Summit Health And Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy, the facility failed to provide incontinence care for in a timely manner for two of three residents (Resident (R) 36 and R41) reviewed for activities of daily living (ADLs) out of a total sample of 30. Failure to provide timely incontinence care places residents at increased risk of urinary tract infections and skin breakdown. Findings include: 1. For R36, facility failed to provide timely incontinent care, as needed. Review of R36's Profile tab of the electronic medical record (EMR) revealed R36 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, adult failure to thrive, and unspecified sequelae of cerebral infarction. Review of R36's Care Plan, dated 01/08/25 and located under the Care Plan tab of the EMR revealed, . the resident is incontinent of bladder and bowel and is not a candidate for a toileting program . The goal was, . the resident will remain clean and dry as possible thru [sic] 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 interview, record review, and job description review, the facility failed to have a certified Activity Director to direct the provision of activities for 114 of 114 residents, as required. Findings include: During an interview on 05/01/25 at 9:03 AM, when asked if she was certified as an Activities Director, the Activity Director (Other Staff (OS) 4) said, No. OS4 stated that she was not informed she needed to be certified when she took the position two years ago. OS4 stated that she had been working at another facility as the Activity Director previously. OS4 stated the previous Administrators had not talked with her about it, but that the current Administrator had informed her certification was necessary. OS4 stated the Administrator had been pushing her to get the certification completed. OS4 stated that she had signed up for the class and was told due to her years of experience she only needed to write an essay. OS4 stated that she had received the book for the class during the previous week, and that the class had been paid for. OS4 stated that she had written the…

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

Based on observation, staff interview and clinical record review, the facility staff failed to ensure a wound dressing was intact for one of thirty residents in the survey sample, (Residents #19). Resident #19's (R19) did not have a wound dressing in place. The Findings Include: Diagnoses for R19 included non-pressure chronic ulcer to left calf, adult failure to thrive, and peripheral vascular disease. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 4/19/25. R19 was assessed with a cognitive score of 15 out of 15, indicating cognitively intact. On 4/29/25 at 12:55 p.m., R19 was interviewed and was asked about having any wounds. R19 verbalized that he had a wound on the left calf that has been there before being admitted and the nurses are taking care of it. At this time, the wound was observed without a dressing and with scant drainage. When asked what happened to the dressing, R19 verbalized it came off when the aides had helped him to get dressed in the morning. On 4/29/25 at 1:16 p.m., registered nurse (RN #6) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy, the facility failed to implement interventions to aid in the prevention of pressure ulcers for one of three residents (Resident (R) 36) reviewed for pressure ulcers out of a total sample of 30. Failure to implement interventions placed R36 at increased risk of developing pressure ulcers. Findings include: Review of the facility's undated policy titled, Pressure Injury Prevention and Management revealed, . The intent of this organization is to develop and maintain systems and processes to ensure that the resident does not develop pressure ulcers/injuries (PU/PIs) unless clinically unavoidable and that the facility provides care and services consistent with professional standards of practice . Frequent encouragement and assistance with turning, repositioning, shift of weight . Assistance with incontinence care, and application of moisture barrier ointments to protect the skin from contact with urine and/or feces . Review of R36's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility failed to ensure the environment was free of accident hazards for one resident (Resident #88) and failed to provide adequate supervision to prevent accidents for two residents (Resident #36 and Resident #69), in a sample of thirty residents. The findings include: 1. For Resident #88, the facility failed to provide safe water temperature at a room sink. Resident #88's room had water temperature at the bathroom sink above the recommended range of 110 degrees (F) to less than 120 degrees (F). Resident #88 (R88) was admitted to the facility with diagnoses that include atrial fibrillation, hypertension, diabetes, hypothyroidism, hypercholesterolemia, edema, rosacea, osteoarthritis and congestive heart failure. The minimum data set (MDS) dated [DATE] assessed R88 as cognitively intact. On 4/29/25 at 1:32 p.m., R88 was interviewed about quality life/care in the facility. When asked about any…

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, record review, and facility documentation review, the facility staff failed to follow professional standards of nursing practice for 7 Residents (Resident #1, #2, #3, #6, #7, #9, and #10) in a survey sample of 11 Residents. For Resident #1, #2, #3, #6, #7, #9, and #10, the facility staff failed to administer medications in accordance with physician orders and failed to notify the physician that the ordered medications were not administered. The findings included: On 1/4/24 and 1/5/24, clinical record reviews were performed, which revealed the following: 1. According to Resident #1's clinical record, the facility staff documented on 05/12/2022 at 10:13 AM, Administration Note: Hydrocodone-Acetaminophen [also known as Lortab and Norco] Tablet 7.5-325 MG, give 1 tablet by mouth two times a day for pain. Have not received from pharmacy. Review of the Medication Administration Record (MAR) revealed that the Norco was not administered on 05/12/22 and 5/20/22, but there was no documentation…

