Guggenheimer Health And Rehab Center

Based on observation, staff interview, resident interview, clinical record review, and facility documentation review, the facility staff failed to provide oxygen at the physician ordered rate for two residents, Resident #115 (R115) and Resident #117 (R117) out of a survey of 21 residents and failed to store the respiratory equipment to prevent contamination for one resident, R115 out of a survey of 21 residents. The findings included: 1. For R115, the facility staff failed to ensure that the oxygen orders by the physician were being followed and failed to store respiratory equipment in a bag when not in use to prevent contamination. On 12/9/24 at 12:00 p.m., a tour of the nursing facility's unit one was conducted. During the tour of the unit, the surveyor observed a CPAP (continue positive airway pressure) mask laying in a bed bath basin on the bedside table. R115 oxygen concentrator setting was set on 1.5 liters per minute via nasal cannula. On 12/9/24 at 12:15 p.m., an interview was conducted with the charge nurse on unit one, licensed practical nurse, LPN#5. LPN#5 stated, 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 2. For resident #111 (R111), the hydrocortisone tablet was not available for administration as ordered by the doctor. On 12/9/24, a clinical record review was conducted. According to the physician order dated 8/21/24, that remained an active order. The order read, Hydrocortisone Tablet 10 MG, Give 1 tablet by mouth one time a day for adrenal insufficiency. According to the nursing progress notes, R111 was not given a dose on 12/3/24 and 12/4/24, because the medication was not available. On 12/3/24 at 10:09 p.m., the administration note read, on order, not in Omnicell, pharm notified pervious shift per nurse [sic]. The nursing note dated 12/4/24 at 12:12 p.m., read, Medication not given, contacted pharmacy and medication will be delivered this evening. NP notified, no new orders. Resident is aware. On 12/10/24 at approximately 9:30 a.m., the director of nursing was interviewed about R111's medication not being available. The DON explained that when medications are not available the staff are to check the Omnicell…

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, clinical record review, and facility documentation review, the facility staff failed to assist one resident, Resident #121 (R121) out of a survey of 21 residents, with transportation arrangements to an appointment with radiology services. The findings included: The facility staff failed to assist R121 with transportation to a procedure he had been prepped for at the facility. On 12/9/24 at 2:44 p.m., an interview was conducted with facility's scheduler, OS5. OS5 said, there was some confusion about the appointments, but we didn't know about them. The appointment for September 28th we didn't have a time for the pre surgery, so they had to fax us a time, I do remember that. I remember that the transport driver called off and alternate transport was not available but cannot remember all the details and no note in his record about that appointment on 10/1/24. On 12/10/24 at 9:35 a.m., an interview conducted with OS5. OS5 looked up in R121 clinical record on her schedule and verified that R121 had an appointment on 10/1/24, and orders to be NPO (nothing by…

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

Based on observations, resident interviews, staff interviews, and facility documentation review, the facility staff failed to follow the resident food preference for two residents, Resident #103 (R103) and Resident #106 (R106), in a survey sample of 21 residents. The findings included: 1. The facility staff failed to follow the meal ticket and R103's food preference. On 12/9/24 at 12:10 p.m., an observation of the lunchtime meal was conducted. R103's lunch tray was served, according to the meal ticket on his tray, he was supposed to receive salad and soup, neither of those items were present. On 12/9/24 at 12:10 p.m., an interview was conducted with R103 about his lunch meal and meal ticket. R103 stated he was supposed to get soup and salad with two meals every day. R103 said, that generally I will get one or the other and sometimes I don't get either one. On 12/9/24 at 12:15 p.m., an interview was conducted with licensed practical nurse, LPN#5 (LPN5). LPN5 stated that R103 is supposed to have salad and soup on his lunch tray according to the meal ticket. LPN5 stated she would check…

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, clinical record review and facility documentation review, the facility staff failed to maintain a complete and accurate clinical record for one resident (Resident #111- R111) in a survey sample of 21 residents. The findings included: 1a. For R111, who saw a dental provider outside of the facility, the facility staff failed to document that the resident attended the appointment and failed to have any documentation of the visit in the resident's clinical record. On 12/9/24 at approximately 2:30 p.m., R111 was visited in the dining room. R111 was noted to be non-verbal but able to nod yes and no to questions. On 12/9/24, a clinical record review was conducted. There was a physician order with a revision date of 11/12/24, that read, Appointment- November 20, 2024 @ 9am Affordable Dentures & Implants. There was no further documentation within the clinical chart to indicate if R111 went to the appointment or not, or if there were any recommendations. On 12/9/24 at approximately 3:45 p.m., an interview was conducted with a registered nurse (RN #2), who was the…

