Bella Terra St George (Black Rock Health and Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 65 sampled residents, that the facility did not accurately assess residents. Specifically, one resident's Minimum Data Set (MDS) assessment did not reflect a discharge to home. Resident identifier: 68. Findings included: Resident 68 was admitted to the facility on [DATE] with diagnoses which included fracture of unspecified part of neck of left femur and subsequent encounter for closed fracture with routine healing. Resident 68's medical record was reviewed 11/3/24 through 11/13/24. A Minimum Data Set (MDS) assessment, dated 8/7/24, indicated a discharge status of, Short-Term General Hospital (acute hospital, IPPS). A Discharge Progress Note, dated 8/7/24 at 12:53 PM, indicated resident was discharged to a private residence. On 11/7/24 at 11:38 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated he did not know why the MDS assessment reflected resident 68 went to the hospital because she was discharged home.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 4 out of 65 sampled residents, that the facility did not ensure that baseline care plans were developed and implemented within 48 hours of the resident's admission and contained the minimum information necessary to care for the resident including, but not limited to, initial goals, physician orders, dietary orders, therapy services, social services and Preadmission Screening and Resident Review (PASRR). Specifically, baseline care plans were not completed for residents timely and they did not contain the minimum healthcare information. Resident identifier: 38, 51, 65, and 66. Findings included: 1. Resident 51 was admitted to the facility on [DATE] with diagnoses which included intracerebral hemorrhage, hemiplegia and hemiparesis of left side, neurologic neglect syndrome, chronic kidney disease, hypertension, congestive heart failure, cognitive communication deficit, aphasia, visual loss both eyes, and insomnia. On 1/11/24, resident 51's care plan had…

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 4. Resident 55 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease with dyskinesia without mention of fluctuations, chronic obstructive pulmonary disease, type 2 diabtes mellitus, tremor, and personal history of other infectious and parasitic disease. On 11/4/24 at 8:40 AM, an interview was conducted with resident 55. Resident 55 stated he had pain in his back, that radiated down his right side to his groin and left hip. Resident 55 stated he thought it was a pinched nerve but the nurse got a urine sample on 10/28/24. Resident 55 stated he had not heard about the results from his urine and was not sure if he was taking antibiotics. Resident 55 stated the pain from his back to his groin was new. Resident 55 stated that his catheter was removed about a month ago. Resident 55's medcal record was reviwed 11/5/24 thought 11/13/24. Resident 55's Admit/Readmit Screener dated 4/29/24 revealed resident 55 had a catheter when admitted . An admission MDS assessment dated [DATE] revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 4 of 65 residents sampled, that the facility did not ensure that the resident was given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living. Specifically, resident's were not provided bathing/shower assistance, nail care, and incontience care for over 3 hours. Resident identifier: 15, 49, 51 and 60. Findings included: 1. Resident 49 was admitted to the facility on [DATE] with diagnoses which included dementia, psychotic disturbance, mood disturbance and anxiety. On 11/3/24 at 6:44 PM, an interview and observation was made of resident 49. Resident 49 stated he did not get showers as often as he wanted. Resident 49 stated when his roommate showered there was water everywhere because of how poorly the drain for the shower was designed. Resident 49 stated he would like to shower daily, but was only getting showers once per week because of the poorly designed showers. On 11/3/24 through…

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, for 4 of 65 sampled residents, the facility did not ensure residents maintained acceptable parameters of nutritional status. Specifically, residents meal portion sizes were not adequate, residents weights were not obtained and residents nutrition assessments were not being completed. Resident identifiers: 3, 4, 55, 60, and 65. Findings included: 1. Resident 60 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, hypertension, dysphagia, history of falling, constipation and dementia. On 11/3/24 at 4:04 PM, an interview was conducted with resident 60. Resident 60 stated he had not been weighed so he did not know if he had lost weight. Resident 60's medical record was reviewed. Resident 60's weight on 8/26/24 was 170.0 pounds and on 10/6/24 was 178.5 pounds. An admission Nutritional assessment dated [DATE] was in progress and had not been completed by the Registered Dietitian (RD). Progress notes revealed the following…