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 provide pharmaceutical services to meet the needs of 4 Residents (Resident #1, #2, #4, and #6) in a survey sample of 11 residents. The findings included: On 1/4/24 and 1/5/24, clinical record reviews were conducted, which included a review of progress notes, physician orders, medication administration records and care plans. The following was noted: 1. Resident #1 was ordered protonix to be given twice a day for gastro-esophageal reflux disease (GERD). The medication was not administered as ordered by the physician. A progress note dated 05/12/2022 at 10:13 AM, read, do not have from pharmacy. 2. Resident #2 was admitted to the facility on [DATE]. Review of the medication administration record (MAR) revealed that the resident missed multiple medication administrations due to medications not being available/ pharmacy had not delivered. They included, dexamethasone, Alfuzosin HCL ER, and rivaroxaban.…

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 ensure residents were free from significant medication errors, affecting 5 residents (Resident #1, #5, #6, #9, and #11), in a survey sample of 11. The findings included: On 1/4/24 and 1/5/24, comprehensive record reviews were conducted that revealed the following omissions in the medication administration records (MARs), physician orders. 1. Staff failed to administer sliding scale insulin to Resident #5 for the treatment of diabetes mellitus. Resident #5 had orders for Humulin R insulin to be administered on a sliding scale dependent upon the blood sugar level. On 6/4/22, Resident #5's blood sugar at 11 AM was 209, for which 2 units of insulin should have been administered, according to the sliding scale order. Then at 4 PM the blood sugar level was 164, for which 1 unit of insulin should have been administered. On 6/12/22, Resident #5's blood sugar at 9 PM was 349, for which 4 units of insulin…

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 document review, and clinical record review, it was determined that the facility staff failed to notify the POA (power of attorney) of a change in condition for one resident (Resident #11) in a survey sample of 11 Residents. The findings included: On 1/4/24 and 1/5/24, a clinical record review was conducted of Resident #11's chart. The progress notes on 8/16/22 read, Patient found unresponsive and nurse practitioner notified and order received to send Resident #11 out to the hospital. On 8/16/22 at 3:42 p.m., a progress note documented that the POA was notified at 10:30 a.m. of Resident #11 being sent out to the hospital due to a blood sugar of 43. On 1/4/24 at 1:30 p.m., the DON [Director of Nursing] was interviewed and stated, the expectation of notifying NP [Nurse Practitioner] and family is during the transfer or shortly after unless unable to reach, then it may be a delay. On 1/5/24 at 10:55 a.m., Surveyor C interviewed Resident #11's POA. The POA stated, I was notified by facility staff after calling to the facility and not being able to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident interviews, and facility document review, the facility staff failed to offer alternate menu entrée items that were prepared in advance and compatible to other menu items. No meal alternatives menu entrée items were listed on the main menus posted on each unit, or on the copy provided to the residents. The census was 79 residents. The findings include: On 04/19/2022 during the initial tour, three3 residents, Resident #8, Resident #35, and Resident #14 stated they were not offered alternate menu items. Resident #8 was admitted with diagnoses that included, pneumonia, sepsis, chronic kidney disease, and major depression. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #9 as moderately impaired for daily decision making with a cognitive score of 11 out of 15. On 04/19/22 at 11:00 a.m. when asked about food and choices Resident #8 stated the food was not very appealing and they did not get a choice or alternative. Resident #35 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 and clinical record review, the facility staff failed to follow infection control protocols for one of twenty-one residents in the survey sample, Resident #75; and failed to implement facility protocols for Legionella prevention. The findings include: 1. Resident #75 was admitted to the facility with diagnoses that included clostridium difficile (C-diff), sepsis, chronic respiratory failure, hypoxia, COPD (chronic obstructive pulmonary disease), epilepsy, chronic pain, history of venous thrombosis and major depressive disorder. The minimum data set (MDS) dated [DATE] assessed Resident #75 as cognitively intact. Resident #75's clinical record documented a physician's order dated 3/31/22 for contact precautions due to C-diff colitis. On 4/20/22 at 8:56 a.m., certified nurses' aide (CNA) #1 was observed entering Resident #75's room. CNA #1 had on a mask but no gown or gloves and performed no hand hygiene prior to entering the room. CNA #1 retrieved 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 document review, the facility staff failed to notify the physician of medications not available for administration for three of 21 residents in the survey sample, Resident #230, Resident #59 and Resident #15. Findings include: 1. Resident #230 was admitted with diagnoses that included, but were not limited to: BPH (benign prostatic hypertrophy) with urinary retention, indwelling Foley catheter, urinary tract infection, entercolitis, C-Diff (clostridium difficile) infection, PVD (peripheral vascular disease), dementia, high blood pressure and bacteremia (infection in the blood). The resident's admission MDS (minimum data set) was still in progress. Resident #230's nursing admission assessment dated [DATE] documented, that the resident had dementia with cognitive deficits (unable to answer to place, time and situation). On 04/20/22 at 11:36 AM, Resident #230 was observed in his room. An IV (intravenous) pole with machine 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 and clinical record review, the facility staff failed to develop a comprehensive care plan (CCP) for 3 of 21 residents in the survey sample, Resident #28, Resident #13, and Resident #15. Resident #28's CCP did not include a focus area with goals and interventions for the use of antidepressants. Resident #13's CCP did not include a focus area with goals and interventions for nutrition. Resident #15's CCP did not include a focus area with goals and interventions for having an impacted ear related to wax build-up. The findings include: 1. Resident #28 was admitted to the facility with cerebral infarction, major depressive disorder, anemia, hypertension, dysphasia, adult failure to thrive, hemiplegia and hemiparesis, and heart disease. The most recent minimum data set (MDS) dated [DATE] was a 5-day significant change and assessed Resident #28 as having long and short term memory problems, severely impaired for daily decision-making, having hallucinations and delusions; and fluctuating…