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

Based on staff observation, staff interviews, and facility documentation the facility staff failed to follow infection control standards on one of three units. The findings included: The facility failed to follow the infection control standards regarding glove use, hand hygiene, and transporting of soiled linen in the hallways. On 12/9/24 at 12:15 p.m., a tour of the nursing facility on unit one was conducted. During the tour of unit one, the surveyor observed a certified nursing assistant, CNA#3 (CNA3) transporting dirty linen in the hallway and holding the linen against her body, with gloves on. CNA3 then removed her gloves and began serving lunch trays without performing hand hygiene. On 12/9/24 at 12:25 p.m., an interview was conducted with CNA3. CNA3 said, I didn't know not to carry dirty linen in the hallways or up against my body. I didn't know not to wear gloves in the hallway, and I just forgot to wash my hands. The director of nursing and the floor nurse educated me on gloves and linen in the hallway and to put dirty linen in trash bags earlier this morning. On 12/10/24 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, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to review and revise the care plan for five residents (Resident #78, Resident #70, Resident #83, Resident #15, and Resident #106), in a survey sample of 29 residents. The findings included: 1. For Resident #78 (R78), who had a hernia and was scheduled for surgical repair, the care plan was not revised to reflect the hernia being present nor pre-operative instructions/care that the facility needed to provide. On 10/1/24 at 8:34 a.m., R78 was interviewed in his room. R78 reported that he had a knot in his lower abdomen/groin and was scheduled to have surgery. On 10/1/24 and 10/2/24, a clinical record review was conducted. There was no documentation within the progress notes with regards to an upcoming surgery. However, in the miscellaneous tab of the clinical record was a document titled, Doctor Order Sheet, which was uploaded into R78's chart on 9/16/24. The document…

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 interviews, resident interviews, clinical record review and facility documentation review the facility staff failed to provide activity of daily living (ADL) care for three residents (Resident #13 (R13), Resident #43 (R43) and Resident #56 (R56)) of 29 residents in the survey sample. The findings included: 1. The facility staff failed to provide showers for one resident (R13). R13 was admitted to the facility on [DATE]. Diagnoses for R13 included but are not limited to periprosthetic fracture around internal prosthetic right hip joint, subsequent encounter. R13's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 9/6/24 coded R13 with no cognitive impairment. In addition, the Minimum Data Set coded R13 requiring maximal assistance on staff, for Activities of Daily Living care. On 9/30/24 at 10:00 a.m. a tour of the unit one nursing unit was conducted. R13 was observed in her room and sitting in her wheelchair. Her hair was oily in appearance and lower…

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 and clinical record review, the facility staff failed to follow physician orders for seven of twenty-nine residents in the survey sample (Residents #20, #24, #56, #70, #27, #76 and #78). The findings include: 1. Resident #24 did not have weights obtained as ordered by the physician. Resident #24 (R24) was admitted to the facility with diagnoses that included osteomyelitis, chronic pressure ulcers, quadriplegia, heart failure, atrial fibrillation, methicillin resistant staphylococcus aureus and neurogenic bladder. The minimum data set (MDS) dated [DATE] assessed R24 as cognitively intact. R24's clinical record documented a physician's order dated 9/9/24 for daily weights for three days, weekly weight for four weeks then monthly weights. R24's clinical record documented a weight on 9/15/24. There was no other weight documented until 9/30/24. On 10/1/24 at 1:42 p.m., the licensed practical nurse unit manager (LPN #1) was interviewed about R24's weights not obtained as ordered.…

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 resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure medications were available for administration for three residents (Resident #27-R27, resident #83-R83, and resident #76-R76), in a survey sample of 29 residents. The findings included: 1. For R27 the facility staff delayed treatment of bilateral impacted cerumen as ordered, due to medication not being available. On 9/30/24 at 1:05 p.m., R27 was visited in his room. It was noted that R27 had cotton in his left ear, when asked R27 reported he had wax buildup and was getting drops in his ears. On 9/30/24, a clinical record review was conducted of R27's clinical chart. This review revealed a physician order dated 9/14/24, that read, Debrox Solution 6.5 % (Carbamide Peroxide) Instill 5 drop in both ears two times a day for cerumen impaction for 7 Days. According to the medication administration record (MAR) the medication was not given but once in the 7 days ordered. According…

