Springtree Healthcare & Rehab Center

Based on observation, staff interview and clinical record review, the facility staff failed to provide care and services as ordered by the primary care physician for one (1) of 32 residents in the survey sample (Resident # 46). The findings include: For resident # 46, the facility staff failed to ensure water flushes were delivered according to the physician's order through the PEG (percutaneous endoscopic gastrostomy) tube. Resident # 46's diagnoses include but are not limited to dysphagia following a cerebrovascular accident, hemiplegia, hemiparesis, unspecified protein-calorie malnutrition, and unspecified heart failure. Resident # 46's minimum data set (MDS) assessment with an assessment reference date of 3/26/24 indicated that resident was severely cognitively impaired and is rarely or never understood. On 5/21/24 at 4:14 PM this surveyor observed resident lying in bed with tube feeding pump at bedside. Surveyor noted that the pump was running and was set to deliver 250 milliliters (mls) of water every 4 hours. Resident # 46 was not interviewable. The medical record was…

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

Based on observation, resident interview, clinical record review and facility document review, the facility staff failed to administer oxygen according to the attending medical provider's orders for 1 of 32 sampled residents, Resident #44. The findings include: For Resident #44 (R44) the facility staff failed to administer oxygen per the medical provider orders at 4 liters per minute via nasal cannula. Diagnoses for R44 included but were not limited to, heart failure, acute and chronic respiratory failure with hypoxia, obstructive sleep apnea, and morbid severe obesity due to excess calories. The most recent minimum data set (MDS) assessment with an assessment reference date of 5/7/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15, indicating intact cognition. On 05/21/24 at 4:30 PM, surveyor observed R44 in a wheelchair in the dining room receiving oxygen (02) with a nasal cannula via a portable 02 tank that was observed to be on three (3) liters of oxygen. On 05/22/24 at 1:17 PM, surveyor observed R44 lying in bed and observed resident to be…

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 document review, the facility staff failed to ensure provider ordered medications were available for administration for 1 of 27 current sampled residents, Resident #94 and failed to ensure nursing staff correctly implemented the facility scheduled/control monitoring system for 1 of 6 medication carts, the 400-hall medication cart. The findings included: 1. The facility staff failed to ensure Resident #94's provider ordered narcotic pain medication Oxycodone was available for administration. Resident #94's clinical record included the diagnoses, malignant neoplasm of bronchus of lung, chronic obstructive pulmonary disease, muscle weakness, and cirrhosis of liver. Section C (cognitive patterns) of Resident #94's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 03/12/24 included a brief interview for mental status (BIMS) score of 15 out of a possible 15 points. Resident #94's comprehensive care plan included the focus area at risk for pain. Interventions included…

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 document review, the facility staff failed to ensure residents are free of significant medication errors for 2 of 32 sampled residents, Resident #314 and #62. The findings included: 1. For Resident #314, the facility staff failed to follow medical provider orders for the administration of the medications, Diltiazem, Metoprolol Tartrate, and Midodrine on 2/15/24 and 2/16/24. Diltiazem and Metoprolol Tartrate are antihypertensives and Midodrine is used to treat low blood pressure. Resident #314's diagnosis list indicated diagnoses, which included, but not limited to Pneumonia, Generalized Muscle Weakness, Protein Calorie Malnutrition, Essential Hypertension, and Gastro-Esophageal Reflux Disease. Resident #314's minimum data set (MDS) with an assessment reference date (ARD) of 1/17/24 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 indicating the resident was cognitively intact. The resident's provider orders included orders dated 2/09/24 for Diltiazem 60 mg by mouth one time a…

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

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide laboratory services to meet the needs of the resident for 1 of 32 sampled residents, Resident #314. The findings included: For Resident #314, the facility staff failed to obtain a urinalysis as ordered by the medical provider on 2/13/24. Resident #314's diagnosis list indicated diagnoses, which included, but not limited to Pneumonia, Generalized Muscle Weakness, Protein Calorie Malnutrition, Essential Hypertension, and Gastro-Esophageal Reflux Disease. Resident #314's minimum data set (MDS) with an assessment reference date (ARD) of 1/17/24 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 indicating the resident was cognitively intact. Resident #314 was assessed by the facility family nurse practitioner (FNP) on 2/13/24, the progress note read in part .[adult child] reports last night patient showing signs of UTI [urinary tract infection] and was reportedly hallucinating today, patient denies acute issues when asked about…