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 follow professional standards of practice for three of twenty-one residents in the survey sample, Resident #15, #23, and #230. A nurse administered the medication Depakote to Resident #15 in error. There was no report or investigation of the error by nursing administration. Resident #23 was administered a deep IM (intramuscular) injection of an antibiotic in the deltoid muscle which was against the manufacturer's recommendation. The facility failed to accurately transcribe a physician's order resulting in Resident #230 missing an IV (intravenous) antibiotic (Vancomycin) for four days. The findings include: 1. Resident #15 was admitted to the facility with diagnoses that included bladder-neck obstruction, diabetes, anemia, acute kidney failure, atrial fibrillation, hyperlipidemia, hematuria and hypertension. The minimum data set (MDS) dated [DATE] assessed Resident #15 as cognitively intact. Resident #15's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure six of 21 residents in the survey sample were administered medications as ordered by the physician, Resident #230, #59, #15, #46, and #14; and failed to ensure glucometer calibration monitoring was completed on three of 4 nursing units, The Gardens, [NAME] Square, and The Peaks. 1. Resident #230 was not administered IV (intravenous) Vancomycin, oral Vancomycin, or Aricept as ordered by the physician. 2. Resident #59 was not administered a sodium chloride supplement or medications for a bowel regimen as ordered by the physician. 3. Resident #15 had no prescribed medication/irrigation treatment for impacted ear wax for over a week, as ordered by the provider, was not administered the medication lisinopril as ordered by the physician, and was administered the medication Depakote in error. 4. Resident #46 was not administered the medications Aricept and Remeron 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 3. Resident #15 was admitted to the facility with diagnoses that included bladder-neck obstruction, diabetes, anemia, acute kidney failure, atrial fibrillation, hyperlipidemia, hematuria and hypertension. The minimum data set (MDS) dated [DATE] assessed Resident #15 as cognitively intact. a) On 4/19/22 at 2:40 p.m., Resident #15 was interviewed about quality of care in the facility. Resident #15 stated his right ear had been stopped up with wax for over a week. The resident stated staff told him they were going to order drops and then irrigate the ear to remove the wax. The resident stated he had received no drops as of today (4/19/22). Resident #15 stated he had pressure and was not able to hear well out of the right ear due to the impacted wax. The resident described the condition as aggravating. Resident #15 stated he had reported to nurses and the nurse practitioner that he had not received drops and nothing had been done to relieve the ear wax. A nurse practitioner (NP) progress note dated 4/12/22…