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 5 out of 65 sampled residents, that the facility did not ensure that a resident who used psychotropic drugs was not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Further, as needed (PRN) orders for psychotropic drugs are limited to 14 days, unless the attending physician or prescribing practitioner believes that it was appropriate for the PRN order to be extended beyond 14 days, and should document their rationale in the resident's medical record and indicate the duration for the PRN order. Specifically, a resident was prescribed an antipsychotic without a supporting diagnosis and no gradual dose reduction was initiated. In addition, residents were given PRN psychotropic medications beyond 14 days, a resident was not monitored for adverse side effects to the psychotropic medication, behaviors were not monitored, and non-pharmacological interventions prior to 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, for 7 of 65 sampled residents, the facility did not file in the resident's clinical record laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, results from laboratory tests completed at outside facilities were not obtained and filed into resident's medical record. Resident identifiers: 1, 2, 13, 50, 52, 54, and 55. Findings included: 1. Resident 13 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included Hereditary and idiopathic neuropathy, chronic respiratory failure, symptomatic epilepsy and epileptic syndromes with simple partial seizures, morbid obesity, hypertensive heart and chronic kidney disease with heart failure, muscle weakness, major depressive disorder, and chronic pain. Resident 13's medical records were reviewed between 11/3/24 and 11/13/24. On 7/10/24 at 11:01 AM, a general progress note revealed, Phlebotomist was unable to obtain lab draw this morning for CBC…

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 of 65 sampled residents, that the facility did not have menus that met the nutrition needs of residents in accordance with established nutritional guidelines. Specifically, menus were not followed and correct portion sizes were not provided to residents. Resident identifiers: 15, 16 and 55. Findings included: 1. On 11/3/24 at 1:15 PM, an initial observation was made in the kitchen. Several additional observations were made in the kitchen between 11/3/24 an 11/13/24. a. On 11/3/24 at 1:15 PM an observation was made of the lunch meal being plated. The meal served included 1 piece of chicken, a 4 ounce (oz) slotted spoon of cubed yams, a 6 oz slotted spoon of green beans, 1 dinner roll with a pat of butter, and a slice of chocolate cream pie, serving size unknown. A review of the spreadsheet for the lunch meal revealed the recipe called for a 1-3 oz piece of chicken, 1-5 oz baked sweet potato, a 4 oz serving of green beans, 1 slice of bread…

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 11 out of 65 sampled residents, that the facility did not provide food prepared by methods that conserve flavor and appearance or provide food and drink that was palatable, attractive, and at an appetizing temperature. Specifically, there were multiple complaints from residents about the quality of food, there were multiple resident council complaints about the flavor of food, and when surveyors pulled a test tray during the lunch meal, the food was found to be lacking in flavor and appearance. Resident identifiers: 9, 12, 16, 22, 26, 27, 28, 32, 50, 55, and 120. Findings included: 1. Observations: On 11/3/24 at 5:48 PM, an observation was made of the kitchen staff plating the dinner meal. The meal consisted of a grilled cheese quesadilla, herbed fettuccini noodles and a green salad. The Dietary Manager (DM) was at the steam table plating the food, cook 2 was putting the meal trays together. The Housekeeping Supervisor (HS) was helping in the kitchen, making salad and cooking the quesadillas. The DM put 2…