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 document review, the facility staff failed to meet the needs of a resident in regard to the timeliness of providing radiology services for 1 of 32 sampled residents, Resident #44. The findings include: For Resident #44 (R44) the facility staff failed to obtain radiology services timely, per the medical providers orders, on 1/19/24 and on 2/13/24. Diagnoses for R44 included but were not limited to, heart failure, acute and chronic respiratory failure with hypoxia, obstructive sleep apnea, and morbid severe obesity due to excess calories. A review of R44's clinical record revealed physician's orders that included an order dated, 1/19/24, that read in part, .cxr (chest x-ray) d/t (due to) worsening cough. [sic] s/p (status post) treatment for PNA (Pneumonia) 1/19 [sic] .end date 1/22/24 . A physician's order dated, 2/13/24, revealed, .CXR 2/13 [sic] .end date 2/16/24 . A review of R44's Radiology Result Reports revealed the chest x-ray that was ordered on 1/19/24 was not completed until 1/23/24 and a Radiology Result Report…

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 document review, the facility staff failed to support the nutritional well-being for 4 of 27 current samples residents (R 89, R 76, R 411, R 412), of the facility with a nourishing, well-balanced diet. The findings include: The facility staff failed to support the nutritional well-being for residents of the facility with a nourishing well-balanced diet, by not serving an adequate amount of ham salad as indicated on the corporate recipe. On 5/21/24 at 5:43 PM, Resident #89 (R 89), asked surveyor to look at her ham salad sandwich on her dinner tray. R 89 removed the top slice of bread from the sandwich and surveyor observed a minimal amount of ham salad on the bottom slice of bread. The ham salad appeared as a flat smear that was approximately the size of a teaspoon. R 89 stated she didn't think it was even a teaspoon amount. Surveyor asked R89's roommate, Resident #76 (R 76), if she could observe her ham salad sandwich. R 76' s' ham salad sandwich was observed to have a minimal amount of ham salad on the bottom…

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 and staff interview, clinical record review and facility document review, the facility staff failed to follow physician orders for 1 of 8 (eight) residents reviewed, Resident #1. The findings were: For Resident #1, facility staff failed to administer Timolol eye drops as directed by provider order. Timolol eye drops treat glaucoma (an eye condition which can damage the optic nerve). Resident #1's facesheet listed diagnoses which included but were not limited to, fracture of left femur, difficulty walking, gout, and glaucoma. A quarterly minimum data set with an assessment reference date of 06/16/23 assigned the resident a brief interview for mental status score of 15 out of 15 in Section C, cognitive patterns. This surveyor interviewed Resident #1 on 02/20/24 at 11:45 a.m. The resident reported it had been 5 days since she received her eye drops and stated, They keep saying they should be here tomorrow. Later the same day, Resident #1 clarified the eye drop she had not been receiving was the one administered in the mornings. Resident #1's clinical record was…

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

Based on resident interview, staff interview, and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for 1 of 8 (eight) residents reviewed, Resident #1. The findings were: For Resident #1, facility staff failed to accurately document Timolol eye drops were unavailable for administration and instead, documented the medication was administered. Timolol eye drops treat glaucoma (an eye condition which can damage the optic nerve). Resident #1's facesheet listed diagnoses which included but were not limited to, fracture of left femur, difficulty walking, gout, and glaucoma. A quarterly minimum data set with an assessment reference date of 06/16/23 assigned the resident a brief interview for mental status score of 15 out of 15 in Section C, cognitive patterns. This surveyor interviewed Resident #1 on 02/20/24 at 11:45 a.m. The resident reported it had been 5 days since she received her eye drops. Later the same day, Resident #1 clarified the eye drop she had not been receiving was the one administered in the mornings. Resident #1's clinical…