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 ensure two of 21 residents in the survey sample were free of a significant medication error, Resident #230 and #59. Resident #230 was not administered IV (intravenous) antibiotics for a blood infection for four consecutive days; and Resident #59 was not administered sodium chloride for hyponatremia for 5 days and wasn't administered a bowel regimen, Dulcolax for 9 days. Findings include: 1. Resident #230 was admitted with diagnoses that included, but were not limited to: BPH (benign prostatic hypertrophy) with urinary retention, indwelling Foley catheter, urinary tract infection, entercolitis, C-Diff (clostridium difficile) infection, PVD (peripheral vascular disease), dementia, high blood pressure and bacteremia (infection in the blood). The resident's admission MDS (minimum data set) was still in progress. Resident #230's nursing admission assessment dated [DATE] documented, that the resident had dementia with cognitive deficits…

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, the facility failed to evaluate for self administration of medications for one of 21 residents, Resident #8. The Findings Include: Diagnoses for Resident #8 included; Pneumonia, sepsis, chronic kidney disease, and major depression. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 1/29/22. Resident #8 was assessed with a cognitive score of 11 indicating moderately cognitively intact. On 4/19/22 at 10:56 a.m., while interviewing Resident #8 medications were observed on the bedside table in a dispense cup. Resident #8 verbalized not wanting to take the medications until after breakfast so had asked the nurse to leave them on the table. On 4/19/22 at 11: 06 a.m., licensed practical nurse (LPN #4) was interviewed and stated she had brought the medications in to Resident #8 earlier and Resident #8 said to leave them and would take them after breakfast. When asked about concerns of leaving medications at the bedside, LPN #4 stated understanding that medications…

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

Based on staff interview, and clinical record review, the facility failed to document a discharge to the hospital in the clinical record for one of 21 residents, Resident #12. The Findings Include: Resident #12 was admitted with diagnosis that included: Dementia, Hypotension, dysphagia, peripheral vascular disease, and depression. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 2/25/22. Resident #12 was assessed with a cognitive score of 10 indicating moderately cognitively intact. On 4/19/22 Resident #12's medical record was reviewed. The MDS list indicated Resident #12 had been discharged to the hospital on 3/15/22. Review of the progress notes dated 3/15/22 indicated Resident #12 was found in bed with . medium amount of coffee ground emesis A nursing note dated 3/16/22 documented, Resident returned from the hospital There were no other progress notes or discharge notes indicating why Resident #12 had gone to the hospital. On 04/20/22 at 10:19 a.m. registered nurse (RN #2) reviewed Resident #12's medical record 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, clinical record review and facility document review, the facility staff failed to ensure admission orders for the immediate care and services of a central line catheter for one of 21 residents in the survey sample, Resident #230. Findings include: Resident #230 was admitted with diagnoses that included, but were not limited to: BPH (benign prostatic hypertrophy) with urinary retention, indwelling Foley catheter, urinary tract infection, entercolitis, C-Diff (clostridium difficile) infection, PVD (peripheral vascular disease), dementia, high blood pressure and bacteremia (infection in the blood). The resident's admission MDS (minimum data set) was still in progress. Resident #230's nursing admission assessment dated [DATE] documented, that the resident had dementia with cognitive deficits (unable to answer to place, time and situation). This admission assessment did not include the presence of a central line for Resident #230. Resident #230's hospital Discharge summary 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, staff interview and clinical record review the facility staff failed to ensure a baseline care plan for a central venous access catheter was completed for one of 21 residents in the survey sample, Resident #230. Findings include: Resident #230 was admitted with diagnoses that included, but were not limited to: BPH (benign prostatic hypertrophy) with urinary retention, indwelling Foley catheter, urinary tract infection, entercolitis, C-Diff (clostridium difficile) infection, PVD (peripheral vascular disease), dementia, high blood pressure and bacteremia (infection in the blood). The resident's admission MDS (minimum data set) was still in progress. Resident #230's nursing admission assessment dated [DATE] documented, that the resident had dementia with cognitive deficits (unable to answer to place, time and situation). This admission assessment did not include the presence of a central line for Resident #230. Resident #230's hospital Discharge summary dated [DATE] documented the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and clinical record review, the facility staff failed to provide pain management for 1 of 21 residents in the survey sample, Resident #14. Resident #14 was not administered scheduled Lidocaine 4% patches for 4 consecutive days. The findings include: Resident #14 was admitted to the facility with diagnoses including chronic pain syndrome, gastro-esophageal reflux disease (GERD), glaucoma, hypo-osmoliaty, hyponatremia, major depressive disorder, anxiety disorder, hypertension, and joint pain (knees and hands). The most recent MDS dated [DATE] was a quarterly assessment and assessed Resident #14 as cognitively intact for daily decision making with a score of 15 out of 15. Resident #14 was interviewed on 04/19/2020 at 12:11 p.m. Resident #14 stated there had been 3 to 4 days when the scheduled Lidocaine pain patches were not available for administration. Resident #14 stated, I get 3 of the same patches a day on my knees and shoulder because I have joint pain. From my…