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 and facility document review, the facility staff failed to properly store insulins on four out of five medication carts inspected. The findings include: Unopened insulins were stored at room temperature on 1st and 3rd floor medication carts. Insulin vials and/or insulin pens were stored on 1st, 2nd and 3rd floor medication carts without labeling of the date opened. An insulin pen on a 3rd floor medication cart was stored and available for use beyond the recommended 28 days after opening. On 10/2/24 at 9:23 a.m., accompanied by licensed practical nurse (LPN #2), a 1st floor medication cart was inspected. Stored in the cart at room temperature were two unopened 10 ml (milliliter) vials of Lispro insulin, an unopened vial of Humalog insulin and an unopened Fiasp flextouch insulin pen. Each of these insulins were labeled for current residents and had a pharmacy label stating refrigeration was required until opened. A Lantus solstar insulin pen for a current resident was also…

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 documentation review, the facility staff failed to store food in accordance with professional standards for food safety in the main kitchen. The findings included: Multiple open food products were not labeled with an open date and/or use by date and was accessible for distribution. On 9/30/24 at 10:45 a.m. an initial tour of the main kitchen was conducted with the dietary manager (other staff, OS #7). Prior to observation of dry goods area and refrigerators, OS #7 was asked what is the expectation of opened items (dry goods and refrigerated items) in regard to labeling. OS #7 verbalized all opened items should have an open date and used by date when the product is opened. The kitchen tour was then conducted with OS #7. The dry storage room yielded the following open products without opened or use by dates: Bag vanilla wafers, two bags of cake mix, bag of pasta noodles, and bag of corn bread mix. The walk in refrigerator had an opened container of olives with a date of 7/16/24 but no use by date, a partial ham loaf (for sandwiches)…

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 resident interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to follow infection control practices for one resident (Resident #106- R106). The facility also failed to develop and implement an infection control program and failed to respond to a COVID outbreak in accordance with the guidance from the Centers for Disease Prevention and Control (CDC), which involved two staff (registered nurse #6 (RN #6) and certified nursing assistant #2 (CNA #2) but had the potential to affect numerous residents on 2 of 2 nursing units. The findings included: 1. The facility staff failed to respond to and implement quarantine and testing measures in accordance with CDC (The Centers for Disease Control and Prevention) recommendations to manage COVID-19 during an outbreak. On 10/2/24 at 9:32 a.m., an interview was conducted with registered nurse #5, who is the facility's infection preventionist (IP). When asked about their most recent COVID case, the IP…

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, clinical record review, and facility documentation review, the facility staff failed to provide credible evidence of an antibiotic stewardship program, having the potential to affect residents on 3 of 3 units. The findings included: On 10/1/24 at 8:32 a.m., during an interview with resident #78 (R78), he stated that he had been on an antibiotic but didn't know why. On 10/1/24, a clinical record review was conducted of R78's medical chart. This review revealed that R78 did have an order dated 8/12/24 for Ciprofloxacin HCl Oral Tablet 500 MG that read, give 1 tablet by mouth two times a day for uti [urinary tract infection] for 7 Days. According to the medication administration record, R78 received four doses of the antibiotic before the order was discontinued on 8/14/24. According to a urinalysis that was collected on 8/13/24, the results were negative for a urinary tract infection. According to a progress note from the nurse practitioner dated 8/14/24, regarding R78's antibiotic use, it read in part, . being seen today for follow-up of abnormal penile…

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 interview, clinical record review and facility documentation review, the facility staff failed to provide education and offer pneumonia immunizations, to 4 of 5 residents (resident #2-R2, Resident #24-R24, Resident #13-R13, and resident #70-R70) sampled for immunizations. The findings included: On 9/30/24, during the initial tour, R2 verbalized to the surveyor that she had been asking daily for administration of vaccines but had yet to be given any. On 10/1/24, five residents, which included R2, were reviewed for compliance with immunization protocols as part of the infection control task. During this review, the clinical record of each resident was reviewed. For R2, R24, R13 and R70, the record documented no evidence the residents had been educated nor offered the pneumonia vaccine, which all of them were eligible for. On 10/02/24 at 9:32 a.m., an interview was conducted with the facility's infection preventionist (IP). During the interview, the IP reviewed and confirmed the above findings with regards to the lack of documentation within 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 resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide education and offer COVID immunizations, to 3 of 5 residents (Resident #2-R2, Resident #24-R24, and Resident #13-R13) sampled for immunizations. The findings included: On 9/30/24, during the initial tour, R2 verbalized to the surveyor that she had signed the consent form and had been asking daily for administration of the COVID booster vaccine, but had yet to be given any. On 10/1/24, five residents, which included R2, were reviewed for compliance with immunization protocols as part of the infection control task. During this review, the clinical record of each resident was reviewed. For R2, R24 and R13, documentation revealed that all the residents were eligible for the COVID spike vac, and there was no evidence the residents had been educated nor offered the vaccine. On 10/02/24 at 9:32 a.m., an interview was conducted with the facility's infection preventionist (IP).…