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 6 of 65 sampled residents, that the facility did not ensure that each resident received the food and drink that accommodated the resident allergies, intolerances, and preferences. Specifically, residents with food allergies and intolerances were served food containing identified allergens, and one resident who was admitted on [DATE] had not been questioned about food allergies until 11/5/24. Resident identifiers: 1, 10, 16, 26, 28, and 38. Findings included: 1. Resident 38 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, type 2 diabetes with skin ulcer and neuropathy, cirrhosis of liver, morbid obesity, hemiplegia affecting right dominant side, anxiety disorder, aphasia, major depressive disorder, seizures and dysphagia. On 11/5/24 at 12:38 PM, an interview was conducted with resident 38 who stated he was allergic to onions and was provided a lunch entree that contained onions. Resident 38 stated 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 for 4 of 65 sampled residents, the facility did not ensure each resident received drinks, including water and other liquids, consistent with the residents' needs and preferences and sufficient to maintain resident hydration. Specifically, water was not being provided to residents between meals, residents had to seek out staff to obtain fresh water and resident water mugs were not being cleaned regularly. Resident identifiers: 26, 27, 55 and 120. Findings include: 1. Resident 26 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, facioscapulohumeral muscular dystrophy, unspecified protein-calorie malnutrition, hyperlipidemia, hypomagnesemia, hypo-osmolality and hyponatremia, and weakness. Resident 26's meal ticket revealed an alert to encourage fluids. A review of resident 26's care plan revealed the following: a. Focus: Potential for Health Maintenance related to: Facioscapulohumeral muscular dystrophy, malnutrition,…

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 12 of 65 sampled residents, the facility failed to provide each resident with 3 meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. Additionally, snacks were not provided to residents who wanted to eat at non-traditional times or outside of the scheduled meal service times and consistent with the resident plan of care. Specifically, meals were not served according to meal times, meal times were changed without resident input, snacks were not being provided regularly. Resident identifiers: 9,13, 16, 26, 27, 29, 32, 49, 53, 55, 60, and 120. Findings include: 1. Resident 9 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included heart failure, renal insufficiency, depression, and hypertension. On 11/3/24 at 5:33 PM, an interview was conducted with resident 9 who stated the food was cold 90% of the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that, for 6 of 65 sample residents, medical records were complete and accurately documented. Specifically, neuro checks were not documented in the resident's medical record, records were not obtained after a resident went to and returned from the hospital, a resident's medical information was found in another resident's medical record, and a physician documented a progress note in the wrong resident's medical chart. Resident identifiers: 10, 13, 26, 220, 221 and 371. Findings include: 1. Resident 221 was admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis, paraplegia, infection and inflammation due to indwelling urethral catheter, and extended spectrum beta lactamase resistance. Resident 221's medical records were reviewed between 11/3/24 and 11/13/24. On 10/18/24 at 8:07 PM, an alert charting progress note revealed, At 7:00 PM CNA [Certified Nursing Assistant] informed me that resident was acting really wierd [sic].…

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 5 sampled residents, that the facility did not ensure that residents were offered the COVID-19 immunization and that the medical records included documentation that the resident either received the immunization or did not due to medical contraindications or refusal. Specifically, three residents did not have immunization documentation in their medical records. Resident identifiers: 49, 61, and 269. Findings included: 1. Resident 49 was admitted to the facility on [DATE] with diagnoses which included dementia, paroxysmal atrial fibrillation, heart failure, cognitive communication deficit, and pain. On 11/12/24 resident 49's medical records were reviewed. No documentation could be found for the administration or declination for the COVID-19 vaccine for the current season. 2. Resident 269 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, severe sepsis, cognitive communication deficit, dementia, anxiety disorder,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined, for 3 of 65 residents sampled, that the facility did not adequately equip residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside and toilet and bathing facilities. Specifically, resident's bedside and toilet call lights were not in working condition or were not present at all. Resident identifiers: 44, 51, and 55. Findings included: 1. Resident 51 was admitted to the facility on [DATE] with diagnoses which included intracerebral hemorrhage, hemiplegia and hemiparesis of left side, neurologic neglect syndrome, chronic kidney disease, hypertension, congestive heart failure, cognitive communication deficit, aphasia, visual loss both eyes, and insomnia. On 11/03/24 at 2:48 PM, an interview was conducted with resident 51. Resident 51 stated that she had fallen previously in the morning when attempting to get up and toilet…