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 develop a dementia care plan for 1 of 21 in the survey sample, Resident #13. Resident #13 who was diagnosed with dementia without behavioral disturbance did not have a dementia specific care plan including person centered interventions. The findings include: Resident #13 was admitted to the facility with diagnoses that included major depressive disorder, hypertension, type 2 diabetes, atrial fibrillation, dementia without behavioral disturbance, hypothyroidism, hyperlipidemia, dysphasia, and muscle weakness. The most recent minimum data set (MDS) dated [DATE] was a significant change and assessed Resident #13 as severely cognitively impaired with a score of 3 out of 15, having fluctuating periods of inattention and disorganized thinking; and wandering. The MDS documented in Section V- Care Area Assessments (CAA) that Resident #13 should be care planned for Dementia. Resident #13's clinical record was reviewed on 04/20/2022 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.

Based on observation, staff interview, and facility document review, the facility staff failed to ensure medications and biologicals were dated when opened on two of 4 units, Town Square and The Gardens. On the Peaks unit, facility staff failed to ensure an expired medication was not available for administration. A bottle of oral vancomycin (an antibiotic) was dated as do not use beyond 4/18/22 was still in the medication refrigerator. Findings include: On 4/20/22 beginning 8:00 a.m. the medication storage inspection was conducted in the facility. On the Town Square unit, the medication refrigerator was inspected with RN (registered nurse) # 4. An vial of tuberculin skin test solution was open with no date recorded on the box or the vial. RN # 4 stated I'm pretty sure that was opened last Wednesday when we sent a patient out .do you want me to date it now? RN # 4 was advised to do whatever the facility policy or procedure was. The medication refrigerator on Peaks unit was inspected with RN # 5. A bottle of vancomycin was observed in the refrigerator with a red label dated 4/18/22…

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 have an physician's order for a therapeutic diet for Resident #13. Resident #13's clinical record did not document a nutrition/diet order upon readmission from the hospital. The findings include: Resident #13 was admitted to the facility with diagnoses that included major depressive disorder, hypertension, type 2 diabetes, atrial fibrillation, dementia without behavioral disturbance, hypothyroidism, hyperlipidemia, dysphasia, and muscle weakness. The most recent minimum data set (MDS) dated [DATE] was a significant change and assessed Resident #13 as severely cognitively impaired with a score of 3 out of 15, having fluctuating periods of inattention and disorganized thinking; and wandering. The MDS documented in Section V - Care Area Assessments (CAA) that Resident #13 should be care planned for nutritional needs. Resident #13's electronic health record (EHR) was reviewed on 04/20/2022. A review of EHR and order summary report did…

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, the facility staff failed to ensure professional standards of practice by a hospice provider for 1 of 21 residents in the survey sample, Resident #35. Records of weekly hospice visits for Resident #35 were not provided to the facility as required in the hospice services agreement. The findings include: Resident #35 was admitted to the facility with diagnoses that included anxiety disorder, cirrhosis of the liver, hepatic failure, congestive heart failure, stage 3 kidney disease, type 2 diabetes, hyperlipidemia, and encounter for palliative care (hospice). The most recent minimum data set (MDS) dated [DATE] was a quarterly and assessed Resident #35 as moderately impaired for daily decision making with a score of 11 out of 15. Under Section O - Special Programs and Treatments, the MDS documented Resident #35 was receiving hospice care. Resident #35 was interviewed on 04/19/2022 at 11:30 a.m. regarding the quality of care and quality 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 clinical record review and staff interview, facility staff failed to obtain physician orders for the immediate care of a wound vac for one of 22 residents, Resident #89. Findings were: Resident #89 was admitted to the facility on [DATE] with the following diagnoses including but not limited to: Left hip fracture, malignant neoplasm of the bone, COPD (chronic obstructive pulmonary disease), dysphagia, and pain. He died at the facility on [DATE]. A five day MDS (minimum data set) assessment was completed with an ARD (assessment reference date) of [DATE]. Resident #89 was assessed as cognitively intact with a cognitive summary score of 15. The clinical record was reviewed on [DATE]. On [DATE] the following nursing note was written: Pt [patient] arrived by [name of transport company] via stretcher at 1420 [2:20 p.m.] Pt moved to bed .on 4 L NC [liters nasal cannula] .skilled for left hip fracture. Wound vac on and running . A physician's order dated [DATE] contained the following information: Wound vac.…