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, resident interviews, staff interviews and facility documentation review, the facility staff failed to have an alternate means for residents to communicate with staff after an extended call bell outage affecting residents on two of three nursing units. The findings included: On 9/30/24 at approximately 10:45 a.m., an initial tour was conducted on each of the three resident care units. It was noted that the call bell system was not functioning at all on the entire second floor. Multiple residents verbalized that the call bells had not been operational for the entire weekend. On the third floor it was noted that the call bell system was not operating in various areas and not affecting the entire unit. On 9/30/24, in the afternoon, various call bells were attempted to be engaged, which included but were not limited to resident #78 and resident #15 and were noted to not function, no visual notification or auditory notification of the call bell being engaged was noted. Certified nursing assistant…

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, resident interviews, staff interviews, and facility documentation review, the facility staff failed to maintain an effective pest control program ensure the facility is free of pests affecting 2 of 3 resident care units. The findings included: The facility staff failed to maintain an effective pest control program to ensure the resident care areas were free of mice. On 9/30/24 and 10/1/24, during resident interviews, multiple residents on the 2nd and 3rd floors complained of an ongoing problem with mice. On 9/30/24 at 10:35 a.m., an interview was conducted with resident #83-R83. R83 said, they have a mouse problem. When asked what is being done R83 said, maintenance sets traps and caught one and I caught one in a Walmart bag. R83 went on to report that he told the staff on Friday he is hearing them in the wall, but maintenance was off the weekend, so he was expecting them to come that day to set some traps. On 9/30/24, in the afternoon resident #78 (R78) and his roommate reported an ongoing…

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, resident interview, and clinical record review, the facility staff failed to provide respect for privacy for one of twenty-nine residents in the survey sample (Resident #44). The findings include: Facility staff entered Resident #44's room and private space without knocking or requesting verbal permission to enter. Resident #44 (R44) was admitted to the facility with diagnoses that included peripheral vascular disease, hypertension, and carotid stenosis. The minimum data set (MDS) dated [DATE] assessed R44 with moderately impaired cognitive skills. On 9/30/24 at 11:11 a.m., R44 was interviewed in his room about quality of life/care in the facility. During this interview, a staff person entered the room without knocking or giving any verbal announcement prior to entering the room. The employee went to R44's roommate, pulled the center curtain and did not acknowledge or address R44 in any manner. R44 stated at this time, This goes on all the time. R44 stated staff members frequently entered…

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, facility documentation review and clinical record review, the facility staff failed to complete a SNF ABN (Skilled Nursing Facility Advance Beneficiary Notice) for 2 residents in a survey sample of 3 residents (Resident #316, Resident #317, Resident # 318) reviewed for Beneficiary Notifications. The findings included: For Resident #317 and Resident #318, the facility staff failed to provide a SNF ABN notice prior to skilled care services ending. As a result of this deficient practice Resident #317 and Resident #318 were not afforded the opportunity to continue skilled care services and have Medicare decide about coverage of such services, known as a demand bill, nor the option for services to continue and the resident be financially responsible. Resident #316 was issued a NOMIC on 4/29/24 but service ended on 4/3/24, so the notice was not given in a timely manner. On 10/1/24 a clinical record was reviewed. The clinical record revealed no evidence of an ABN (Advanced Beneficiary Notice) being issued. The progress notes made no reference with regards to 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.

Based on observations, staff interviews and resident interviews, the facility staff failed to uphold the resident's right to privacy with regards to mail and failed to provide timely mail delivery for residents on 3 of 3 units. The findings included: The facility staff failed to deliver mail opened and does not deliver/distribute any mail on Saturdays. On 10/1/2024 at 2:30 p.m. a resident council meeting was conducted with the surveyor and six residents, (R#41, R#43, R#46, R#47, R#56, R#59). Of the six residents, two were from each of the resident units. Residents expressed concerns that mail is opened when they receive it and 4 confirmed, it is particularly with bills. They don't get mail on Saturdays, despite an activity assistant is working every other Saturday. Residents expressed concerns about not receiving packages in a timely manner. R#56 had a package delivered on Monday 9/30/24, that his sister had tracked the package, and he hasn't received it on 10/1/24. R#59 stated that the mail had recently just started being delivered opened to their rooms. The residents stated that…