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 provide treatment and care in accordance with the comprehensive person-centered care plan and physician's orders for 8 of 34 residents in the survey sample, Resident #109, #113, #316, #317, #318, #167, #216, and #41. 1. For Resident #109, the facility staff failed to administer medications as ordered by the medical provider and failed to treat a wound to the chest for five days following admission. Resident #109's diagnosis list indicated diagnoses, which included, but not limited to Neuropathy, Muscle Weakness, Cardiogenic Shock, Laceration to Left Front Wall of Thorax, Pericardial Effusion, Cardiac Tamponade, Hypovolemic Shock, and Low Back Pain. The most recent admission minimum data set (MDS) with an assessment reference date (ARD) of 5/22/23 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively…

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 CMS report the facility staff failed to ensure the services of a registered nurse for at least 8 consecutive hours per day on 6 dates in one fiscal quarter. The PBJ (payroll based journal) staffing data report for January 1-March 31 2022 listed 8 dates with no RN hours reported. The surveyor reviewed the daily staffing sheets for those dates with the director of nursing. On 2 of those dates, 2/6/22 and 2/26/22, a registered nurse supplied by an agency worked 7AM-7PM. On the remaining dates (1/29/22, 2/5/22, 2/19/22, 2/20/22, 3/5/22, and 3/19/22) no registered nurse worked in the facility. The administrator and director of nursing were made aware of the concern during a summary meeting on 6/8/23.

Based on observation and staff interview, the facility staff failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The findings included: During a tour of the facility kitchen on 6/5/23 at 2:06 PM, the surveyor noted 4 containers of expired food in the walk- in cooler. The first container was a 5 pound container of sour cream with an expiration date of 3/23/23. The clear plastic film covering the opening was intact indicating it had not been used. The second container was a 5 pound container of cottage cheese with an expiration date of 3/21/23. The clear plastic film covering the opening was intact. The third container was a 5 pound container of cottage cheese with an expiration of 4/22/23. The clear plastic film was intact. The fourth was a 5 pound container of cottage cheese with an expiration of 2/12/23, the clear plastic film was intact. Surveyor interviewed the Dietary Manager who had no knowledge of the expired food and stated that it was their first day on the job. They informed the surveyor that there had 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 resident interview, staff interview, clinical record review and facility document review, the facility staff failed to provide advanced written notice of room or roommate change for one of 34 residents in the survey sample, resident #76. The findings included: Resident #76 was moved to a different room on a different unit in April 2022 without being notified of the room move in advance or in writing. Resident #76's annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 9/17/22 had assigned them a brief interview for mental status (BIMS) score of 15, indicating they were cognitively intact. The most recent MDS assessment with an ARD of 5/24/23 had not assessed cognitive status, but did indicate there had not been a change in cognition. Resident was noted by surveyor to be alert, oriented to self, time and place. Surveyor interviewed resident #76 on 6/6/23 at 8:13 AM. They stated that they were moved to their current room about a year ago. Resident #76 stated, they just came in there and started grabbing up my stuff and carrying it out the door. I…

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 facility staff failed to ensure the correct code status was ordered for 3 of 34 records reviewed (Resident #41, #22, 318). The findings were: 1. For Resident #41, the facility staff failed to ensure their Do Not Resuscitate (DNR) preference was accurately ordered by a provider. Resident #41's admission record listed diagnoses to include but not limited to pain in left hip, severe protein-calorie malnutrition, esophagitis, major depressive disorder, diaphragmatic hernia, gastrointestinal hemorrhage, gastrostomy, and dysphagia. Resident #41's minimum data set with an assessment reference date of 4/11/23 coded the resident's brief interview for mental status summary score a 15 out of 15. Resident #41's clinical record contained a Durable Do Not Resuscitate Order document dated 10/06/22, signed by Resident #41 and one of the facility's nurse practitioners (NP #1). The document had two areas where a check was required to indicate the choice. The first area 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 clinical record review, facility document review and staff interview, the facility staff failed to notify the resident physician of a change in condition for one of 34 residents in the survey sample. The findings include: For resident #366, the facility staff failed to notify the attending physician of a fall that occurred 10/24/22. Resident #366's diagnoses included, but were not limited to an unspecified fracture of the neck, muscle weakness and hypertension. Resident #366's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/22, assigned them a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating they were cognitively intact. The MDS had the resident coded as requiring extensive assistance of one person for bed mobility, transfers, walking and toileting. Review of resident #366's clinical record revealed a progress note labeled, late entry for 10/24/22 at 10:10 PM that read, Writer called to room by assigned CNA (Certified Nursing Assistant). Upon entering room CNA was attempting to transfer resident to bed when resident's foot…

