and other diagnostic services. Specifically, a resident had a venous doppler and electrocardiogram (EKG) ordered and the results were not located in the residents medical records. Resident identifier 20. Findings included: Resident 20 was admitted to the facility on [DATE] with diagnoses which consisted of alcohol withdrawal, dysphagia, alcohol induced pancreatitis, cirrhosis, chronic obstructive pulmonary disease, type 2 diabetes mellitus, congestive heart failure, cognitive communication deficit, viral hepatitis C, supraventricular tachycardia, stimulant abuse, abdominal pain, osteoporosis, hypertension, thrombocytopenia, hyperlipidemia, anxiety disorder, gastro-esophageal reflux disease, anemia, opioid abuse, sensorineural hearing loss, major depressive disorder, post-traumatic stress disorder, intervertebral disc…

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, the facility did not provide or obtain routine dental services. Specifically, for 1 out of 41 sampled residents, a resident stated her dentures did not fit and needed to be adjusted. In addition, a dental appointment revealed the resident needed her dentures realigned. Resident identifier: 10. Findings included: Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnose which included cerebrovascular disease, mononeuropathy, chronic respiratory failure with hypercapnia, caervicalgia, urinary tract infection, and chronic pain due to trauma. On 2/6/23 at 12:35 PM, resident 10 was interviewed. Resident 10 stated her dentures did not fit and were too big. Resident 10 stated she was unable to get new dentures because it was too soon. Resident 10's medical record was reviewed on 2/8/23. A significant change Minimum Data Set (MDS) assessment dated [DATE], revealed resident 10 had no broken or loosely fitting full or partial…

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, the facility did not ensure all professional staff were licensed, certified, or registered in accordance with applicable State laws. Specifically, for 1 out of 41 sampled residents, a nurse with a suspended license was providing patient care and was not following the restrictions on their license. Resident Identifier: 47. Finding included: Resident 47 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, spina bifida, type two diabetes mellitus with hyperglycemia, muscle weakness, bladder disorder, anxiety disorder, chronic pain, essential hypertension, and a colostomy. On 2/6/23 at 12:31 PM, an interview was conducted with resident 47. Resident 47 stated that the Patient Care Coordinator (PCC) was a nurse that provided care for him until he was injured by the PCC. Resident 47 stated that the PCC yanked him up in bed by himself and made the wounds on his buttocks start to bleed. Resident 47 stated that the PCC…

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, the facility did not establish an infection prevention and control program that included, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, for 2 out of 41 sampled residents, a resident with a urinary tract infection (UTI) was not treated for a pathogen that was listed on the urinalysis (UA). In addition, a resident with a UTI was treated with two antibiotics that were not listed on the susceptibility laboratory report. Resident identifiers: 15 and 68. Findings included: 1. Resident 15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included multiple sclerosis, influenza, pneumonia, Methicillin-resistant Staphylococcus aureus, UTI, kiebsiella penumoniae, polyneuropathy, dysphagia, and super pubic catheter. On 2/7/23 at 9:30 AM, an interview was conducted with resident 15. Resident 15 stated he went to the hospital for a UTI. Resident 15 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined, for 8 of 40 sample residents, that the facility did not provide a safe, clean, comfortable and homelike environment. Specifically, floors were sticky, there were stains on the carpets, bathrooms had missing base boards, fans in the hallway were soiled, a wheelchair was not clean, and there was debris in resident rooms. Resident identifiers: 13, 21, 39, 41, 44, 51, 60 and 65. Findings include: 1. On 7/12/21 at 11:53 AM, an observation was made or room [ROOM NUMBER]. There were crumbs on the floor at the end of the bed. 2. On 7/12/21 at 11:55 AM, an observation was made of room [ROOM NUMBER]. There was a black/brown substance dried on the floor at the bottom of the bed. 3. On 7/12/21 at 2:50 PM, an observation was made of a fan outside of room [ROOM NUMBER]. The fan was observed to have dried brown substance that had dripped down the front of the fan. 4. On 7/12/21 at 3:06 PM, an interview was conducted with resident 51. Resident 51's floor 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 observation, interview and record review it was determined, for 8 of 40 sampled residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframe's to meet resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, a resident who smoked did not have a care plan, two residents who had an altercation with another resident did not have a care plan, a resident with a urinary tract infection (UTI) did not have a care plan, a care plan was not updated after resident sustained a fall with an injury, a resident with an altercations with another resident did not have a behavioral health care plan, and a resident with a Continuous Positive Airway Pressure (CPAP) machine did not have a care plan for the use of the machine. Resident identifiers: 5, 14, 23, 44, 45, 48, 51 and 52. Findings include: 1. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined, for 1 of 40 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 over 4 hours without incontinence cares. Resident identifier: 39. Findings include: Resident 39 was admitted to the facility at 5/21/2020 with diagnoses which included morbid obesity, adult failure to thrive, diabetes, post-traumatic stress disorder, dysphagia, heart failure and irritable bowel syndrome. On 7/14/21 at 8:46 AM, an observation was made of resident 39 in the hallway outside of the activities room. Resident 39 was sitting in a wheelchair with a visibly saturated urine spot in his groin area. At 8:55 AM, an observation was made of the Director of Nursing (DON) asking resident 39 if he wanted to lay down. Resident 39 was observed 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 interview and record review it was determined, for 3 out of 35 sampled residents, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (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 indicate the dose should be reduced or discontinued; or any of these combinations. Specifically, medications were not administered per the physician ordered parameters. Resident identifiers: 5, 40, and 182. Findings included: 1. Resident 5 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of sialoadenitis, hemiplegia and hemiparesis, dysphagia, chronic obstructive pulmonary disease, chronic kidney disease, hepatitis A, biventricular heart failure, asthma, anemia, diabetes mellitus type 2, restless leg syndrome, chronic pain, hypothyroidism,…

