Mountain Laurel Rehabilitation And Nursing

2. For Residents #6, #21, #32, #34, and #50 Licensed Practical Nurse (LPN) #15 documented they were unable to complete provider orders due to increased patient load. A review of Resident #21's clinical record revealed that on 02/19/25 at 7:41 p.m. LPN #15 documented they were unable to complete due to increased patient load. This note did not reference what the nursing staff was not able to complete and during the clinical record review the surveyor was unable to find any medication and/or treatment that had been coded as being incomplete. This note type was identified in the clinical record as being a medication administration note. Resident #21 was not interviewable. On 04/07/25 at 9:34 a.m., the surveyor requested the facility census and work assignment for this nurse for 02/19/25. The Assistant Director of Nursing (ADON) and Regional Director of Clinical Services (RDCS) were made aware of the documentation by LPN #15. The RDCS stated they were aware and stated this nurse wanted a 1:10 ratio and was on a do not return list and was no longer allowed to work at the facility. 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.

3. For Resident #9, the facility staff failed to obtain PT/INR (prothrombin time with international normalized ratio) laboratory testing as ordered by the medical provider on three (3) separate occasions. A PT/INR test measures how long it takes for blood to form a clot and is used to monitor blood-thinner treatment (anticoagulant) medications. Resident #9's diagnosis list indicated diagnoses, which included, but not limited to Chronic Atrial Fibrillation, Displaced Fracture of the Right Femur, and Osteoarthritis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 3/04/25 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 indicating the resident was cognitively intact. Resident #9's current comprehensive person-centered care plan included a focus area stating the resident was on an anticoagulant related to atrial fibrillation with an intervention for labs as ordered. Resident #9's medical provider orders included orders for Coumadin 2.5 mg by mouth every evening and in addition, 0.5 mg by mouth every Tuesday,…

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

Based on observations, staff interviews, and facility document review, the facility staff failed to: (a) store food in accordance with professional standards for food service safety and (b) failed to serve food according to menu serving size. The findings included: The facility staff failed to ensure residents refrigerated and/or frozen foods were correctly labeled and/or stored on two (2) of two (2) resident unit pantry/nutrition areas. On 4/1/25 at 2:40 p.m., the surveyor and Dietary Manager completed observations of the storage of resident food items in the [NAME] Unit pantry/nutrition area. The freezer housing resident foods contained: (a) an undated, unlabeled multi-serving vanilla ice cream container that had been opened, (b) an undated, unlabeled multi-serving cookie-dough ice cream container that had been opened, (c) a frozen individually packaged handheld filled pastry/pocket (ice crystals were noted inside the packaging; this item was removed from its box therefore it was not labeled with a use by date or an expiration date), (d) a frozen individually packaged handheld…

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

Based on observations and staff interviews, the facility staff failed to ensure proper disposal and/or containment of the facility's garbage/waste. The findings include: On 4/7/25 at 4:40 p.m., the surveyor and the Dietary Manager made observations of the garbage disposal area outside of the facility but located on the facility's campus. The following observations were noted: - The facility had two (2) dumpsters. One (1) dumpster had two (2) of its doors open; the other dumpster had one (1) of its doors open. - The following debris was noted on the ground around the dumpsters: (a) eight (8) blue medical gloves, (b) two (2) plastic drinking cups, (c) one (1) piece of foil, (d) one (1) disposable towel, (e) three (3) small medication cups, and (f) one (1) empty plastic cup which had held an individual serving of jello or pudding. On 4/7/25 at 5:00 p.m., the survey team met with the facility's Administrator, Director of Nursing, Assistant Director of Nursing, and Regional Director of Clinical Services. During this meeting, the aforementioned observations of the facility's garbage…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. For Resident #453, the facility staff failed to maintain an accurately documented clinical record by inaccurately documenting a left hip x-ray was completed on 3/9/25. Resident #453's diagnosis list indicated diagnoses that included, but were not limited to, Hypertension, Atrial Fibrillation, Diverticulosis, Macular Degeneration, Unsteadiness on Feet, Depression, Difficulty Walking, Weakness, Polyosteoarthritis, Dementia, Alzheimer's, Chronic Kidney Disease-Stage 2, and Nightmare Disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/19/25, assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A review of a medical providers orders contained an order with a start date of 3/8/25 and an end date of 3/9/25 that read in part, .Left hip X-ray one time only for Pain for 1 (one) day . A review of the MAR (medication administration record) and TAR (treatment…