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, family interview, clinical record review and facility document review the facility staff failed to complete a comprehensive minimum data set (MDS) assessment after a significant change in status for one of 34 residents, Resident #29. The findings included: For Resident #29 the facility staff failed to complete a significant change MDS after resident was admitted to hospice services. Resident #29's face sheet listed diagnoses which included but not limited to chronic obstructive pulmonary disease, atrial fibrillation, anemia, and dementia. Resident #29's most recent MDS with an assessment reference date of 05/25/23 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Section O, Special Treatments, Procedures, and Programs had no areas marked. This is quarterly MDS assessment. Resident #29's comprehensive care plan was reviewed and contained no care plan related to hospice/end of life care. Resident #29's clinical record was reviewed 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 staff interview and clinical records review facility staff failed to implement a baseline care plan within 48 hours of admission to address the resident's care needs for one of 34 records in the survey sample. (Resident #171) Resident #171 was admitted with post-surgical malabsorption, protein-calorie malnutrition, and generalized weakness. On the Minimum Data Set assessment with assessment reference date 6/5/23, the resident scored 14/15 on the Brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. On 6/5/23, the surveyor observed the resident with total parenteral nutrition administered through a central line at 63 cc/hour. Orders to change the central line weekly had been entered in the clinical record. There was no admission [DATE]) weight. The resident weighed 98 lbs on 6/5/23. A dietary note dated 6/5/23 documented BMI 15.2 with ideal body weight 135. The resident's baseline care plan initiated 6/3/2023 for a 6/1/2023 admission…

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 staff failed to develop a comprehensive care plan for 2 of 34 residents, Resident #26 and Resident #76. The findings included: 1. For Resident #26 the facility staff failed to develop a care plan for hospice services. Resident #29's face sheet listed diagnoses which included but not limited to chronic obstructive pulmonary disease, atrial fibrillation, anemia, and dementia. Resident #29's most recent MDS with an assessment reference date of 05/25/23 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Section O, Special Treatments, Procedures, and Programs had no areas marked. This is quarterly MDS assessment. Resident #29's comprehensive care plan was reviewed and contained no care plan related to hospice/end of life care. Resident #29's clinical record was reviewed and contained a physician's order summary, which read in part 4/28/2023 Hospice consult. One time only for hospice consult for 5 days 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 clinical record review, facility document review and staff interview, the facility staff failed to provide services that meet professional standards of quality following a fall for one of 34 residents in the survey sample, resident #366. The findings include: For resident #366, the facility staff failed to perform a physical assessment, notify the physician and update the care plan after a fall on 10/24/22. Resident #366's diagnoses included, but were not limited to an unspecified fracture of the neck, muscle weakness and hypertension. Resident #366's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/22, assigned them a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating they were cognitively intact. The MDS had the resident coded as requiring extensive assistance of one person for bed mobility, transfers, walking and tilting. Review of resident #366's clinical record revealed a progress note labeled late entry for 10/24/22 at 10:10 PM that read, Writer called to room by assigned CNA (Certified Nursing Assistant). Upon entering…