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 27 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include, but not limited to, aftercare following joint replacement surgery, difficulty in walking, muscle weakness, type 2 diabetes mellitus with hyperglycemia, major depressive disorder, anxiety disorder, essential hypertension, unsteadiness on feet, and history of falling. On 11/4/24 at 8:16 AM, an observation was made of resident 27 eating cereal out of a small disposable cup. On 11/4/24 at 8:16 AM, an interview was conducted with resident 27. Resident 27 stated that she had received her cereal in a disposable container. Resident 27 stated the she would like to eat cereal out of a larger bowl and not a small disposable container. Based on observation and interview it was determined, for 2 of 65 sampled residents, that the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of their quality of life,…

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 1 of 65 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 care plan, and the right to request revisions to the person-centered plan of care. Specifically, a resident who wished to participate in her plan of care was not included, and there was no documentation that care plan meetings were being held. Resident identifier: 3. Findings include: Resident 3 was admitted to the facility on [DATE] with diagnoses that included Arnold Chiari Syndrome with spina bifida and hydrocephalus, severe protein-calorie malnutrition, osteomyelitis right ankle and foot, paraplegia, borderline personality disorder, major depressive disorder, morbid obesity, bipolar disorder, and anxiety disorder. On 11/3/24 at 5:16 PM, an interview was conducted with resident 3 who stated the facility was not having care conferences and 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 and interview it was determined, for 2 of 65 sampled residents, that the facility did not ensure the resident right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. Specifically, the resident call lights were out of reach. Resident identifiers: 1 and 30. Findings included: 1. Resident 1 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included cerebral infarction, cognitive communication deficit, chronic obstructive pulmonary disease, morbid obesity, type 2 diabetes mellitus, chronic viral hepatitis C, non-pressure chronic ulcer of left lower leg, mood disorder, encephalopathy, atrial fibrillation, pulmonary embolism, hypospadias, retention of urine, chronic kidney disease, major depressive disorder, pyelonephritis, multiple fractures of ribs, bipolar disorder, dysphonia, insomnia, peripheral vascular disease, chronic pain syndrome, opioid dependence, extended spectrum beta lactamase…

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 for 1 of 65 sampled residents, the facility failed to ensure the resident had reasonable access to the use of a telephone, including TTY and TDD services, and a place in the facility where calls can be made without being overheard. Specifically, a resident was not provided access to a phone in her room as requested. Resident identifier: 28. Findings included: On 11/03/24 at 1:42 PM, an interview was conducted with resident 28. Resident 28 stated multiple staff members told her that she cannot get a phone in her room. Resident 28 stated her cell phone did not work. Resident 28 stated she had to use the phone at the nurse's station. On 11/06/24 at 10:16 AM, an observation of Registered Nurse (RN) 2. RN 2 was observed to tell the resident in room [ROOM NUMBER] that the phone had to stay at the nurse's station because it kept getting lost. Resident 28's medical record was reviewed 11/3/24 through 11/13/24. Resident 28 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that 1 of 65 sampled residents had the right to refuse medical treatment and formulate an advance directive. Specifically, a resident had a signed Provider Order for Life-Sustaining treatment (POLST) form for a Do Not Resuscitate (DNR) but the electronic medical records banner documented that the resident wanted full treatment. Resident identifier: 22. Findings included: Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included schizophrenia, cognitive communication deficit and generalized anxiety. Resident 22's medical record was reviewed on [DATE]. A physician's order dated [DATE] revealed FULL CODE; FULL TREATMENT. No directions specified for order. A POLST form dated [DATE] revealed resident 22 desired for no attempt or any continued resuscitation (DNR) and resident wanted comfort measures for medical interventions with no artificial nutrition. According to the banner in resident 22's electronic…

