Red Cliffs Health and Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined, for 2 out of 53 sampled residents, that the facility did not ensure that the resident had the right to self-determination through support of the resident choice. Specifically, residents were not offered showers according to their preferences. Resident identifiers: 15 and 27. Findings included: 1. Resident 27 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy, cervical root disorders, neuromuscular dysfunction of bladder and major depressive disorder. On 6/33/24 at 9:27 AM, an interview was conducted with resident 27. Resident 27 stated they would like showers every other day but only received showers Mondays and Thursdays. Resident 27 stated it was just how it is. Resident 27 stated they would like more showers but had not been asked. Resident 27 stated he was able to shower independently but there needed to be more staff. Resident 27 was observed to have greasy hair and was observed to be dry shaving his face…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined, for 1 of 53 sampled residents, that the facility did not ensure that the resident had the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely. Specifically, a resident's bathroom toilet was not secured to the ground and wobbled and the toilet seat was not secured to the base and moved from side to side. Resident identifier: 36. Findings included: Resident 36 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, polyosteoarthritis, malignant neoplasm of the ovary, chronic fatigue, morbid obesity, anxiety disorder, bipolar disorder, peripheral neuropathy, presence of left and right artificial knee joint, insomnia, and restless leg syndrome. On 6/06/24 at 9:21 AM, an interview was conducted with resident 36. Resident 36 stated that they had put in multiple work orders for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not prevent misappropriation of resident's medications for 3 of 53 sample residents. Specifically, cognitively impaired residents had missing fentanyl patches on numerous occasions. Resident identifiers: 5, 42, and 43. Findings Included: 1. Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of encounter for palliative care, type 2 diabetes mellitus with diabetic neuropathy, venous insufficiency, hypertensive heart disease with heart failure, chronic respiratory failure with hypoxia, unspecified dementia and Alzheimer's disease. On 6/5/24 at 11:44 AM, an observation was made of resident 5 in their room. Resident 5 was brought back to their room by the licensed practical nurse (LPN) 4 and regional nurse consultant (RNC). The RNC and LPN 4 informed resident 5 they needed to look at their back. The RNC and LPN 4 helped lean resident 5 in the chair and pulled their shirt up. Resident 5's back 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 53 residents sampled, that the facility did not coordinate assessments with the pre-admission screening and resident review (PASARR) program. Specifically, residents with a serious mental illness (SMI) were not referred for a Level II PASARR assessment with a newly evident SMI or upon a significant change in status. Resident identifier: 36 and 44. Findings included: 1. Resident 36 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included, but were not limited to, anxiety disorder and bipolar disorder. On 6/02/24, resident 36's electronic medical records were reviewed. On 1/20/22, resident 36's PASARR Level I documented a serious mental illness of Bipolar Disorder, and Generalized Anxiety Disorder. The Level I indicated that a referral for Level II evaluation was needed. On 2/7/22, the PASARR office screened resident 36 out due to No signs of symptoms, not impaired. The PASARR Level II referral documented…

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 comprehensive person-centered care plan consistent with the resident's rights that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. Specifically, for 1 out of 53 sampled residents, the residents care plan did not identify tasks related to the proper changing and monitoring of the resident's PureWick urinary system device and the resident received a urinary tract infection while using this device. Resident Identifier: 54. Findings Included: Resident 54 was admitted to the facility on [DATE] with diagnoses which included cervical disc disorder, primary osteoarthritis, type 2 diabetes with neuropathy, hypothyroidism, morbid obesity, weakness, muscle weakness, anxiety, obstructive sleep apnea, hypertension, and a history of falling. Resident 54's medical record was reviewed 6/2/24-6/6/24. An admission Minimum Data…