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 document review, the facility staff failed to ensure each resident receives adequate supervision and assistive devices to prevent accidents for one of 34 sampled residents (Resident # 76). The findings include: For resident #76, the facility staff failed to ensure resident #76 had the assistance of two staff members during a transfer using a mechanical lift, causing them to fall. Resident #76's diagnoses included but were not limited to, spinal stenosis of the lumbar region, severe morbid obesity and chronic pain. The annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 5/24/23 did not assess resident #76's cognition, but prior assessments were coded them as being cognitively intact and during multiple interviews with surveyor, resident #76 was oriented to person , place, time and situation. The most recent MDS is coded to indicate that resident #76 requires extensive assistance of two or more with transfers. On 6/6/23 at 8:19 AM resident #76 reported to the surveyor that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure that a resident who needs respiratory care, is provided such care consistent with professional standards of practice for 1 of 34 residents in the survey sample, Resident #320. The findings included: For Resident #320, the facility staff administered oxygen without a physician's order. Resident #320's diagnosis list indicated diagnoses, which included, but not limited to Metabolic Encephalopathy, Acute Pulmonary Edema, Sepsis, Emphysema, Acute Respiratory Failure, Acute on Chronic Diastolic Heart Failure, and Generalized Muscle Weakness. The Medicare 5-Day minimum data set (MDS) with an assessment reference date of 6/05/23 assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 indicating the resident was moderately cognitively impaired. Resident #320 was coded as receiving oxygen while a resident within the last 14 days. On 6/05/23 at 4:08 pm 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 resident interview, clinical record review, and staff interviews the facility staff failed to ensure that pain management was provided for a resident in accordance with professional standards, and the resident's preferences for one of 34 residents, Resident #41. The findings were: For Resident #41, the facility failed to administer scheduled pain medication according to orders, or within acceptable time frames. The medication was available in the Omnicell. Resident #41's admission record listed diagnoses to include but not limited to pain in left hip, severe protein-calorie malnutrition, esophagitis, major depressive disorder, diaphragmatic hernia, gastrointestinal hemorrhage, gastrostomy, and dysphagia. Resident #41's minimum data set with an assessment reference date of 4/11/23 coded the resident's brief interview for mental status summary score a 15 out of 15. The residents care plan included a focus area that read the resident was at risk for pain related to left hip pain. Interventions included: administer medications as ordered, observe for physical indicators 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 staff interview, facility document review and clinical records reviews facility staff failed to ensure sufficient nursing staff to assure resident safety and maintain the highest practicable well-being for one of two nursing units. (Unit 1) During the survey, surveyors investigated 3 complaints alleging there was not sufficient staff to provide care as needed. Two directly addressed medication administration. Review revealed that on 9/23/22, three of 7 nurses scheduled to work that day shift called out. The resident named in the complaint (Res #167) received medications scheduled for 8 or 9 AM at 13:30. The ombudsman and the nurse practitioner verified the complainant's allegation. The administrator and director of nursing were made aware of the concern during a summary meeting on 6/8/23.

Based on staff interview and clinical record review the facility staff failed to ensure 2 of 34 residents were free from significant medication error. The findings included: 1. For Resident #26 the facility staff administered the antihypertensive medications metoprolol and amlodipine outside of the physician ordered parameters. Resident #29's face sheet listed diagnoses which included but not limited to chronic obstructive pulmonary disease, atrial fibrillation, and hypertension. Resident #29's most recent MDS with an assessment reference date of 05/25/23 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #29's comprehensive care plan was reviewed and contained a care plan for The resident has potential for altered cardiovascular status r/t (related to) HLD (hyperlipidemia, HTN (hypertension). Resident #29's clinical record was reviewed and contained a physician's order summary, which read in part Metoprolol Tartrate Tablet 25 mg. Give 1 tablet by mouth…

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 family interview, staff interviews, and clinical record review facility staff failed to maintain an effective infection control and prevention program for one of 34 residents (Resident #22) The findings were: For Resident #22, the facility staff failed to initiate transmission-based precautions (TBP) when concern for C-diff was identified. Resident #22's admission record listed diagnoses to include, but not limited to, pain due to internal orthopedic prosthetic devices, morbid obesity, protein-calorie malnutrition, anxiety disorder, major depressive disorder, chronic kidney disease stage 3, and type 2 diabetes mellitus. Resident #22's minimum data set with an assessment reference date of 5/11/23 coded the resident's brief interview for mental status summary score a 15 out of 15. Prior to meeting any residents on Unit 1's 100 hallway on 6/05/23, the surveyor asked the Unit 1 staff whether any resident was on TBP. The staff denied anyone being on transmission-based precautions. No TBP notifications on residents' doors or carts with personal protective…