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 1 of 65 sampled residents, the facility did not take all the necessary steps to prevent the exploitation of a resident for personal gain. Specifically, when the facility became aware of possible exploitation of a resident, the police were not notified, and no follow-up occurred to protect the resident. Resident identifier: 13. Findings include: Resident 13 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hereditary and idiopathic neuropathy, chronic respiratory failure, symptomatic epilepsy and epileptic syndromes with simple partial seizures, morbid obesity, hypertensive heart and chronic kidney disease with heart failure, muscle weakness, major depressive disorder, and chronic pain. Resident 13's medical record was reviewed between 11/3/24 and 11/13/24. On 6/11/24, an admission Minimum Data Set (MDS) assessment revealed resident 13 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated a normal…

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 1 of 65 sampled residents, that the facility, in response to allegations of abuse, neglect, exploitation, or mistreatment, failed to provide evidence that all alleged violations were thoroughly investigated and failed to report the results of all investigations to the State Survey Agency, within 5 working days of the incident. Specifically, after a resident sustained a fall resulting in a major injury, the facility did not investigate the incident and did not update the resident's care plan to initiate interventions to prevent additional falls. Additionally, the incident was not reported and investigative results were not submitted to the State Agency within 5 working days. Resident identifier: 13. Findings included: Resident 13 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hereditary and idiopathic neuropathy, chronic respiratory failure, symptomatic epilepsy and epileptic syndromes with simple partial seizures, morbid…

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 65 sampled residents, that the facility did not ensure that the receiving health care institution had the resident's medical record information including: the contact information of the practitioner responsible for the care of the resident, resident representative information, advance directive information, special instructions for ongoing care, comprehensive care plan, and any other documentation to ensure a safe and effective transition of care. Specifically, the residents were transferred to the local area hospital emergency department (ED) without any accompanying medical records. Resident identifiers: 8, 123, and 371. Findings included: 1. Resident 8 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included, but not limited to, unspecified intracranial injury with loss of consciousness, human immunodeficiency virus, acute respiratory failure with hypoxia, major depressive disorder,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not provide and document sufficient preparation to 1 of 65 sampled residents to ensure a safe and orderly transfer or discharge from the facility. Specifically, one resident with cognitive impairment signed out of the facility against medical advice and was subsequently imprisoned and charged with criminal trespassing. Resident identifier: 419. Findings Included: Resident 419 was admitted to the facility on [DATE] and discharged on 3/25/24 with diagnoses of metabolic encephalopathy, schizophrenia, psychological and behavioral factors, and polydipsia. Resident 419's medical record was reviewed on 11/13/24. A hospital history and physical dated from 2/6/24 to 3/20/24 documented resident 419 was unable to care for themselves nor make medical decisions and lacked self-awareness. The physician documented resident 419 needed to be placed into a care facility with 24-hour supervision. On 3/7/24, an inpatient psychiatric (psych) evaluation was conducted on 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, for 1 of 65 sampled residents, the facility failed to obtain the written and/or verbal physician orders to provide essential care to the resident upon admission to the facility. Specifically, a resident who was admitted with an indwelling catheter did not have physician orders for catheter care. Resident identifier: 221. Findings included: Resident 221 was admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis, paraplegia, infection and inflammation due to indwelling urethral catheter, and extended spectrum beta lactamase resistance. On 11/4/24 at 10:04 AM, an interview was conducted with resident 221. Resident 21 stated he had a catheter and staff would come to empty the bag or change it when he called them. Resident 221's medical record was reviewed between 11/3/24 and 11/13/24. On 10/18/24 an admission Minimum Data Set (MDS) revealed that resident 221 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated a normal…