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

Based on observation, resident interview, staff interview, and facility documentation review, the facility staff failed to maintain a homelike environment for two residents (resident #70-R70 and resident #78-R78) in a survey sample of 29 residents. The findings included: 1. For R70, whose ceiling was leaking the facility staff failed to make timely repairs to maintain a homelike environment. On 9/30/24 at 11:29 a.m., R70 was visited in her room. R70 was non-verbal but was able to communicate by shaking her head to indicate yes and no. During the interview, R70 pointed to a trashcan that had been placed on top of the air conditioning (ac)/heat unit in the room at the window. The surveyor observed that underneath the trash can was towels that appeared to have been there for an extended period and chips of plaster/sheet rock were on the towel, ac unit, and floor. The trash can had water in it measuring about 1- 1 1/2 inches deep and a black substance was floating on top of the water. When asked about the duration of the leak, R70 indicated it had been like that for months. On 10/1/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to accurately complete a pre-admission screening and resident review (PASARR) to identify if a level II evaluation was warranted for one resident (resident #90-R90) in a survey sample of 29 residents. The findings included: For R90, who had multiple diagnosis of mental illness, the facility staff failed to accurately complete a level I PASARR, to determine if a more in-depth, level II assessment was warranted. On 10/1/24, a clinical record review was conducted of R90's chart. This review revealed that R90 was admitted to the facility on [DATE], and had diagnosis which included, but were not limited to post-traumatic stress disorder, major depressive disorder- recurrent, unspecified psychosis not due to a substance or known physiological condition, paranoid schizophrenia, paranoid personality disorder, and schizophrenia unspecified. Review of the level I PASARR completed 4/21/23, revealed that question…

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, resident interview, staff interview, and facility documentation review, the facility staff failed to develop a comprehensive care plan for one resident (resident #5- R5) in a survey sample of 29 residents. The findings included: For R5, who was edentulous, due to broken and ill-fitting dentures, the facility staff failed to address oral status in the comprehensive care plan. On 9/30/24 at 2:57 p.m., R5 was visited in his room. The surveyor noted while talking to the resident that he appeared edentulous. When asked, R5 reported he had dentures, but they broke and said, I bit into something a while back and it put a hole in one of them [referring to dentures]. R5 went on to say that he had gone to a dentist, had dentures made and was supposed to just pick them up but didn't go. He said he guesses he would have to get new ones made again since it has been so long. On 9/30/24-10/1/24, a clinical record review was conducted. This review revealed a progress note from the nurse practitioner dated…

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, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of care for three of twenty-nine residents in the survey sample (Residents #53, #68 and #166). The findings include: 1. Resident #166's medication Advair diskus (fluticasone-salmeterol) was left at the bedside after administration of the medication. Resident #166 (R166) was admitted to the facility with diagnoses that included COPD (chronic obstructive pulmonary disease), respiratory failure, diabetes, urinary tract infection, asthma, anemia, and rheumatoid arthritis. The minimum data set (MDS) dated [DATE] assessed R166 with moderately impaired cognitive skills. On 9/30/24 at 10:42 a.m., R166 was observed in bed. The medication Advair diskus breath activated inhaler device was observed on R166's over-bed table. R166 was interviewed at this time about the Advair. R166 stated the nurse administered the medication last evening (9/29/24) and left…