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 did not ensure that all drugs and biological's were labeled in accordance with currently accepted professional principles, were stored under proper temperature controls, and included the expiration date when applicable. Specifically, multi use vials of medications were opened and available for use without a documented open date and medications were expired and still available for use. Findings included: 1. On [DATE] at 8:30 AM, the medication storage room on the Quail unit was inspected. A box of Biscolax laxative suppositories with one suppository remaining was available for use and had an expiration date of 3/2020. An opened multi use vial of Tuberculin was available for use, and did not contain an open date. An immediate interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that the Tuberculin should have an open date documented on the vial, and they use to also have a paper to document the open dates listed on 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, interview and record review it was determined, for 6 of 40 sampled residents, that each resident did not received food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, residents complained of the food quality, resident council minutes revealed complaints of food quality, and a test tray revealed the food was not palatable. Resident identifiers: 50, 60, 62, 69, 76 and 278. Findings include: 1. On 7/12/21 at 12:05 PM, an observation was made of the lunch meal. The plate was observed to have a white piece of meat, white beans, white cabbage, and a cream colored bread product. There was a cookie served in a bowl. On 7/12/21 at 12:25 PM, an observation was made of the dining room. The Certified Nursing Assistant (CNA) stated she was not sure what the food was when a resident asked her what the food was. 2. On 7/12/21 at 11:15 AM, an interview was conducted with resident 278. Resident 278 stated the food was inferior to other places and it was always cold. Resident 278 stated the food was not made very well 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 observation and interview 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 was outdated and unlabeled food in the refrigerator, there were soiled areas in the kitchen, and food was transported uncovered through the hallways. Findings include: 1. On 7/12/21 at 10:30 AM, a tour of the kitchen was conducted. The following observations were made: a. There was a bin labeled sliced cheese dated 6/18 with a use by date of 6/24 in the refrigerator. b. There were individual cups with a white substances in them without a label or a date in the refrigerator. c. There were fruit cups dated 7/4 with a use by date of 7/11 in the refrigerator. d. There were 2 containers with watermelon in the refrigerator. One container had a use by date of 7/11. On the fridge a sign revealed all items must have a date and label hand written use by 3 days e. There was a steam table that had tin foil on the front…