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 53 sampled residents, that the facility did not ensure that the discharge needs of the resident was identified and resulted in the development of a discharge plan for the resident; that regular re-evaluation to identify changes that required modification to the discharge plan was completed; and referrals to local agencies for the purpose of returning to the community were documented. Specifically, the resident desired to transfer to another long term care facility closer to family and the facility did not follow-up with the resident or family for the transfer. Resident identifier: 7. Findings included: Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included paroxysmal atrial fib, fibromyalgia, type 2 diabetes mellitus, obesity and major depressive disorder. On 6/3/24 at 10:08 AM, an interview was conducted with resident 7. Resident 7 stated she would like to move to another facility to be closer 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 1 of 53 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, a resident was not provided bathing/shower assistance in a timely manner. Resident identifier: 36. Findings included: Resident 36 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of chronic obstructive pulmonary disease, polyosteoarthritis, malignant neoplasm of ovary, hyperlipidemia, chronic fatigue, morbid obesity, anxiety disorder, bipolar disorder, idiopathic peripheral autonomic neuropathy, presence of left and right artificial knee joint, insomnia, opioid dependence, and restless leg syndrome. On 6/2/24 at 2:09 PM, an interview was conducted with resident 36. Resident 36 stated that her shower schedule was supposed to be Tuesdays and Fridays, but the facility was short staffed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that, for 1 of 53 sampled residents, that the facility failed to provide the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for residents who were unable to carry out activities of daily living. Specifically, a resident was not provided showers for weeks at a time. Resident identifier: 41. Findings Included: 1. Resident 41 was admitted to the facility on [DATE] and again on 4/9/24 with diagnoses which include chronic respiratory failure with hypoxia, functional quadriplegia, obstructive pulmonary disease, neuromuscular dysfunction of bladder, protein-calorie malnutrition, protein-calorie malnutrition, contracture of muscle, rheumatoid arthritis, bed confinement status, urinary tract infection, pyelonephritis, resistance to multiple antibiotics, dependence of supplemental oxygen, acute respiratory failure, anemia in chronic kidney disease, heart failure, major depressive disorder, obstructive sleep apnea, anxiety…

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, interviews and record review it was determined, the facility did not ensure that each resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, for 2 out of 53 sampled residents, residents with limited range of motion were not given restorative nursing services to prevent a further decrease in range of motion in upper and lower extremities. Resident Identifiers: 7, 54. Findings Included: 1. Resident 54 was admitted to the facility on [DATE] with diagnoses which included cervical disc disorder, primary osteoarthritis, type 2 diabetes with neuropathy, hypothyroidism, morbid obesity, weakness, muscle weakness, anxiety, obstructive sleep apnea, hypertension, and a history of falling. Resident 54's medical record was reviewed 6/2/24-6/6/24. On 6/2/24 at 2:39 PM, an interview was conducted with resident 54. Resident 54 stated that she could wiggle her feet a bit, but was unable…

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 53 sampled residents, the facility failed to ensure that residents who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, a resident was not provided the necessary equipment to prevent water buildup in their nasal cannula, and a resident's oxygen tubing was not changed weekly. Resident identifiers 36 and 41. Findings Included: 1. Resident 41 was admitted to the facility on [DATE] and again on 4/9/24 with diagnoses which include chronic respiratory failure with hypoxia, functional quadriplegia, obstructive pulmonary disease, neuromuscular dysfunction of bladder, protein-calorie malnutrition, protein-calorie malnutrition, contracture of muscle, rheumatoid arthritis, bed confinement status, urinary tract infection, pyelonephritis,…

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 53 sampled residents, that the facility did not ensure each resident's drug regimen remained free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which would indicate the dose should be reduced or discontinued. Specifically, a resident's medication was not being monitored and this resulted in the resident being hospitalized . Resident identifier: 41. Findings Included: 1. Resident 41 was admitted to the facility on [DATE] and again on 4/9/24 with diagnoses which include chronic respiratory failure with hypoxia, functional quadriplegia, obstructive pulmonary disease, neuromuscular dysfunction of bladder, protein-calorie malnutrition, protein-calorie malnutrition, contracture of muscle, rheumatoid arthritis, bed confinement status, urinary tract infection,…