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 65 residents sampled, that the facility did not ensure the timely transmission and completion of the Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid (CMS) System. Specifically, two resident's MDS assessments were not encoded and transmitted within 14 days after the facility completed the resident assessment. Resident identifier: 13 and 32. Findings included: 1. Resident 13 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of neuropathy, chronic respiratory failure, epilepsy, chronic kidney disease, congestive heart failure, anterior dislocation of the right humerus, anxiety disorder, hypothyroidism, hypertension, thrombophilia, major depressive disorder, cataract, gout, suicidal ideation, mild cognitive impairment, chronic pain, osteoarthritis, scoliosis, insomnia, hyperlipidemia, obstructive sleep apnea, and fracture of right humerus. Resident 13's medical records were 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 observation, interview and record review it was determined, 3 out of 65 sampled residents, that the facility did not provide an ongoing program to support resident in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community based on the residents comprehensive assessment and care plan. Specifically, there was no activity calendar, there were no activities on the weekends, resident complained of not enough activities, activities were observed during meal times, and there were complaints in resident council minutes. Resident identifiers: 26, 38 and 49. Findings included: 1. On 11/3/24 at 1:04 PM, an observation was made of the activity calendar. The calendar was for October 2024. On 11/4/24 an observation was made of the activity calendar for November 2024 hanging on the wall 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 interview and record review, for 1 of 65 sample residents, the facility did not ensure a resident who required colostomy services received care consistent with professional standards of practice, the person-centered care plan, and the resident's goals and preferences. Specifically, the facility ran out of colostomy supplies and when the supplies were ordered, the wrong item was ordered leaving the resident without colostomy supplies. Resident identifier: 3. Resident 3 was admitted to the facility on [DATE] with diagnoses that included Arnold Chiari Syndrome with spina bifida and hydrocephalus, severe protein-calorie malnutrition, osteomyelitis right ankle and foot, paraplegia, borderline personality disorder, major depressive disorder, morbid obesity, bipolar disorder, and anxiety disorder. On 11/4/24 at 10:59 AM, an interview was conducted with resident 3 who stated the facility had run out of wafers needed for her colostomy care and then the wrong ones were ordered. Resident 3'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.

Based on observation and interview, it was determined that the facility did not have the nurse staffing information posted. The facility must post the following information on a daily basis: Facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses, Licensed practical nurse, Certified Nurse aides, and resident census. The facility must post the nurse staffing data on a daily basis at the beginning of each shift and maintain the posted daily nurse staffing data for a minimum of 18 months. Additionally, the information must be displayed in a prominent place readily accessible to residents and visitors. Specifically, there were days when the nurse staffing information was not posted by 6:00 AM with the current date and the nurse staffing information was not posted on 11/8/24. Findings include: a. On 11/3/24 at 1:04 PM, during the initial tour of the facility, the nurse staff posting was dated 11/1/24. b. On 11/5/24 at 7:54 AM, 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 1 out of 64 sampled residents, that the facility did not ensure that a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Specifically, staff reported ignoring resident behaviors and were not able to identify person-centered interventions or non-pharmacological approaches to resident's dementia care. Resident identifier: 65. Finding included: Resident 65 was admitted to the facility on [DATE] with diagnoses which included dementia, seizures, hypothyroidism, obstructive sleep apnea, depression, presence of a cardiac pacemaker, and violent behaviors. On 11/03/24 at 3:56 PM, an observation was made of resident 65 sleeping in a recliner in his room. The resident's call light was observed on the arm rest within reach and a walker was located near the door. On 11/05/24 at 1:08 PM, an observation was made 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 65 sampled residents, that the facility did not provide pharmaceutical services which included procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's to meet the needs of each resident. Specifically, Darbepoetin Alfa injection for anemia was not available from the pharmacy for administration and laboratory values were abnormal. Additional medications were not available for administration. Resident identifier: 55. Findings included: Resident 55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's disease with dyskinesia, chronic obstructive pulmonary disease, type 2 diabetes mellitus, and anemia. On 11/12/24 at 10:26 AM, an interview was conducted with resident 55. Resident 55 stated he had not been administered an injection and had not been told why he had not received it. Resident 55's medical record was reviewed from 11/3/24 through…