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

Based on observation, resident interview, staff interview, clinical record review and facility document review the facility staff failed to ensure that residents receive proper treatment and assistive devices to maintain vision abilities for one resident (Resident#43, R43) in a survey sample of 29 residents. The findings included: The facility staff failed to replace eyeglasses broken by staff timely. On 10/1/24 at 8:00 a.m. R43 was laying in his bed and was trying to read his newspaper. R43 stated, I can see far away but not up close and I have not received my glasses yet. On 10/1/24 at 2:30 p.m. During resident council meeting R43 stated, I have glasses missing that staff broke, they said they were going to replace them but that was 2 months ago. On 10/2/24 at 9:45 a.m. an interview was conducted with the social worker director. The social worker director stated, I sent out an email of high priority to the director of nursing, unit manager, activity director and unit one's social worker. The email read in part, .he[R43] mentioned that about a week ago a staff member (he did 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 observation, staff interview, resident interview, clinical record review and facility document review, the facility staff failed to offer a therapeutic diet for one resident (Resident #56, R56) out of a survey sample of 29 residents. The findings included: The facility staff failed to provide large portion entrees with meals as ordered by the physician. On 9/30/24 at 12:30 p.m. an observation was made of the lunch time meal. R56 meal ticket had large entree portions. He received the regular serving size of the entree on his meal tray. The entree was Italian chicken, and he only received 3 ounces. On 9/30/24 at 12:33 p.m. a certified nursing assistant (CNA#2) was interviewed. CNA#2 stated, sometimes he [R56] gets double portions but today he [R56] did not get double entree, and he doesn't get double the meats. On 9/30/24 at 12:33 p.m. an interview with R56 was conducted. R56 said that the serving size of the food is too small with his meals. On 10/1/24 at 8:45 a.m. an observation was made of R56's breakfast tray. R56 was in his room and the aide was setting up his meal 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 3. For resident #90- R90, the facility staff failed to maintain the nebulizer mask in a manner to prevent contamination to prevent infection. On [DATE] at 11:26 a.m., R90 was observed in his room having a nebulizer treatment being administered via a mask. The mask nor tubing were dated as to when they were last changed. On [DATE] at approximately 4:02 p.m., R90 was visited in his room. The nebulizer mask was observed open to air and not in a bag. On [DATE] at 3:03 p.m., R90 was again visited in the room. It was noted that the nebulizer mask was laying in the floor at the bedside. On [DATE] at 3:16 p.m., an interview was conducted with licensed practical nurse #4 (LPN #4). LPN #4 was asked about nebulizers and the storage of them. LPN #4 stated they are to be stored in a bag and are changed nightly and dated. When asked why this is important, LPN #4 stated to know it is not expired, being kept clean and safe non-bacterial place, and when things are changed last. LPN #4 was told that R90's nebulizer mask was…

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

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to assist one resident, Resident #121 (R121) out of a survey of 21 residents, with transportation arrangements to an appointment with radiology services. The findings included: The facility staff failed to assist R121 with transportation to a procedure he had been prepped for at the facility. On 12/9/24 at 2:44 p.m., an interview was conducted with facility's scheduler, OS5. OS5 said, there was some confusion about the appointments, but we didn't know about them. The appointment for September 28th we didn't have a time for the pre surgery, so they had to fax us a time, I do remember that. I remember that the transport driver called off and alternate transport was not available but cannot remember all the details and no note in his record about that appointment on 10/1/24. On 12/10/24 at 9:35 a.m., an interview conducted with OS5. OS5 looked up in R121 clinical record on her schedule and verified that R121 had an appointment on 10/1/24, and orders to be NPO (nothing by…

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

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to arrange for routine dental services for one resident (resident #5-R5) in a survey sample of 29 residents. The findings included: On 9/30/24 at 2:57 p.m., R5 was visited in his room. The surveyor noted while talking to the resident that he appeared edentulous. When asked, R5 reported he had dentures, but they broke and said, I bit into something a while back and it put a hole in one of them [referring to dentures]. R5 went on to say that he had gone to a dentist, had dentures made and was supposed to just pick them up but didn't go. He said he guesses he would have to get new ones made again since it has been so long. R5 added, I would like someone to come here to look at them versus me having to go all the way there. On 9/30/24-10/1/24, a clinical record review was conducted. This review revealed a progress note from the nurse practitioner dated 5/23/24, that read in part, . Chief Complaint/Nature of Presenting Problem: Broken dentures . seen today for complaints 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 observations, resident interviews, staff interviews, and facility documentation review, the facility staff failed to follow the resident food preference for two residents, Resident #103 (R103) and Resident #106 (R106), in a survey sample of 21 residents. The findings included: 1. The facility staff failed to follow the meal ticket and R103's food preference. On 12/9/24 at 12:10 p.m., an observation of the lunchtime meal was conducted. R103's lunch tray was served, according to the meal ticket on his tray, he was supposed to receive salad and soup, neither of those items were present. On 12/9/24 at 12:10 p.m., an interview was conducted with R103 about his lunch meal and meal ticket. R103 stated he was supposed to get soup and salad with two meals every day. R103 said, that generally I will get one or the other and sometimes I don't get either one. On 12/9/24 at 12:15 p.m., an interview was conducted with licensed practical nurse, LPN#5 (LPN5). LPN5 stated that R103 is supposed to have salad and soup on his lunch tray according to the meal ticket. LPN5 stated she would check…