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 3. Resident 24 was admitted to the facility on [DATE] with diagnoses which included nondisplaced fracture of right femur, atrial fibrillation, cerebral infarction, dementia without behavioral disturbance, muscle weakness, dysphagia and lupus. On 7/13/21 at 9:57 AM, an observation was made of resident 24. Resident 24 was observed to be agitated and yelling she was going to kill Certified Nurse Assistant (CNA) 2. CNA 2 stated resident 24 did not have pressure ulcers. Resident 24's medical record was reviewed on 7/14/21. A hospice form titled RN (Registered Nurse) - Skilled Nursing Visit revealed a hospice note dated 6/18/21. The note revealed She has a healing unstageable wound on right buttocks and is on a hospital bed with pressure relief mattress. Wound improving somewhat per staff and aide report. No other hospice notes were located in resident 24's medical record. On 7/15/21 at 11:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated that the hospice staff talk to her when they…

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 and sanitary environment and to help prevent the development and transmission of communicable diseases and infections, including properly preventing and/or containing COVID-19. Specifically, observations were made of staff entering and exiting quarantine/droplet isolation precautions rooms without the required Personal Protective Equipment (PPE) donned, staff were observed to wear washable reusable gowns throughout the facility including in the isolation rooms without changing between resident rooms, meal trays from quarantine/droplet isolation rooms were not handled separate nor identified from other meal trays, a licensed nurse was observed to clean a blood pressure cuff with a 2 by 2 alcohol prep pad, multiple staff were observed to wear their surgical mask down below the nose or mouth while in resident care areas, and a resident'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 and interview it was determined that the facility did not have adequate outside ventilation by means of window, or mechanical ventilation, or a combination of the two. Specifically, there were odors throughout the facility during the survey. Findings include: 1. On 7/12/21 at 9:00 AM, the Northwest conference room smelled of urine. Staff moved the cloth chairs out of the room. 2. On 7/12/21 at 9:42 AM, urine odors were detected in room [ROOM NUMBER]'s bathroom. 3. On 7/12/21 at 10:10 AM, urine odors were detected in and outside of room [ROOM NUMBER]. 4. On 7/12/21 at 12:55 PM, a urine odors were detected in room [ROOM NUMBER]'s bathroom. 5. On 7/14/21 at 2:00 PM, odors were detected outside rooms 32 through 41. There was a strong urine and bowel movement odor. 6. On 7/14/21 at 4:28 PM, urine odors were detected in the [NAME] hallway from room [ROOM NUMBER] south to the center of the hall, and the center hallway from the nurses' station to room [ROOM NUMBER]. 7. On 7/14/21 at 5:21 PM, urine…

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 40 sample residents, that the facility did not ensure each resident exercised their rights as a resident of the facility. Specifically, residents wanted to go to the grocery store and were not provided instruction on the process. Resident identifiers: 30 and 51. Findings include: 1. Resident 51 was admitted to the facility on [DATE] with diagnose which included hemiplegia and hemiparesis, cerebral infarction, dysphagia, schizophrenia, diabetes and obesity. On 7/12/21 at 3:06 PM, an interview was conducted with resident 51. Resident 51 stated she wanted to go to the store but could not go because her wheelchair would not fit in the van. Resident 51 stated that the Activities Director (AD) went to the store with a list from her but that was not the same as being able to go to the store. On 7/12/21, the facility activities calendar was reviewed and there were no activities for residents to go to the store. On 7/15/21 at 11:37 AM, 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 interview and record review it was determined, for 2 of 40 sampled residents, that the facility did not inform each resident periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate. Specifically, a resident was not issued a Notice of Medicare Non-coverage (NOMNC) when the Medicare part A services were terminated and another resident did not have a signed copy of a NOMNC in their medical record. Resident identifiers: 128 and 129. Findings include: 1. Resident 128 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, hemiplegia, hemiparesis, memory deficit, aphasia, dysphasia, dementia, cognitive communication deficit, and encelopathy. Resident 128's medical record was reviewed on 7/14/21. Medicare services for resident 128 ended on 4/11/21. NOMNC was signed by resident 128 on 4/19/21, eight days after…

