Tyler's Retreat At Iron Bridge

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to follow the comprehensive care plan for one of four residents in the survey sample; Resident #3. The findings include: For Resident #3, the facility staff failed to obtain weights per the comprehensive care plan. Resident #3 was admitted to the facility on [DATE] and had the diagnoses of but not limited to protein-calorie malnutrition and nutritional/metabolic disease. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 7/26/23 and coded the resident as severely cognitively impaired in ability to make daily life decisions, scoring a 5 out of a possible 15 on the BIMS (Brief Interview for Mental Status). The resident was coded as requiring supervision for eating. The facility policy, Comprehensive Care Planning Policy was reviewed. This policy documented, .D. All staff must be familiar with each resident's Care Plan and all…

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 staff interview, clinical record review and facility document review, it was determined that the facility staff failed to monitor a resident's weight to ensure nutritional status was maintained for one of four residents in the survey sample; Resident #3. The findings include: Resident #3 was admitted to the facility on [DATE] and had the diagnoses of but not limited to protein-calorie malnutrition and nutritional/metabolic disease. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 7/26/23 and coded the resident as severely cognitively impaired in ability to make daily life decisions, scoring a 5 out of a possible 15 on the BIMS (Brief Interview for Mental Status). The resident was coded as requiring supervision for eating. A review of the physician's orders revealed one dated 8/3/22 for Weight on admission and then weekly x 4 one time a day every Thu (Thursday) for monitor weight for 4 weeks. There were no further orders for weights once this…

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 staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide written notice of a hospital transfer to the Resident Representative and/or State Long Term Care Ombudsman office for four of 30 residents in the survey sample; Residents #1, #8, #35, and #72. The findings include: 1. For Resident #1, the facility staff failed to evidence a written notification of a hospital transfer was provided to the resident representative and to the State Long Term Care Ombudsman office for a hospital transfer on 10/19/22; and failed to evidence a written notification of a hospital transfer was provided to the resident representative for a hospital transfer on 12/8/22. A. A review of the clinical record was conducted for Resident #1. Resident #1 was transferred to the emergency room on [DATE] for further evaluation and treatment of anemia. The clinical record failed to reveal any evidence that a written notification of this hospital transfer was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined the facility staff failed to develop and/or implement a comprehensive care plan for five of 30 residents in the survey sample, Residents #123, #23, #1, #21 and #68. The findings include: 1. For R123, the facility staff failed to implement the comprehensive care plan for the administration of medications per the physician order. On the most recent MDS (minimum data set) assessment, a Medicare five-day assessment, with an assessment reference date of 9/8/2022, the resident scored a 7 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired for making daily decisions. In Section N - Medications the resident was coded as receiving antidepressants during the look back period. The comprehensive care plan dated 8/18/2022, documented in part, Resident has altered cardiac status. The Interventions documented in part,…

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 clinical record review, staff interview and facility document review it was determined that the facility staff failed to provide one of 30 residents in the survey sample the opportunity to formulate an advance directive (1); Resident #11. The findings include: For Resident #11 (R11), the facility staff failed to fully review advance directives with the resident and/or the representative, and provide an opportunity to formulate an advanced directive. R11 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 12/16/2022, the resident scored 13 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. Review of R11's clinical record failed to evidence documentation of advanced directive review. The progress notes documented periodic review of DNR (do not resuscitate) status. The comprehensive care plan for R11 documented in part,…

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 staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined the facility staff failed to notify the physician when physician ordered medications were not administered for one of 30 residents in the survey sample, Resident #123 (R123). The findings include: The facility staff failed to notify the physician when antibiotics, antidepressants and medications for cholesterol were not administered per the physician order for R123. On the most recent MDS (minimum data set) assessment, a Medicare five-day assessment, with an assessment reference date of 9/8/2022, the resident scored a 7 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired for making daily decisions. In Section N - Medications the resident was coded as receiving antidepressants and antibiotics during the look back period. The physician orders dated 8/17/2022, documented the following: Lipitor (Atorvastatin) (used to treat high…