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 interview, the facility staff failed to develop a baseline care plan for two of 21 residents. Resident #89 was admitted to the facility with a wound vac and a port-a-cath, and Resident #85 was admitted with a wound vac. A baseline care plan for the devices was not developed for either resident. Findings were: 1. Resident #89 was admitted to the facility on [DATE] with the following diagnoses including but not limited to: Left hip fracture, malignant neoplasm of the bone, COPD (chronic obstructive pulmonary disease), dysphagia, and pain. He died at the facility on [DATE]. A five day MDS (minimum data set) assessment was completed with an ARD (assessment reference date) of [DATE]. Resident #89 was assessed as cognitively intact with a cognitive summary score of 15. The clinical record was reviewed on [DATE]. On [DATE] the following nursing note was written: Pt[patient] arrived by [name of transport company] via stretcher at 1420 [2:20 p.m.] Pt moved to bed .on 4 L NC…

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 develop a comprehensive care plan for two of 22 residents in the survey sample. Resident #62 had no plan of care regarding use of a mitten and Resident #85 had no care plan regarding wound vacuum treatment. The findings include: 1. Resident #62 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #62 included chronic kidney disease, cerebral infarction with right side hemiplegia, atrial fibrillation, high blood pressure, hyperlipidemia, constipation, depression and vascular dementia with behavioral disturbance. The minimum data set (MDS) dated [DATE] assessed Resident #62 with severely impaired cognitive skills and as requiring the extensive assistance of one person for dressing. On 10/23/19 at 9:00 a.m., Resident #62 was observed seated in the day area in a Broda chair. The resident had a purple mitten on her right hand with her right hand and forearm positioned on a pillow.…

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 review and revise a comprehensive care plan for one 22 residents, Resident #86. Interventions regarding the use of a PICC (Peripherally Inserted Central Catheter) line and the administration of IV (intravenous) antibiotics were not removed from the care plan when they were discontinued. Findings were: Resident #86 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: Bacteremia, cellulitis of left lower limb, atrial fibrillation, hypertension, chronic ulcer of left lower limb, and type II diabetes mellitus. The admission MDS (minimum data set) with an ARD (assessment reference date) of 09/18/2019, assessed Resident #86 as cognitively intact with a summary score of 13. On 10/22/2019 at approximately 2:00 p.m., Resident #86 was interviewed. She stated that she came to the facility due to sepsis and cellulitis. She stated, I had it in my left leg and it was resolving…

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, the facility staff failed to accurately assess, obtain informed consents and attempt alternatives prior to the use of bed rails for two of 22 residents in the survey sample. Residents #11 and #62 had bed rails in use with conflicting safety assessments, no prior attempted alternatives and without informed consent from their responsible parties. The findings include: 1. Resident #62 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #62 included chronic kidney disease, cerebral infarction with right side hemiplegia, atrial fibrillation, high blood pressure, hyperlipidemia, constipation, depression and vascular dementia with behavioral disturbance. The minimum data set (MDS) dated [DATE] assessed Resident #62 with severely impaired cognitive skills and as requiring the extensive assistance of one person for bed mobility. On 10/22/19 at 3:00 p.m., Resident #62 was observed in bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to ensure one of 22 residents was free from unnecessary medication. Resident #62 had a prn (as needed) physician's order for the anti-anxiety medication Lorazepam in place for over 14 days without a documented rationale and specified duration. The findings include: Resident #62 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #62 included chronic kidney disease, cerebral infarction with right side hemiplegia, atrial fibrillation, high blood pressure, hyperlipidemia, constipation, depression and vascular dementia with behavioral disturbance. The minimum data set (MDS) dated [DATE] assessed Resident #62 with severely impaired cognitive skills. Resident #62's clinical record documented a physician's order dated 1/31/19 for Lorazepam 0.5 mg (milligrams) to be administered every four hours as needed for treatment of anxiety and restlessness. A pharmacy recommendation to the physician 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.