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 2. Resident 47 was admitted to the facility initially on 4/2/23, and was readmitted on [DATE] with diagnoses that included hemiplegia and hemiparesis, dementia without behavioral, psychotic, mood and anxiety disturbance, type 2 diabetes, bipolar disorder, panic disorder, major depressive disorder, and history of falling. Resident 47's medical records were reviewed between 6/2/24 and 6/6/24. A annual Minimum Data Set (MDS) dated [DATE] revealed that resident 47 had a Brief Interview for Mental Status (BIMS) of 13, indicating resident 47 was cognitively intact. The MDS also revealed that resident 47 did not exhibit any negative behaviors. Additionally, the MDS revealed there had been no Gradual Dose Reductions (GDR) attempted and the physician had not documented that a GDR was clinically contraindicated. On 4/2/23, a physician order documented, Risperidone Oral Tablet 0.25 MG [milligram]; Give 1 tablet by mouth two times a day for irritability. On 4/10/23, a physician order documented, Risperidone Oral Tablet 0.25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review 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, fentanyl patches were not disposed of properly and discontinued eye drops were available for use in a resident room. Resident identifiers: 5, 41, 42, and 43. Finding Included: 1. Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of encounter for palliative care, type 2 diabetes mellitus with diabetic neuropathy, venous insufficiency, hypertensive heart disease with heart failure, chronic respiratory failure with hypoxia, unspecified dementia and Alzheimer's disease. On [DATE] at 11:44 AM, an observation was made of resident 5 in their room. Resident 5 was brought back to their room by the Licensed Practical Nurse (LPN) 4 and Regional Nurse…

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 record review and interview, the facility did not ensure that laboratory services were provided to meet the needs of 2 of 53 sample residents. Specifically, labs were not obtained per the physician order. Resident identifiers: 36 and 42. Findings included: 1. Resident 42 was admitted to the facility on [DATE] with diagnoses that included dementia with psychotic disturbance, restless leg syndrome, anxiety, osteoarthritis, diabetes mellitus, protein calorie malnutrition, hypertension, cognitive communication deficit and delirium. Resident 42's medical record was reviewed from 6/2/24 through 6/6/24. Resident 42 had a physician order dated 12/2/22 that indicated resident 42 was to have a serum creatinine level drawn every 6 months. On 6/4/24, a nursing progress note indicated that the resident had her blood drawn to check the serum creatinine. No lab results for serum creatinine since the lab was ordered were located in resident 42's medical record. On 6/6/24, the Regional Nurse Consultant was asked 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 1 of 53 sampled residents, that the facility did not promptly notify the ordering physician or provider of the laboratory results that fall outside of clinical ranges. Specifically, a resident's lithium levels and urinalysis results were not reported to the physician. Resident identifier: 36. Findings included: Resident 36 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of chronic obstructive pulmonary disease, polyosteoarthritis, malignant neoplasm of ovary, hyperlipidemia, chronic fatigue, morbid obesity, anxiety disorder, bipolar disorder, idiopathic peripheral autonomic neuropathy, presence of left and right artificial knee joint, insomnia, opioid dependence, and restless leg syndrome. On 6/2/24, resident 36's medical records were reviewed. Resident 36's physician orders revealed the following: a. On 9/8/23, a order for a Lithium level was initiated. b. On 9/13/23, a order for a Urinalysis was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 53 sampled residents, that 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, a resident's laboratory results were not located in the electronic medical records. Resident identifier: 36. Findings included: Resident 36 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of chronic obstructive pulmonary disease, polyosteoarthritis, malignant neoplasm of ovary, hyperlipidemia, chronic fatigue, morbid obesity, anxiety disorder, bipolar disorder, idiopathic peripheral autonomic neuropathy, presence of left and right artificial knee joint, insomnia, opioid dependence, and restless leg syndrome. On 6/2/24, resident 36's medical records were reviewed. Resident 36's physician orders revealed the following: a. On 9/8/23, a order for a Lithium level was initiated. b. On 9/13/23, a order for 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 observation, interviews and record review it was determined, the facility did not provide for 1 out of 53 sampled residents, specialized rehabilitative services such as physical therapy and occupational therapy that were required in the resident's comprehensive plan of care. Specifically, a resident was not provided specialized rehabilitation services that were documented as being needed by the facility medical doctor upon admission. Resident Identifier: 54. Findings Included: Resident 54 was admitted to the facility on [DATE] with diagnoses which included cervical disc disorder, primary osteoarthritis, type 2 diabetes with neuropathy, hypothyroidism, morbid obesity, weakness, muscle weakness, anxiety, obstructive sleep apnea, hypertension, and a history of falling. Resident 54's medical record was reviewed 6/2/24-6/6/24. On 6/2/24 at 2:39 PM, an interview was conducted with resident 54. Resident 54 stated that she could wiggle her feet a bit, but was unable to move or feel her lower extremities.…