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 staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to evidence that all required documentation was provided to the receiving facility for hospital transfers for three of 30 residents in the survey sample; Residents #1, #8, and #72. The findings include: 1. For Resident #1, the facility staff failed to evidence that all, if any, required documentation was provided to the receiving facility upon a hospital transfer on 12/8/22. A review of the clinical record was conducted for Resident #1. Resident #1 was transferred to the emergency room on [DATE] for further evaluation and treatment for uncontrolled abdominal pain. Further review of the clinical record failed to reveal any evidence that the required documentation was provided to the receiving facility. On 1/19/23 at 9:36 AM an interview was conducted with ASM #2 (Administrative Staff Member) the Director of Nursing. She stated that there was no evidence of what documentation was sent.…

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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to review and revise the comprehensive care plan for one of 30 residents in the survey sample, Resident #10. The findings include: For Resident #10 (R10), the facility staff failed to review and revise the comprehensive care plan after a self-harm incident on 7/22/2022. On the most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 12/23/2022, the resident scored 5 of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. Section E documented no behaviors. The progress notes for R10 documented in part, - 7/22/2022 21:30 (9:30 p.m.) Nursing note. Note Text: While doing rounds CNA (certified nursing assistant) found patient in his room crying and making an apparent attempt to commit suicide. Patient had a small cutting tool resembling a pocket knife and 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 Based on staff interview, clinical record review, and in the course of a complaint investigation, it was determined the facility staff failed to follow professional standards of practice for medication administration. to clarify a physician order for one of 30 residents in the survey sample, Resident #123 (R123). The findings include: The facility staff failed to clarify a physician order for the administration time of an IV (intravenous) antibiotic for Resident #123 (R123). On the most recent MDS (minimum data set) assessment, a Medicare five-day assessment, with an assessment reference date of 9/8/2022, the resident scored a 7 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired for making daily decisions. In Section N - Medications the resident was coded as receiving antidepressants and antibiotics during the look back period. The physician order dated, 8/17/2022, documented, Ceftriaxone Sodium Solution Reconstituted 2 GM (grams) (used to treat infections) (1),…

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 staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence a complete discharge summary for one of 30 residents in the survey sample, Resident #70. The findings include: For Resident #70 (R70), the facility staff failed to evidence a discharge summary that included a recapitulation of the resident's stay, a final summary of the resident's status at the time of discharge, reconciliation of all pre-discharge medications with the resident's post discharge medications, and a post discharge plan of care for the discharge on [DATE]. On the most recent MDS (minimum data set), a discharge assessment with an ARD (assessment reference date) of 10/27/2022, the resident was coded as being severely impaired for making daily decisions. The progress notes for R70 documented in part, 10/27/2022 11:31 (11:31 a.m.) Note Text: Resident discharged home left via transportation van with attendant. Resident took all her belongings with her at discharge.…

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 clinical record review, staff interview and facility document review it was determined that the facility staff failed to obtain a physician order and provide treatment to promote non-recurrence of a healed pressure injury for one of 30 residents in the survey sample, Resident #23. The findings include: For Resident #23 (R23), the facility staff failed to transcribe orders and provide treatment for a healed Stage 3 pressure injury (1). On the most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 12/15/2022, the resident scored 3 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired for making daily decisions. Section M documented R23 having one Stage 3 pressure injury. The progress notes for R23 documented in part, - 1/10/2023 07:00 (7:00 a.m.) Note Text: Wound type is pressure. Stage: 3 Wound Location L (left) heel .Treatment: Wound care to left heel as follows: apply skin prep q (every) shift. Area is resolved skin prep q shift ppx (prophylaxis). The weekly wound…

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, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to implement fall interventions per the plan of care for two of 30 residents in the survey sample; Residents #21 and #23. The findings include: 1. For Resident #21, the facility staff failed to ensure bilateral fall mats were in place per the plan of care. A review of the comprehensive care plan revealed one dated 3/23/21 for Actual fall; Risk for further falls . This care plan included an intervention dated 7/19/21 for Fall mats on both sides of bed. A review of the clinical record revealed the January 2023 eTAR (electronic treatment administration record) which included an item dated 7/20/21 for Fall Matts [sic] to each side of the bed for safety while in bed every shift for preventative. This document identified Day Evening and Night as three opportunities each day for staff to sign off that placement of the fall mats had been verified. Staff had completed this sign off each day through 1/18/23 (the date of survey review). Observations 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.

Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to administer oxygen per physician's orders for one of 30 residents in the survey sample; Resident #1. The findings include: For Resident #1, the facility staff failed to administer oxygen at 3 liters per minute as per the physician's order. A review of the clinical record revealed a physician's order dated 10/20/22 for Oxygen 3LPM (liters per minute) via nasal cannula every shift . On 1/17/23 at 12:00 PM and at 2:25 PM, observations of the resident revealed the oxygen rate on the oxygen concentrator flow meter was set at 1.5 liters as evidenced by the ball of the flow meter centered on the line between the 1 and 2 liter marks. A review of the comprehensive care plan revealed one dated 8/27/21 for Resident is receiving continuous oxygen therapy. This care plan included an intervention dated 8/27/21 for Administer oxygen as ordered. On 1/19/23 at 10:00 AM an interview was conducted with LPN (Licensed Practical Nurse) #2 . She stated that when…

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 staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 30 residents in the survey sample, Resident #68. The findings include: The facility failed to provide communication to the dialysis facility for 1 of 1 visits in December 2022 (12/30/22) and 3 of 7 visits in January 2023 (1/2/23, 1/4/23 and 1/6/23); and failed to evidence monitoring of the bruit (swishing sound) and thrill (vibration) in the left upper arm fistula. Resident #68 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: end stage renal disease, diabetes mellitus, heart failure and paroxysmal atrial fibrillation. The most recent MDS (minimum data set) assessment, a Medicare five-day assessment, with an ARD (assessment reference date) of 1/3/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not…

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 staff interview and facility document review, it was determined that the facility staff failed to ensure eight consecutive hours of RN (registered nurse) coverage on three of 34 days reviewed. The findings include: The facility staff failed to ensure eight consecutive hours of RN coverage for three days, 8/13/2022, 9/4/2022 and 9/18/2022. Review of the PBJ Staffing Data Report for 7/1/2022-9/30/2022 revealed concerns related to the facility's requirement to have a Registered Nurse on duty for at least 8 consecutive hours a day. The report documented no RN hours on 7/31/2022, 8/13/2022, 8/14/2022, 9/4/2022 and 9/18/2022. On 1/17/2023 at approximately 11:14 a.m., during entrance conference, ASM (administrative staff member) #1, the administrator stated that the facility did not have any staffing waivers in place in the facility. On 1/17/2023 at approximately 12:00 p.m., a request was made to ASM #1 for evidence of RN coverage for the dates listed above. On 1/17/2023 at 12:52 p.m., ASM #1 provided time card reports for the dates listed above and stated that they did not have…

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 staff interview, facility document review, clinical record review and in the course of a complaint investigation, it was determined the facility staff failed to ensure one of 30 residents in the survey sample was free of a significant mediation error, Resident #123 (R123). The findings include: For R123, the facility staff failed to administer an intravenous (IV) antibiotic on 8/17/2022. On the most recent MDS (minimum data set) assessment, a Medicare five-day assessment, with an assessment reference date of 9/8/2022, the resident scored a 7 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired for making daily decisions. In Section N - Medications the resident was coded as receiving antidepressants and antibiotics during the look back period. The physician order dated, 8/17/2022, documented, Ceftriaxone Sodium Solution Reconstituted 2 GM (grams) (used to treat infections) (1), Use 2000 milligrams intravenously every 24 hours related to abscess of liver for…

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

Based on observation, staff interview, and clinical record review, it was determined that the facility staff failed to ensure a complete and accurate clinical record for one of 30 residents in the survey sample; Resident #21. The findings include: For Resident #21, the facility staff failed to ensure accurate documentation regarding the placement of fall mats. Observations of Resident #21 on 1/17/23 at 10:57 AM, 1/17/23 at 2:30 PM, 1/18/23 at 11:49 AM, 1/18/23 at 3:51 PM, and 1/19/23 at 8:38 AM, all revealed Resident #21 in the bed. There were no fall mats down and no evidence of fall mats anywhere in the room. A review of the clinical record revealed the January 2023 eTAR (electronic treatment administration record.) This document included an item dated 7/20/21 for Fall Matts [sic] to each side of the bed for safety while in bed every shift for preventative. This document identified Day Evening and Night as three opportunities each day for staff to sign off that placement of the fall mats had been verified. Staff had completed this sign off each day through 1/18/23. On 1/19/23 at…