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, resident interviews, staff interviews, clinical record review and facility documentation review, the staff failed to maintain a complete and accurate clinical record for 3 residents (Resident #13, R13, Resident #78, R78, and Resident #53, R53) in a survey sample of 29 residents. The findings included: 1. The facility staff failed to accurately document R13's activity of daily living (ADL) care regarding showers. On 9/30/24 at 10:00 a.m. a tour of unit one was conducted. R13 was observed in her room and sitting in her wheelchair. Her hair was oily in appearance and lower extremities had some dry skin noted. On 9/30/24 at 10:45 a.m. an interview was conducted with R13. R13 stated, that the staff has given me one bath since I have been here and the rest of the time, I bathe myself the best I can. I have not had a shower since I have been here and staff is short especially on weekends and my bed has been like it is right now since Friday, unmade. On 10/2/24 at 10:30 a.m. a clinical record…

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, resident interview, staff interview and facility documentation review, the facility staff failed to maintain resident beds in operating condition for one resident (Resident #78-R78) in a survey sample of 29 residents. The findings included: For R78, whose bed was not operational for three days, the facility staff failed to replace the bed to provide the resident with an operational bed, which left the resident to lay in an upright position for several days. On 9/30/24 at 12:14 p.m., R78 was visited in his room and interviewed. R78 was lying in bed with the head of the bed elevated. R78 reported that his bed had been in that position since Friday, and he was uncomfortable. R78 asked if the surveyor could help with this problem. On 9/30/24 in the afternoon, certified nursing assistant #9 confirmed that R78's bed was not working throughout the entire weekend, and they had a problem with several beds. On 9/30/24 at 4:20 p.m., an interview was conducted with registered nurse #6 (RN#6), who was the unit manager. RN#6 was asked about R78's bed. RN#6 said, I just 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 and clinical record review, the facility staff failed to follow physician orders for one of 6 residents in the survey sample: Resident # 4. Resident # 4 was ordered to have 3 showers a week, but received bed baths. Findings include: Resident # 4 (R4) was admitted to the facility with diagnoses that included, but were not limited to: other acquired deformity of the head, encephalopahty, dementia, high blood pressure, and congestive heart failure. The discharge MDS (minimum data set) dated 6/10/22 had R4 assessed with severely impaired cognition with a total score of 7/15. R4's clinical record was reviewed 10/10/23 beginning at 10:55 a.m. Review of R4's physician order summary (POS) revealed an order dated 5/27/22 for Pt. to shower M-W-F per MD order. If he refuses, please notify nurse. A preceding order dated 5/16/22 also documented that R4 was to have a shower three times a week. Review of the progress notes did not document any refusals by R4 for a shower. On 10/10/23 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 staff interview, facility document review, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for one of six residents in the survey sample (Resident #1). The findings include: Multiple dressing changes/pressure ulcer treatments and an updated physician order were not accurately documented on Resident #1's February 2023 treatment administration record (TAR). Resident #1 (R1) was admitted to the facility with diagnoses that included dementia, mood disturbance, anxiety, lower leg vascular ulcers, pneumonia, COVID-19, deep vein thrombosis, urinary tract infection, respiratory failure with hypoxia, congestive heart failure, sacral pressure ulcer, and dysphagia. The minimum data set (MDS) dated [DATE] assessed R1 with short and long-term memory problems and severely impaired cognitive skills. R1's clinical record documented the resident was re-admitted to the facility from a hospitalization on 2/1/23 with an unstageable sacral pressure ulcer. R1's…

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

Based on observation, staff interview, clinical record review, and facility document review, the facility failed to ensure medications were stored correctly for one of 6 residents in the survey sample. Resident #5's (R5) inhaler medication was at the bedside. The Findings Include: Diagnoses for R5 included: Respiratory failure, dysphagia, and kidney disease. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 10/5/23, in which Resident #5 was assessed with moderately cognitive impairment. On 10/10/23 at 10:30 AM, during an initial tour of the facility, R5 was observed laying in bed. During a conversation with R5, it was noted that an inhaler labeled Trelegy 100/62.5 mcg [micrograms] was sitting on the bed side table. When asked about the medication, R5 verbalized uncertainty why the medication was in the room. On 10/10/23 at 10:35 AM, registered nurse (RN1, assigned to R5) was interviewed. When questioned about the presence of the medication, RN1 went to R5's room and retrieved the medication. RN1 verbalized that she 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 2. Resident #384 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: Acute chronic anemia, chronic kidney disease, heart failure and hypercalcemia. Due to her recent admission an MDS (minimum data set) had not been completed. A Nursing admission Assessment Comprehensive dated 10/11/2021 contained the following information under the cognitive section: .Short Term Memory of-seems/appears to recall after 5 minutes .Usually Understood-difficulty finding words or finishing thoughts .Unclear Speech-slurred mumbled words .Usually Understands-may miss some part/intent of message . Her admission nursing not dated 10/12/2021 at 2:56 a.m., described Resident #384 as alert with confusion. Initial tour of the third floor of the facility was conducted on 10/12/2021 beginning at approximately 10:30 a.m. At approximately 11:05 a.m. the door to Resident #384's room was observed closed. A staff member came down the hallway carrying an isolation cart and signs. She stopped at 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.