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 53 sampled residents, that the facility did not keep confidential all information contained in the resident's records, regardless of the form or storage method of the records. Additionally, the facility did not maintain the medical records on each resident that were complete, accurately documented, and readily accessible. Specifically, a resident's name was included in a different residents medical record, and a resident's medical records from the hospital were not included in the residents electronic medical records at the facility. Resident identifiers: 18, 42, and 43. Findings Included: 1. Resident 43 was admitted to the facility on [DATE] with diagnoses that included dementia, chronic obstructive pulmonary disease, hypothyroidism, muscle wasting, adult failure to thrive, nicotine dependence, and osteoarthritis. Resident 42 was admitted to the facility on [DATE] with diagnoses that included dementia, restless legs syndrome, anxiety disorders,…

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 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, the facility did not demonstrate having an assessment to identify Legionella and other opportunistic waterborne pathogens, control measures to prevent the growth of opportunistic waterborne pathogens, and how to monitor them. Additionally, a resident was observed helping another resident during dining and was touching the other resident's food with bare hands. Resident identifier: 24 and 46. Findings included: 1. On 6/6/24 at 9:38 AM, an interview was conducted with Assistant Director of Nursing (ADON) 2, who was the facilities designated infection preventionist. ADON 2 stated the Director of Maintenance (DOM) was the person in charge of water management. On 6/6/24 at 10:12 AM, an interview was conducted with the DOM who stated all of the facility domestic water goes through the water…

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 distribute and serve food in accordance with the professional standards of food service safety. Specifically, food items in a walk-in freezer were open to air, the walk-in freezer was not functioning properly, food items in the walk-in refrigerator were open to air, and the kitchen was not clean. Findings include: On 7/18/22 at 4:03 PM, an initial walk-through of the kitchen was conducted. Observations were made of the food storage areas. a. In the reach-in freezer, a box of frozen cookie dough was open to air. A package of frozen hashbrowns was open to air. b. In the walk-in freezer, a box of dinner rolls was open to air. A box of frozen beef patties was open to air. An observation was made of ice on the ceiling and floor of the freezer, and frost buildup on food boxes near the freezer door. c. The floor under 2 oven units in the corner of the kitchen near the entrance to the assisted living side of the facility was observed to be dirty. d. The drain under a large mixer stand was observed to be dirty.…

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

Based on interview and record review, it was determined that the facility did not inform residents, resident's families and representatives of a confirmed COVID-19 infection in a timely manner. Specifically, the facility did not send a notification to resident families and representatives by 5 p.m. the next calendar day following the occurrence of a confirmed COVID-19 infection. Findings included: On 7/19/22 at 3:10 PM, an interview was conducted with the Administrator (ADM). The ADM stated a Certified Nurses Assistant (CNA) had tested positive that morning at home. The ADM stated the CNA had not been working in the facility for the previous four days. On 7/21/22 at 10:15 AM, an interview was conducted with the Infection Preventionist (IP). The IP stated if there was someone who tested positive for COVID-19, the facility would test them again. The IP stated that if there was still a positive result the family and the physician would be contacted. The IP stated that only the families of the residents who were on the hallway where the positive case was located or the positive employee…