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

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to maintain a bedpan in a clean and sanitary manner for one of 30 residents in the survey sample; Resident #35. The findings include: Observations were made of Resident #35 on 1/17/23 at 11:36 AM, 1/17/23 at 2:30 PM, 1/18/23 at 11:49 AM, 1/18/23 at 3:51 PM, and 1/19/23 at 8:38 AM. In the resident's bathroom was a bedpan, unlabeled (whether for Resident #35 or for their roommate), and unbagged, sitting directly on the floor. On 1/18/23 at 4:22 PM, an interview was conducted with LPN #4 (Licensed Practical Nurse). She stated that Resident #35 started using the bedpan upon return from a hospital visit after surgery a couple months prior, and still used it sometimes. On 1/19/23 at 10:00 AM an interview was conducted with LPN #2 (Licensed Practical Nurse). She stated that the bedpan should be in plastic bag in the bathroom, and should be labeled. She stated that being on the floor, not in a plastic bag, is not sanitary. She stated that she does not check the bedpan every…

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 5. The facility failed to develop a comprehensive care plan to address the use of bed rails for Resident #67. Resident #67 was admitted to the facility on [DATE]. Resident #67s diagnoses included but were not limited to: Alzheimer's disease (progressive loss of mental ability and function often accompanied by personality changes) (1), fracture of left femur (break in left thighbone) (2) and degeneration of discs (physical decline that involves tissue and cellular changes of the cushioning tissue between the vertebrae) (3). Resident #67's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 7/25/21, coded the resident as scoring 99 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was unable to complete the interview. MDS Section G- Functional Status: coded the resident, as extensive assistance with bed mobility, transfers, dressing, eating, personal hygiene and bathing; walking and locomotion did not occur. A review 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 observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to review and revise the comprehensive care plan for four of 37 residents in the survey sample, Residents #31, #25, #37 and #21. The findings include: 1. The facility staff failed to review and revise Resident #31's comprehensive care plan for the use of bed rails. Resident #31 was admitted to the facility on [DATE]. Resident #31's diagnoses included but were not limited to stroke, chronic kidney disease and anxiety disorder. Resident #31's quarterly minimum data set assessment with an assessment reference date of 6/23/21, coded the resident's cognition as severely impaired. Review of Resident #31's clinical record revealed a bed rail assessment dated [DATE] that documented the resident had not shown any clinical need for side rails (bed rails) at that time. On 8/3/21 at 11:22 a.m. and 8/4/21 at 8:01 a.m., Resident #31 was observed in bed with bilateral U bar bed rails.…

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, staff interview, and facility document review it was determined facility staff failed to store food and failed to to maintain dietary equipment in a sanitary manner. The facility failed to dispose of tomatoes in the walk-in refrigerator with visible black spots and signs of spoilage and observation of the round blade on the kitchens electric food slicer revealed a rust-colored area on the surface and edging of the blade approximately one-quarter inch in size. The findings include: 1. On 8/3/2021 at approximately 11:15 a.m., an observation was conducted in the kitchen of the facility with OSM (other staff member) #2, the dietary manager. Observation of the kitchen's walk in refrigerator revealed a 25 pound cardboard box of tomatoes with a date of 7/26/21 hand-written on the lid. Upon removal of the lid from the box, four tomatoes were observed with visible signs of spoilage on them. Two tomatoes were observed with black colored spots on the surface of the outer skin and two tomatoes were observed with a white colored substance at the stem area of the tomato. 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, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to ensure the accommodation of needs for one of 37 residents in the survey sample, Resident #29. The facility staff failed to place Resident #29's call bell within reach on 8/3/21 and 8/4/21. The findings include: Resident #29 was admitted to the facility on [DATE] with diagnoses including dementia (1) and bipolar disorder (2). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 6/22/21, Resident #29 was coded as being severely cognitively impaired for making daily decisions, having scored five out of 15 on the BIMS (brief interview for mental status). She was coded as having had a fall in the month prior to admission, and as having had no falls since admission to the facility. Observations conducted on the following dates and time: 8/3/21 at 12:47 p.m. and 4:00 p.m.; 8/4/21 at 9:53 a.m., revealed Resident #29 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 staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement the facility abuse policy to immediately report an allegation of abuse to the administrator/ abuse coordinator for one of 37 residents in the survey sample, Resident #31. Resident #31 reported an allegation of abuse to facility staff on 1/16/21. The facility staff failed to immediately report this allegation to the facility administrator, ASM #1. ASM #1 stated he did not report Resident #31's allegation of abuse to the SA (state agency) and other officials until 1/19/21, because he was not made aware of the allegation until that date. The findings include: The facility abuse policy documented, Facility staff must immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy. 6)…