Based on observation, staff interview, and facility document review, the facility failed to dispose of expired IV (intravenous) antibiotic medication which was available for administration, in one of four medication rooms, Unit 1. Findings include: An observation of the Unit 1 medication room was conducted on 10/12/21 at 11:40 AM, with RN (Registered Nurse) #2. In the medication refrigerator was one bag of IV medication, ertapenem 1 gram/50 ml (milliliters) of normal saline. The medication had a pharmacy label with an expiration date of 09/22/21. RN #2 was asked if this resident was a current resident and RN #2 stated, Yes. RN #2 then stated, That (medication) should have been trashed. RN #2 then stated that the pharmacy doesn't take back this type of medication and that they are to dispose of expired medications. On 10/12/21 at approximately 1:15 PM, a policy was requested on medication storage and expired medications. On 10/13/21 at approximately 12:10 PM, the administrator and corporate consultant were made aware of the above concern and was again asked for a policy on expired…

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 policy review, facility staff failed to store and prepare food properly in the main kitchen. Findings included: On 10/12/21 at 10:45 A.M. an initial tour of the main kitchen was conducted along with the dietary manager (other staff, OS #1). A sink was observed, partially filled with cold water, and 4 packages of vacuum sealed beef. There was no running water over the meat. OS #1 stated the meat was supposed to be thawed using running water so that the water is constantly draining off. On 10/13/21 1:25 PM the above information was presented to the administrator, no other information was presented prior to exit conference.

Based on observation, staff interview, and facility policy review, facility staff failed to prepare, store and serve food in a sanitary manner in the main kitchen. Facility staff failed to obtain initial food temperatures before plating food for resident consumption on the first floor and the cook failed to wear a cover over his beard while preparing and serving food. Two quart-size containers of V8 juice and two pint-size containers of cranberry juice were noted open and not dated in the refrigerator. Findings included: During the initial tour of the kitchen on 01/14/19 at 11:35 a.m. the cook was observed without a beard cover in place. He was observed preparing and serving food in the main kitchen. Also during the tour, the tray line was observed set up. This surveyor asked if initial food temperatures had been obtained. The cook stated, No, I am getting ready to do them here in a minute. A cart with plated food on trays was noted behind the serving line. The Dietary Manager (DM) was asked what those trays were. The DM stated, Those are trays for the first floor. This surveyor…

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 resident interview, staff interview and clinical record review, the facility staff failed to give advance notice of a care plan meeting for two of 22 residents in the survey sample. Residents #39 and #60 were not given advance notice of their most recent care plan meeting and stated they had not been invited to the meeting. The findings include: 1. Resident #39 was not given advance notice of her last care plan meeting and stated she was not invited to attend and/or participate in the meeting. Resident #39 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #39 included diabetes, atherosclerotic heart disease, depression, gastroesophageal reflux and osteoarthritis. The minimum data set (MDS) dated [DATE] assessed Resident #39 as cognitively intact. On 1/14/19 at 4:10 p.m., Resident #39 was interviewed about quality of life and care in the facility. When asked about her attendance or participation in her care plan conference, Resident #39 stated she did not recall…

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 and staff interviews, the facility failed to discontinue an order for PRN (as needed) psychotropic medication for one of 22 residents in the survey sample. Resident #43 had a physician's order for PRN (as needed) Lorazepam for more than 14 days without a stop date reflected. The findings include: Resident #43 was admitted to the facility on [DATE]. Diagnoses for Resident #43 included hyperlipidemia, dementia, anxiety, depression, chronic obstructive pulmonary disease (COPD), chronic pain, restless/agitation and palliative care/hospice. The most recent minimum data set (MDS) dated [DATE] assessed Resident #43 as having severe cognitive impairment. Resident #43's clinical record was reviewed on 01/15/19 at 1:30 p.m. Included in this resident's physician order sheet was an order that stated, Lorazepam 0.5 mg (milligrams) (1) TABLET Oral. Notes: Anxiety, Instructions: Take one (1) tablet p.o. (by mouth) every 12 hours as needed for anxiety or agitation., Therapeutic Range: Physical…

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.