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 31 sample residents, that the facility did not ensure that resident's had the right to request, refuse, and /or discontinue treatment and to formulate an advance directive. Specifically, resident's were not given the right to request, refuse, and/or formulate an advance directive. Resident identifiers: 40, 58, 62, and 332. Findings included: 1. Resident 40 was admitted to the facility on [DATE] with diagnoses that included, type II diabetes, rheumatoid arthritis, anxiety, major depressive disorder, history of falling, gastro-esophageal reflux disease, primary hypertension, and fracture of right pubis. On 7/21/22, resident 40's medical record review was completed. No POLST (Physician Orders for Life Sustaining Treatment) form was found in resident 40's medical record on 7/19/22 or 7/20/22. On 7/19/22, physician orders were reviewed and revealed an order for resident 40's code status to be DNR (Do Not Resuscitate) with a revision date 2/23/22. 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 interview and record review, it was determined the facility did not ensure that each drug regimen was free from unnecessary drugs for 3 of 31 sample residents. An unnecessary drug is any drug when used in excessive dose; excessive duration; without adequate monitoring; without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued. Specifically, the facility was not assessing residents' blood pressure levels as necessitated for safe administration of blood pressure medication, causing residents to receive blood pressure medications outside of the medical provider's established parameters. Resident identifiers: 58, 62, and 74. Findings include: 1. Resident 58 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, chronic combined systolic and diastolic heart failure, atrial fibrillation, atherosclerotic heart disease, major depressive disorder, acute respiratory failure, stage III chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview it was determined, for 4 of 31 sample residents, that the facility did not maintain medical records on each resident that were complete, accurately documented, and readily accessible. Specifically, residents Physician Orders for Life-Sustaining Treatment (POLST) forms and weekly skin notes were not included in the medical record. Resident identifiers: 40, 48, 58, and 62. Findings included: 1. Resident 40 was admitted to the facility on [DATE] with diagnoses that included, type II diabetes, rheumatoid arthritis, anxiety, major depressive disorder, history of falling, gastro-esophageal reflux disease, primary hypertension, and fracture of right pubis. On 7/20/22, resident 40's medical record review was completed. No POLST form was found in resident 40's medical record on 7/19/22 or 7/20/22. On 7/19/22, physician orders were reviewed and revealed an order for resident 40's code status to be DNR (Do Not Resuscitate) with a revision date of 2/23/22. On 7/20/22 at 1:30 PM, 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 that for 1 of 31 sample residents that the facility did not immediately consult with the resident's appropriate physician when there was a significant change in the resident's physical status and a need to alter treatment significantly, resulting in hospital intervention. Specifically, the appropriate physician was not immediately notified when a resident's wound worsened and the resident developed decreased blood pressure with tachycardia. Resident Identifier: 57 Finding include: Resident 57 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that initially included morbid obesity, anemia, low back pain, malignant neoplasm of breasts, lymphedema, and pressure-induced deep tissue damage of right upper and left upper back. On 6/30/22, resident 57 was readmitted with diagnoses that included severe sepsis with septic shock, myositis of right thigh and pressure ulcers of left and right buttock. On 7/20/22, a review of 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 that for 3 of 31 sample residents, the facility did not ensure that all residents were free from abuse. Specifically, one resident repeatedly and intentionally hit, shoved, swore at (e.g. bitch, asshole, son of a bitch), and threatened other residents. In addition, abused residents occasionally hit the abusive resident after being assaulted. Resident identifiers: 29, 46 and 49. Findings include: 1. Resident 29 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with behavioral disturbances, chronic obstructive pulmonary disease (COPD), incontinence, osteoarthritis, and irritability and anger. 2. Resident 49 was admitted to the facility on [DATE] with diagnoses that included pulmonary hypertension, spondylitis, osteoarthritis, chronic pain, anxiety, and mitral valve insufficiency. On 7/19/22 at 12:20 PM, resident 29 was observed with bruises on her arms. On 7/20/22 at 1:36 PM, resident 29 was observed in 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 record review and interview, it was determined, for 3 of 31 sample residents, that in response to allegations of abuse, exploitation, or mistreatment, the facility failed to thoroughly investigate the abuse and identify abuse that occurred. Additionally, incidence of verbal abuse and injuries of unknown origin were not investigated. Resident identifiers: 29, 46, and 49. Findings include: 1. Resident 29 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with behavioral disturbances, chronic obstructive pulmonary disease (COPD), incontinence, osteoarthritis, and irritability and anger. 2. Resident 49 was admitted to the facility on [DATE] with diagnoses that included pulmonary hypertension, spondylitis, osteoarthritis, chronic pain, and mitral valve insufficiency. 3. Resident 46 was admitted to the facility on [DATE] and readmitted on [DATE] with current diagnoses that included penile cancer, palliative care, and a history of COVID-19. On 7/19/22 at 12:20 PM, 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 that the facility failed, for 1 of 31 sample residents, to develop and implement a comprehensive person-centered care plan for each resident that described services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Specifically, the facility staff did not update a resident's care plan when the resident experienced a fall. Resident identifier: 62. Findings included: Resident 62 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included metabolic encephalopathy, essential hypertension, dehydration, chronic pain syndrome, accidental poisoning by unspecified narcotics, personal history of transient ischemic attack and cerebral infarction without residual deficits, dementia with behavioral disturbance, and dysphagia. On 07/18/22 at 4:35 PM, an interview was conducted with resident 62. Resident 62 stated she fell in her room about 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 interview and record review it was determined, for 1 of 31 sample residents, that the facility did not ensure that residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Specifically, a psychotropic medication that had a black box warning for the resident's condition was administered to the resident. Resident identifier: 22. Findings include: Resident 22 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, primary hypertension, chronic pain syndrome, metabolic encephalopathy, history of transient ischemic attack (TIA), and cognitive communication deficit. On 7/21/22, resident 22's medical record review was completed. Resident 22's physician orders included a physician's order for Seroquel (Quetiapine fumarate), extended release tablet, 150 mg (milligrams), give 1 tablet by mouth at bedtime for dementia with psychotic…