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 staff interview, facility document review and clinical record review, it was determined that the facility staff failed to report an allegation of abuse was reported immediately but no later than two hours for one of 37 residents in the survey sample, Resident #31. Resident #31 reported an allegation of abuse on 1/16/21. The facility staff failed to report this allegation to the SA (state agency) until 1/19/21. The findings include: Resident #31 was admitted to the facility on [DATE]. Resident #31's diagnoses included but were not limited to stroke, chronic kidney disease and anxiety disorder. Resident #31's quarterly minimum data set assessment with an assessment reference date of 6/23/21, coded the resident's cognition as severely impaired. A nurse's note dated 1/16/21 documented, resident refused medication stated this evening while other staff was around that she was beat up by this person that she named HR sec heard not close i to her name but also said that she was hiding from her husband all shift…

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 staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide all required documents to the receiving facility upon transfer for two of 37 residents in the survey sample, Residents #64 and #25. 1. The facility staff failed to evidence Resident #64's comprehensive care plan goals and other documents required to care for the resident were sent to the hospital when Resident #64 was transferred and discharged there on 7/23/21. 2. The facility staff failed to provide evidence Resident #25's comprehensive care plan goals were provided to receiving hospital staff when the resident was transferred to the hospital on 6/26/21. The findings include: 1. Resident #64 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (1) and generalized weakness. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 7/22/21, Resident #64 was coded as being moderately impaired…

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 staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to notify the resident and or RR (resident representative), and ombudsman in writing of the resident's discharge to the hospital for three of 37 residents in the survey sample, Residents #69, #64, and #25. The findings include: 1. The facility staff failed to notify the resident and or the RR in writing when Resident #69 was transferred and discharged to the hospital on 7/16/21. Resident #69 was admitted to the facility on [DATE] with diagnoses including endocarditis (1), COPD (chronic obstructive pulmonary disease) (2), and dementia (3). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 7/26/21, Resident #69 was coded as being moderately cognitively impaired for making daily decisions. A review of Resident #69's clinical record revealed the following progress note dated 7/16/21: Contacted [name of local hospital] to f/u…

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 staff interview and clinical record review, it was determined that the facility staff failed to maintain a complete and accurate MDS (minimum data set) assessment for one of 37 residents in the survey sample, Resident #21. The facility staff failed to complete assessments for sections B0700, B0800 and section C of Resident #21's quarterly MDS with an ARD (assessment reference date) of 6/12/21. The findings include: Resident #21 was admitted to the facility on [DATE]. Resident #21's diagnoses included but were not limited to high blood pressure, chronic respiratory failure and pain. Review of Resident #21's quarterly MDS with an ARD of 6/12/21 revealed sections B0700 and B0800 (assessments of whether the resident can make self-understood and whether the resident can understand others) were not completed. Also, section C (a cognition assessment) was not completed with the resident or with staff. On 8/5/21 at 7:53 a.m., an interview was conducted with RN (registered nurse) #4 (the MDS coordinator and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to develop a baseline care plan for two of 37 residents in the survey sample, (Residents #59 and #69). For Resident #59, the facility staff failed to develop a base line care plan for the use of side rails. For Resident #69, the facility staff failed to develop a care plan for the use of side rails. The findings include: 1. Resident #59 was admitted to the facility on [DATE] with diagnoses including history of a heart attack and heart failure. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 7/19/21, Resident #59 was coded as being moderately impaired for making daily decisions, having scored nine out of 15 on the BIMS (brief interview for mental status). She was coded as requiring the assistance of two staff members for bed mobility. On the following dates and times: 8/3/21 at 12:22 p.m. and 3:48 p.m.; 8/4/21 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, family interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide care and services to promote a resident's quality of life for one of 37 residents in the survey sample, Resident #59. The facility staff failed to get Resident #59 out of bed into a chair from her admission on [DATE] through 8/3/21. The findings include: Resident #59 was admitted to the facility on [DATE] with diagnoses including history of a heart attack and heart failure. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 7/19/21, Resident #59 was coded as being moderately impaired for making daily decisions, having scored nine out of 15 on the BIMS (brief interview for mental status). She was coded as requiring the assistance of two staff members for bed mobility. She was coded as not having transferred from her bed to any other surface during the look back period. She was coded as…