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 5 of 40 sample residents, that the facility did not ensure each resident had the right to be free from abuse and neglect. Specifically, the facility did not protect residents from another resident. Resident identifiers: 14, 17, 44, 45 and 51. Findings include: 1. Resident 14 was admitted to the facility 7/12/18 and readmitted on [DATE] with diagnoses which included epilepsy and epileptic, displaced bicondylar fracture of right tibia, dysphagia, displaced comminuted fracture of shaft of right fibula, fracture of neck of left femur, cognitive communication deficit, anemia, age related osteoporosis, and history of left hip replacement. Resident 44 was admitted to the facility on [DATE] with diagnoses which included bipolar disorder, schizoaffective disorder, generalized anxiety, panic disorder, and dysphagia. On 7/12/21 at 3:06 PM, an interview was conducted with resident 51. Resident 51 stated that she had a roommate (resident 44) hit her…

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 40 sample residents, that in response to allegations of abuse, exploitation, or mistreatment, the facility failed to have evidence that all alleged violations were thoroughly investigated and prevented. Specifically, there was an allegation of physical abuse that were not thoroughly investigated, was not identified as abuse in the final investigation report, and residents were not protected. Resident identifier: 17 and 45. Findings include: Resident 45 was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia, diabetes mellitus, history of stroke, traumatic brain injury, Parkinson's disease, depression and respiratory failure. On 7/12/21 at 10:20 AM, resident 45 was interviewed. Resident 45 stated that she liked not having a roommate. Resident 45 stated that she had issues with a previous roommate. On 6/25/21 at 2:56 PM, a Nurses Note revealed that resident 45 had pushed room[mate] to the floor and was on top of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not ensure that when the facility transferred a resident the receiving health care institution or provider received contact information for the practitioner responsible for the care of the resident, resident representative information including contact information, advance directive information, comprehensive care plan goals, all other necessary information for ongoing care, and a copy of the discharge summary to ensure a safe and effective transition of care. Specifically, a resident was transferred to the hospital without any transfer or discharge paperwork. Resident identifier 5. Findings included: Resident 5 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of sialoadenitis, hemiplegia and hemiparesis, dysphagia, chronic obstructive pulmonary disease, chronic kidney disease, hepatitis A, biventricular heart failure, asthma, anemia, diabetes mellitus type…

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 40 sample residents, that the facility did not coordinate assessments with the pre-admission screening and resident review (PASARR) program. Including referring all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. Specifically, after a resident was diagnosed with a mental illness there was no referral for a level II. Resident identifier: 35. Findings include: Resident 35 was admitted to the facility on [DATE] with diagnoses which included frontotemporal dementia, memory deficit following cerebral infarction, vascular dementia, anxiety, major depressive disorder, and bipolar disorder. Resident 35's medical record was reviewed on 7/13/2021. A review of resident 35's Pre-admission screening Application/Resident Review (PASRR) dated 4/16/2020 revealed there was no serious mental illness diagnoses. According 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, it was determined, for 1 of 40 sample residents, that the facility did not develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality of care. Specifically, a resident did not have a baseline care plan regarding assistance with eating, therapy or dietary needs. Resident identifier: 228. Findings include: 1. Resident 228 was admitted to the facility on [DATE] with diagnoses which included osteomyelitis, diabetes, toxic encephalopathy, diabetes, dysphagia following cerebral infarction, anemia, stage 3 kidney failure, and great toe amputation. On 7/13/21 at approximately 10:00 AM, resident 228 was observed in his room. Resident 228 had his eyes closed. Resident 228's bedside table was located approximately 2 feet away from his right side. On 7/14/21 at 8:03 AM, resident 228 was observed to be laying in his bed. His…