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

Based on observations and interviews it was determined that the facility did not ensure, for 2 of 31 sample residents, safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, opened multi-dose vials of medication were found past their dispense dates and were available for use. Resident Identifiers: 3 and 14. Findings include: On 7/20/22 at 9:14 AM, the medication cart for the 300 hallway was observed. One multidose vial of Insulin Aspart/Novolog flex pen, 3 ml (milliliters) prefilled insulin syringe pen, was found with a dispensed date of 6/20/22 for resident 14. An interview was immediately conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the medications found in the cart was what nurses administered to the residents. LPN 1 stated that insulin was only good for 28 days once opened and proceeded to look in the cart. LPN 1 stated that resident 14's insulin syringe needed to be taken out of the drawer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined that for 3 of 25 sample residents the facility did not notify and consult with the physician when there was a need to alter treatment significantly. Specifically the physician was notified consulted with in a timely manner when a residents wound condition deteriorated, when a resident's catheter become clogged, or when a resident experienced a change of condition after a fall. Resident identifiers: 8, 52, 118. Findings include: 1. Resident 52 was admitted to the facility on [DATE] with diagnoses which include dementia without behavioral disturbance, generalized anxiety, hypertension, and major depression. A record review for resident 52 was conducted on 1/7/20 and revealed the following progress notes. a. A progress note dated 12/22/19 at 2:50 PM, documented Patient has abrasion/skin tear on the back of her left leg. Injury occurred during transfer treated and will follow up for wound care orders. b. A progress note dated 12/22/19 at 7:35 PM, documented…