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

Based on observation and staff interview the facility staff failed to maintain dignity for 1 of 19 residents, Resident #48. The findings included: For Resident #48 the facility staff failed to maintain dignity as evidenced by a posting above resident's bed reading She is a feeder!! Resident #48's face sheet listed diagnoses which included but not limited to dementia, hypertension, atrial fibrillation, depression, and anxiety. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 02/25/21 assigned the resident a BIMS (brief interview for mental status) score of 5 out 15 in section C, cognitive patterns. Section G, functional status coded the resident as needing extensive assistance of one person in the area of eating. Resident #48's comprehensive care plan was reviewed and contained a care plan for The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) deconditioning and gait/balance issues, feeding assistance. The interventions for this care plan included Eating: The resident is a feeder 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 staff interview and clinical record review, facility staff failed to ensure residents with pressure ulcers receive necessary treatment and services to promote healing as evidenced by failure to initiate wound treatment for 1 of 19 residents, Resident #51. The findings included: For Resident #51, the facility staff failed to initiate treatment to a SDTI (suspected deep tissue injury) to the left great toe noted on readmission on [DATE]. Resident #51's diagnosis list indicated diagnoses, which included, but not limited to COVID-19, Pneumonia Unspecified Organism, Unspecified Diastolic (Congestive) Heart Failure, Permanent Atrial Fibrillation, Acute Respiratory Failure Unspecified Whether with Hypoxia or Hypercapnia, and Toxic Liver Disease with Hepatic Necrosis without Coma. The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of 2/15/21 assigned the resident a BIMS (brief interview for mental status) score of 11 out of 15 in section C, Cognitive Patterns. Resident #51…

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, facility staff failed to ensure the resident environment remains as free of accident hazards as is possible as evidenced by the presence of an unsecured oxygen cylinder located in the hallway on 1 of 2 facility units, Unit 1. The findings included: The facility staff failed to secure a portable oxygen cylinder on Unit 1 that remained one half full of oxygen. On 3/23/21 at 3:57 pm, surveyor #1 observed an unsecured portable oxygen cylinder located in the hallway of the COVID-19 isolation unit placed against the wall and touching a three-drawer plastic caddy containing PPE (personal protective equipment) supplies on one side and the bristles of a broom on the other side. The portable oxygen cylinder included an attached [NAME] Integrated Valve. No residents were in the hallway at the time of the observation. At 4:05 pm, surveyor spoke with CNA (certified nursing assistant) #1 who stated the oxygen cylinder may have come off the back of a…

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

Based on observation, staff interview, clinical record review, and facility document review, facility staff failed to ensure a resident who is fed by enteral means receives the appropriate treatment to prevent complications as evidenced by failure to label and date tube feeding formula for 1 of 19 residents, Resident #67. The findings included: For Resident #67, facility staff failed to label and date tube feeding formula being administered on 3/23/21. Resident #67's diagnosis list indicated diagnoses, which included, but not limited to Parkinson's Disease, Pneumonitis due to Inhalation of Other Solids and Liquids, Gastrostomy Status, Dysphagia Oropharyngeal Phase, and COVID-19. The most recent 5 day MDS (minimum data set) with an ARD (assessment reference date) of 3/08/21 assigned the resident a BIMS (brief interview for mental status) score of 5 out of 15 in section C, Cognitive Patterns. In section K, Swallowing/Nutritional Status, Resident #67 was coded as receiving 51% or more total calories received through parenteral or tube feeding and 501 cc/day or more of average fluid…

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 properly store medications in locked compartments on 1 of 2 facility units, Unit 1. The findings included: On 3/24/21 at 2:50 pm, surveyor observed an unattended medication cart in the hallway of Unit 1 located in the plastic zippered area of the COVID-19 observation area between resident rooms (number omitted) and (number omitted). On top of the medication cart were eight (8) blister pack cards of medications. Surveyor remained beside the medication cart until 2:55 pm when LPN (licensed practical nurse) #1 entered through a plastic zippered divider wall from the COVID isolation area. LPN #1 stated I just came back from break and someone delivered them. Surveyor asked LPN #1 if the medications were delivered from the pharmacy and LPN #1 stated yes. In the direct presence of LPN #1, surveyor observed one blister pack card of Metformin HCL 500 mg (an antidiabetic used to treat diabetes) containing 30 tablets and seven (7) blister pack cards of Methocarbamol 500 mg (a skeletal muscle…

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.