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 65 sampled residents, that the facility did not provide or obtain laboratory services timely to meet the needs of its residents. Specifically, a resident's urinalysis (UA) with culture and sensitivity (C & S) was not followed up on timely resulting in a delay of treatment and another resident did not have weekly labs completed for an ordered Complete Blood Count (CBC) and a Comprehensive Metabolic Panel (CMP). Resident identifiers: 1 and 55. Findings included: 1. Resident 1 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included but were not limited to hypospadias, retention of urine, chronic kidney disease, pyelonephritis, extended spectrum beta lactamase resistance, obstructive and reflux uropathy, and methicillin resistant staphylococcus aureus infection classified elsewhere. On 11/4/24 at 9:07 AM, an observation was made of resident 1's room. A sign was posted outside of resident 1's room for enhanced…

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 65 sampled resident, that the facility did not provide therapeutic diets as prescribed by the attending physician. Specifically, a resident with a physician's order for thickened liquids was observed to have thin water at the bedside. Resident identifier: 60. Findings include: Resident 60 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, hypertension, dysphagia, history of falling, Gastroesophageal reflux disease (GERD), constipation and dementia. On 11/7/24 at 11:51 AM, an observation was made of resident 60. Resident 60 was laying in bed with 2 bottles half full with water on his bedside table. An interview was conducted with Certified Nursing Assistant (CNA) 4. CNA 4 stated the water on resident 60's bedside table was not thickened. CNA 4 stated resident 60 requested regular water. CNA 4 stated she needed to ask the nurse if resident 60 was able to drink regular water. CNA 4 was observed…

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 65 sampled residents, that the facility failed to provide special eating equipment and utensils for residents who needed them to ensure that the resident could use the assistive devices when consuming meals and snacks. Specifically, one resident was not provided with a lipped plate when identified as needing one. Resident identifier: 5. On 11/4/24 at 10:06 AM, an observation was made of resident 5 feeding himself in his room. The resident was eating off of a flat plate, no lip or divided plate was observed. A meal ticket was observed on his tray and indicated, Adaptive Equip: Lip Plate. Findings included: Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included quadriplegia, dysphagia, chronic kidney disease, chronic obstructive pulmonary disease, paralysis of vocal cords and larynx, congestive heart failure, and major depressive disorder. Resident 5's medical record was reviewed 11/3/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 65 sampled residents, that the facility did not ensure that the hospice services met professional standards and principles that applied to individuals providing services in the facility, and to the timeliness of those services. Specifically, facility staff documented they were unable to contact hospice, the facility did not obtain from the hospice provider the nursing notes and there were no coordination of care notes. Resident identifier: 4. Findings include: On 11/4/24 at 8:06 AM, an interview was conducted with resident 4. Resident 4 stated she needed her brief changed. Resident 4 was laying in bed with greasy hair and a substance coming out the side of her mouth. On 11/6/24 at 1:23 PM, an observation was made of resident 4. Resident 4 was laying in bed with her eyes closed. At 1:36 PM, an observation was made of Certified Nursing Assistant (CNA) 6 standing and feeding resident 4. Resident 4's bed was in a high position with the head of her bed…

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 65 sampled residents, that the facility did not establish an infection prevention and control program (IPCP) that included an antibiotic stewardship program with protocols and a system to monitor antibiotic use. Specifically, a resident was treated for a urinary tract infection (UTI) with an antibiotic that the organism was resistant to. Resident identifier: 1. Findings included: Resident 1 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included but was not limited to hypospadias, retention of urine, chronic kidney disease, pyelonephritis, extended spectrum beta lactamase resistance, obstructive and reflux uropathy, and methicillin resistant staphylococcus aureus infection classified elsewhere. On 11/4/24 at 9:07 AM, an observation was made of resident 1's room. A sign was posted outside of resident 1's room for enhanced barrier precautions (EBP) and a personal protective equipment (PPE) cart was located…