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, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to implement interventions to prevent a resident's injury from a fall for one of 37 residents in the survey staff, Resident #29. The facility staff failed to place Resident #29's call bell within reach and to place fall mats beside the resident's bed on 8/3/21 and 8/4/21. The findings include: Resident #29 was admitted to the facility on [DATE] with diagnoses including dementia (1) and bipolar disorder (2). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 6/22/21, Resident #29 was coded as being severely cognitively impaired for making daily decisions, having scored five out of 15 on the BIMS (brief interview for mental status). She was coded as having had a fall in the month prior to admission, and as having had no falls since admission to the facility. Observations conducted on the following dates and 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 The facility staff failed to provide respiratory care, consistent with professional standards of practice, and the comprehensive person-centered plan of care for one of 37 residents in the survey sample, Resident #17. The facility staff failed to replace Resident #17's nebulizer tubing (1) as ordered by the physician. The findings include: Resident #17 was admitted to the facility with diagnoses that included but were not limited to chronic obstructive pulmonary disease (COPD) (2) and atrial fibrillation (3). Resident #17's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 6/8/2021, coded Resident #17 as scoring a 12 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 12- being moderately impaired for making daily decisions. Section G coded Resident #6 as requiring extensive assistance from two staff members for bed mobility, transfers and toilet use. On 8/3/2021 at approximately 1:20 p.m., an observation was made of Resident #17 in bed in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. The facility staff failed to evidence Resident #67 was assessed for risk of entrapment, failed to review risks / benefits and failed to obtain informed consent prior to the use of bed rails. Resident #67 was admitted to the facility on [DATE]. Resident #67's diagnoses included but were not limited to: Alzheimer's disease (progressive loss of mental ability and function often accompanied by personality changes) (1), fracture of left femur (break in left thighbone) (2) and degeneration of discs (physical decline that involves tissue and cellular changes of the cushioning tissue between the vertebrae) (3). Resident #67's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 7/25/21, coded the resident as scoring 99 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was unable to complete the interview. MDS Section G- Functional Status: coded the resident, as extensive assistance with bed mobility, transfers, dressing,…

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 resident interview, staff interviews, clinical record reviews and facility document reviews it was determined that the facility staff failed to ensure one of 37 residents in the survey sample was free of unnecessary medications, Resident #58. The facility staff failed to implement non-pharmacological interventions prior to the administration of as needed pain medication for Resident #58. The findings include: Resident #58 was admitted to the facility with diagnoses that included but were not limited to encephalopathy (1) and cirrhosis of the liver (2). Resident #58's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 7/18/2021, coded Resident #58 as scoring a 13 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 13- being cognitively intact for making daily decisions. Section J coded Resident #58 as receiving scheduled and as needed pain medications. Section J further coded Resident #58 as not receiving non-medication interventions for pain and having pain almost constantly. On 8/3/2021 at approximately…

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, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to ensure a resident did not receive an unnecessary psychotropic medication for one of 37 residents in the survey sample, Resident #59. The facility staff failed to document adequate indications for the use of the anti-anxiety medication Alprazolam, failed to offer non-pharmacological interventions prior to the administration of the medication to Resident #59 and failed to monitor Resident #59 for side effects of the Alprazolam(1). The findings include: Resident #59 was admitted to the facility on [DATE] with diagnoses including history of a heart attack and heart failure. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 7/19/21, Resident #59 was coded as being moderately impaired for making daily decisions, having scored nine out of 15 on the BIMS (brief interview for mental status). She was coded as not having…

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.