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 ensure that the residents' medical records were secure and confidential. Specifically, observations were made of computer screens unattended which displayed resident personal information. Resident identifier: 9. Findings include: On 1/8/20 at 9:56 AM, Licensed Practical Nurse (LPN) 1 was observed walking down the hall. LPN 1 was observed to be out of visual range from the computer on the medication cart. The computer screen was observed to be open with a resident's identifying information. On 1/8/20 at 9:58 AM, observations were made of the 100 and 200 halls. There were laptop computers on top of the medication carts. The computers were observed to be unlocked and unattended with a resident's identifying information visible. On 1/8/20 at 11:21 AM, an observation was made of the 300 hall. There was a laptop computer observed to be unlocked and unattended by staff on medication cart. The computer screen was observed to have resident's identifying information visible. On 1/8/20 at 11:23 AM, an observation…

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

Based on interview and record review, the facility did not conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there was, or the facility plans for, any change that would require a substantial modification to any part of this assessment. Findings include: On 1/6/20, the Facility Assessment was requested to conduct the facility recertification survey. On 1/7/20, a breakdown of the resident population was provided by the Administrator. On 1/9/20 at 7:32 AM, an interview was conducted with the Administrator. The Administrator produced a binder with building information that was not part of the facility assessment. A third binder, labeled Emergency Binder, with a risk assessment for hazards was also located. The Administrator stated that the facility assessment did not include the training and competencies…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not 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 for 2 of 25 sampled residents. Specifically, one resident who was colonized with MRSA (methicillin resistant staphylococcus aureus) did not have precautions in place to keep from infecting other residents and staff, and cross contamination was observed during medication pass and wound care. Resident identifiers: 1, 41, and 52. Findings include: 1. Resident 41 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cellulitis, fibromyalgia, respiratory failure, MRSA, lupus, sepsis, heart failure, kidney failure, and skin picking disorder. Resident 41 was also receiving palliative care. On 1/6/20 at 4:10 PM, resident 41 was observed to be in her room with contact or isolation…

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 25 sampled residents, that the facility did not ensure that the residents were free from abuse. Specifically, one resident was grabbed on the arm by another resident, leaving a red mark. Resident identifiers: 1 and 54. Findings include: Resident 54 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, hypertension, arthritis, chronic pain syndrome, heart disease, depression, and a history of hip fracture. On 1/7/20 at 10:03 AM, an interview was conducted with a family member of resident 54. The family member stated that resident 54 was beat up by another resident. On 1/9/20, resident 54's electronic medical record was reviewed. On 11/12/19 at 2:58 PM, an Interdisciplinary Team (IDT) meeting was held. The review stated Alleged incident: 11/8/19. During the afternoon of Friday, 11/8/19 resident stated that her roommate was on top of her on the ground 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 2 of 25 sample residents, that the facility did not report the results of an abuse investigation to the State Survey Agency within 5 working days of the incident. Specifically, an allegation of abuse was not reported to the State Agency. Resident identifiers: 1, 52 and 54. Findings include: 1. Resident 54 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, hypertension, arthritis, chronic pain syndrome, heart disease, depression, and a history of hip fracture. On 1/7/20 at 10:03 AM, an interview was conducted with a family member of resident 54. The family member stated that resident 54 was beat up by another resident. On 1/9/20, resident 54's electronic medical record was reviewed. On 11/12/19 at 2:58 PM, an Interdisciplinary Team (IDT) meeting was held and an IDT meeting minutes note was entered in the nursing notes. The review stated Alleged incident:…