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 2 of 40 sample residents, that the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, one resident who was admitted for alcohol detoxification was drinking alcohol repeatedly without intervention and one resident who had urosepsis had a delay in treatment and required hospitalization. Resident identifiers: 40 and 43. Findings include: 1. Resident 43 was admitted to the facility on [DATE] with diagnoses which included alcohol detoxification, muscle pain, surgical history, congestive heart failure, chronic obstructive pulmonary disease (COPD), alcohol and opioid dependence, insomnia, and cirrhosis of the liver. On 1/22/21, resident 43 was referred to hospice services. On 7/12/21 at 9:30 AM, an observation was made of room [ROOM NUMBER]. A note on the door revealed that the resident was 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 observation, interview, and record review it was determined, for 2 of 40 sampled residents, the facility did not ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision to prevent accidents. Specifically, a resident was not properly assessed to smoke independently and another resident was not provided adequate supervision while intoxicated and was allowed to continually leave facility unsupervised. Resident identifiers: 52 and 78. Findings include: 1. Resident 78 was admitted on [DATE] with diagnoses which included alcohol dependence with withdrawal, hematemesis, gastrointestinal hemorrhage, paroxysmal atrial fibrillation, hypokalemia, mood disorder, anxiety, major depressive disorder, and epileptic seizures. Resident 78's medical record reviewed 7/14/21. A care plan focus initiated on 12/23/2020 revealed resident 78 was at risk for falls and required assistance with activities of daily living (ADL's) r/t (related 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 it was determined, for 1 of 40 sampled residents, that the facility did not ensure that a resident who needed respiratory care was provided care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences. Specifically, a resident who required a Continuous Positive Airway Pressure (CPAP) machine was not provided the machine. Resident identifier: 60. Findings include: Resident 60 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included paraplegia, encephalopathy, disorders of brain, respiratory failure, dysphagia, acute kidney failure, muscle weakness, post-traumatic stress disorder, neurogenic bladder, heart failure and diabetes. On 7/13/21 at 9:57 AM, an interview was conducted with resident 60. Resident 60 stated that he needed a CPAP machine and did not have one. Resident 60 stated he had not been sleeping well and would like to have a good night…

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 2 of 40 sample residents, that the facility did not provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being. Specifically, a resident who was in crisis and abused another resident was not provided behavioral health services in the facility and was not provided interventions to avoid another crisis. Resident identifiers: 17 and 45. Findings include: Resident 45 was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia, diabetes mellitus, history of stroke, traumatic brain injury, Parkinson's disease, depression and respiratory failure. On 7/15/21, resident 45's electronic medical records review was completed. Resident 45 was moved in with a roommate on 5/11/21. 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 out of 40 sampled residents, that the facility did not ensure that residents who have not used a psychotropic drug were not given the drug unless the medication was necessary to treat a specific condition diagnosed and documented in the clinical record, and residents do not receive psychotropic drugs pursuant to a as needed (PRN) order for greater than 14 days unless the prescribing practitioner has documented a rationale to extend the use with a documented duration for the PRN order. Additionally, an unnecessary drug was any drug when used in excessive dose (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 indicate the dose should be reduced or discontinued; or any of these combinations. Specifically, a resident received duplicate therapy with two anti-anxiety medications and monitoring was not documented, a 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 40 sample residents, that the facility did not ensure that resident's laboratory reports were filed in the clinical record. Specifically, a resident had orders for laboratory reports that were not be located in the medical records. Resident identifier 5. Findings included: Resident 5 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of sialoadenitis, hemiplegia and hemiparesis, dysphagia, chronic obstructive pulmonary disease, chronic kidney disease, hepatitis A, biventricular heart failure, asthma, anemia, diabetes mellitus type 2, restless leg syndrome, chronic pain, hypothyroidism, mood disorder, hepatitis C, mitral stenosis, hypokalemia, insomnia, hypertension, rhinitis, major depressive disorder, history of pulmonary embolism, atrial-fibrillation, aortocoronary bypass graft, cardiac pacemaker, hyperlipidemia, pulmonary hypertension, cardiomyopathy, mitral valve insufficiency, gastro-esophageal…

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 40 sampled residents, that the facility did not have a written agreement with hospice that was signed by an authorized representative of the hospice and authorized representative of the LTC facility before hospice care was furnished to any resident. The written agreement must set out at least the following: The services that hospice will provide; The hospice responsibilities for determining the appropriate hospice plan of care; The services the LTC facility will continue to provide based on each resident's plan of care; A communication process; including how the communication was documented between the LTC facility and the hospice provider, to ensure that the needs of the resident were addressed and met 24 hours per day. Resident identifiers: 24 and 182. Findings include: 1. Resident 24 was admitted to the facility on [DATE] with diagnoses which included nondisplaced fracture of right femur, atrial fibrillation, cerebral infarction, dementia…

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.