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 5 sampled residents, that the facility did not ensure that residents were offered the influenza and pneumococcal immunizations and that the medical records included documentation that the resident either received the immunization or did not due to medical contraindications or refusal. Specifically, three residents did not have immunizations documentation in their medical records. Resident identifiers: 49, 61, and 269. Findings included: 1. Resident 49 was admitted to the facility on [DATE] with diagnoses which included dementia, paroxysmal atrial fibrillation, heart failure, cognitive communication deficit, and pain. On 11/12/24 resident 49's medical records were reviewed. No documentation could be found for the administration or declination for the Influenza or Pneumococcal vaccine for the current season. 2. Resident 269 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, severe sepsis, cognitive communication…

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 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 meet professional standards of quality care, and be developed within 48 hours of the resident's admission. Specifically, for 1 out of 32 sampled residents, a resident that was a fall risk did not have a baseline care plan developed within 48 hours of the admission. Resident identifier: 47. Findings included: Resident 47 was admitted to the facility on [DATE] with diagnoses which include, but were not limited to, pneumonitis due to inhalation of food and vomit, abnormalities of gait and mobility, dysphagia, protein-calorie malnutrition, chronic obstructive pulmonary disease, opioid dependence, cognitive communication deficit, low back pain, essential hypertension, repeated falls, pain in right shoulder, and esophageal obstruction. Resident 47's medical record was reviewed…

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 develop and implement a comprehensive person-centered care plan for each resident. Specifically, for 1 out of 32 sampled residents, a resident that had care areas trigger on the Minimum Data Set (MDS) Care Area Assessment (CAA) Summary did not have a care plan developed and implemented in a timely manner. In addition, the care plan was not updated with safety interventions after the resident had four falls. Resident identifier: 47. Findings included: Resident 47 was admitted to the facility on [DATE] with diagnoses which include, but were not limited to, pneumonitis due to inhalation of food and vomit, abnormalities of gait and mobility, dysphagia, protein-calorie malnutrition, chronic obstructive pulmonary disease, opioid dependence, cognitive communication deficit, low back pain, essential hypertension, repeated falls, pain in right shoulder, and esophageal obstruction. Resident 47's medical record was reviewed on 6/26/23. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined, the facility did not ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections (UTI). Specifically, for 1 out of 32 sampled residents, facility staff did not promptly respond with a resident presented with signs and symptoms of a UTI and they did not ensure the resident received an antibiotic susceptible to the organism causing the UTI. Resident identifier: 3. Findings included: Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right, chronic obstructive pulmonary disease, urinary tract infection, and overactive bladder. Resident 3's medical record was reviewed on 6/26/23. A quarterly Minimum Data Set assessment dated [DATE], documented that resident 3 was frequently incontinent of bladder and occasionally incontinent 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, the facility did not ensure residents who displayed or were diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Specifically, for 1 out of 32 sampled residents, the facility was unable to demonstrate implementation of interventions for managing a residents dementia with behavioral disturbances. The resident had uncontrolled anxiety and agitation for two months that resulted in a fall with a fracture. Resident identifier: 164. Findings included: Resident 164 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Parkinson's disease, insomnia, vascular dementia, and osteoporosis without current pathological fracture. Resident 164's medical record was reviewed on 6/26/23. A care plan Focus initiated on 12/27/22, documented Elopement risk/wanderer r/t [related to] vascular dementia and confusion. 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, the facility did not ensure that the antibiotic stewardship program included antibiotic use protocols and a system to monitor the antibiotic use. Specifically, for 2 out of 32 sampled residents, a resident with a Urinary Tract Infection (UTI) was started on an antibiotic and the culture and sensitivity (C&S) was never received which indicated to repeat the culture. In addition, a resident with a UTI was started on an antibiotic and a C&S was not completed per physician's orders. Resident identifiers: 25 and 31. Findings included: Resident 31 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, type 2 diabetes mellitus, mild intellectual disabilities, cognitive communication deficit, obstructive and reflux uropathy, retention of urine, essential hypertension, presence of urogenital implants, hydronephrosis, and history of falling. Resident 25's medical record was reviewed on 6/28/23. On 5/14/23 at 3:59 PM, a Health…

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.