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 25 sample resident, that in response to allegations of abuse, exploitation, or mistreatment, the facility failed to thoroughly investigated. Specifically, the facility failed to thoroughly investigate an allegation of physical abuse of a resident by another resident. Resident identifiers: 1 and 54. Findings include: 1. Resident 54 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, hypertension, arthritis, chronic pain syndrome, heart disease, depression, and a history of hip fracture. On 1/7/20 at 10:03 AM, an interview was conducted with a family member of resident 54. The family member stated that resident 54 was beat up by another resident. On 1/9/20, resident 54's electronic medical record review was completed. On 11/12/19 at 2:58 PM, an Interdisciplinary Team (IDT) meeting was held. The IDT meeting minutes, found in the nursing notes, 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 1 of 25 sample residents, that the facility did not ensure that the resident's environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specially, a skin tear occurred for one resident that required sutures. Resident identifier: 52. Findings include: Resident 52 was admitted to the facility on [DATE] with diagnoses which include dementia without behavioral disturbance, generalized anxiety, hypertension, and major depression. A record review was completed for resident 52 on 1/7/20 and revealed the following. a. A progress note dated 12/22/19 at 2:50 PM, documented Patient has abrasion/skin tear on the back of her left leg. Injury occurred during transfer treated and will follow up for wound care orders. b. A progress note dated 12/22/19 at 7:35 PM, documented Resident's left leg abrasion is approximately 5 inch half circle. Do to continue oozing 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 25 sampled residents, the facility did not ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. Specifically, a resident with a catheter developed an E. coli urinary tract infection. Resident identifier: 8. Findings include: Resident 8 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy, chronic pain syndrome, depression, benign prostatic hyperplasia (BPH), urinary device (suprapubic catheter) for neurogenic bladder and/or obstructive uropathy, and a diaphragmatic hernia. On 1/7/20 at 10:39 AM, resident 8 was observed to have sediment in his catheter tubing. Resident 8 was interviewed and stated that he had problems with his catheter clogging. A record review was completed on 1/9/20 for resident 8's electronic medical record. Nursing notes revealed the following; a. On 6/14/19 at 1:54 PM, Resident was seen at the office of [a urologist] 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 that for 1 of 25 sample residents the facility did not ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complication of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. Specifically, one resident had multiple emergency room visits for a clogged tube and went 24 hours without any food or fluids. Resident identifier: 118. Findings include: Resident 118 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include pneumonitis, type 2 diabetes, unspecified dementia without behavioral disturbance, history of falling and major depressive disorder. A record review was conducted for resident 118 on 1/8/20 and revealed the following progress notes. a. A progress note dated 11/4/19 at 10:03 AM, documented Patient nasal gastric (NG) tube is clogged. Unable to flush or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 25 sample residents that the facility did not promptly notify the ordering physician, physician assistant, nurse practitioner or clinical nurse specialist of results that fell outside of clinical reference ranges. Specifically the facility did not notify a medical provider for 39 hours after the results were complete and faxed to the facility, and did not accurately report the results. Resident identifier: 21. Findings include: Resident 21 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which include Sepsis, type 2 diabetes, acute and chronic respiratory failure, multiple sclerosis, chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, and use of long term (current) use of anticoagulants. Resident 21's medical records were reviewed on 1/7/20 and revealed resident 21 had a DVT of the right lower extremity. A review of the Venous Doppler Ultrasound of the Right Lower Extremity 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 that for 1 of 25 sample resident the facility did not maintain medical records on each resident that were complete, accurately documented, readily accessible and systematically organized. Specifically ones resident did not have weekly wound assessment documented in the medical record, and a weekly wound assessment was documented on a different day than it was completed. Resident identifier: 52. Findings include: Resident 52 was admitted to the facility on [DATE] with diagnoses which include dementia without behavioral disturbance, generalized anxiety, hypertension, and major depression. A record review for resident 52 was competed on 1/7/20 and revealed no documentation of wound assessments from the wound nurse. A record review of resident 52 progress notes completed on 1/9/20 revealed the following progress note. a. A progress note dated 1/9/20 at 7:11 AM, documented Resident skin tear has ulcerate and it measures 4.5 centimeters (cm) x5.0 cm x 0.3 cm with…

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.