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 a Quality Assurance and Performance Improvement (QAPI) Program to meet the needs of the facility and failed to monitor and revise as needed the plan of corrections for the standard recertification and abbreviated surveys dated 7/01/21 through 1/23/25, in order to maintain compliance as evidenced by repeated deficiencies in the areas of Quality of Care, Pharmacy Services, Food and Nutrition Services, and Infection Control. The findings included: The area of Quality of Care was previously cited with the 7/01/21 and 8/09/23 standard surveys and the 1/23/25 abbreviated survey for failure to follow medical provider orders. This deficiency was cited again on the current standard survey dated 4/08/25 due to facility staff failing to follow medical provider orders for 20 of 55 sampled residents. The area of Pharmacy Services was previously cited with the 7/01/21 standard survey, and the 12/04/24 and 1/23/25 abbreviated surveys due to failure to ensure provider ordered…

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

Based on staff interview and facility document review, the facility staff failed to provide quality assurance and performance improvement (QAPI) training to the facility staff. The findings include. The facility staff failed to provide QAPI training to the facility staff. During the entrance conference the team leader requested the facility assessment. This document read in part, .Staff training/education and competencies. Each job description identifies the required education and credentials for the job .Additional knowledge competencies for all staff include .QAPI . On 04/07/25 at 5:00 p.m., during an end of the day meeting with the Administrator, Regional Director of Clinical Services, Regional [NAME] President of Operations. Assistant Director of Nursing, and Director of Nursing the surveyor requested any information regarding QAPI training for the facility staff. On 04/08/25 at 8:21 a.m., the Administrator stated they were unable to find any training/education regarding their QAPI program. On 04/08/25 at 1:35 p.m., during a review of nursing assistant files for education…

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 resident interview the facility staff failed to treat resident with dignity and respect for 1 of 55 residents, Resident #1. The findings included: For Resident #1 the facility staff failed to treat the resident with dignity and respect during incontinence care. Resident #1's face sheet listed diagnoses which included but not limited to cerebral infarction, chronic kidney disease, chronic pain syndrome, and anxiety. Resident #1's most recent minimum data set with an assessment reference date of 01/10/25 assigned the resident a brief interview for mental status score of 8 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. On 04/07/25 at 9:55 am, surveyor went to speak with resident. Resident's door was observed open and lights in the room were off/dim. Surveyor knocked on the door and heard someone say come in. Surveyor entered the room and observed Resident #1's roommate lying on their bed, facing toward Resident #1. When surveyor entered the room, certified nurse's aide (CNA) #13…

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 notify the physician of a significant change in condition for 1 of 55 residents in the survey sample, resident # 74 (R74). The findings included: R74 had diagnoses that included but were not limited to diabetes, atheroclerosis, peripheral vascular disease with a left below knee amputation of leg, gastroesophageal reflux disease, essential hypertension, and major depressive disorder. The minimum data set (MDS) assessment with an assessment reference date of 3/8/25 was reviewed. Resident was coded as having a significant weight gain of 5% or more in 30 days or 10% or more in the last 6 months. R74's weight record was reviewed. On 11/05/2024, the resident weighed 127.5 pounds (lbs.) On 12/16/2024, the resident weighed 146 pounds which is a 14.51 % gain from the previous month. On 09/05/2024, the resident weighed 126.8 lbs. On 03/04/2025, the resident weighed 153 pounds which is a 20.66 % gain in 6 months. The progress notes were reviewed. The Registered Dietician had reviewed…

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

Based on observation, staff interview, resident interview, and clinical record review the facility staff failed to ensure personal privacy during activities of daily living care for 1 of 55 residents, Resident #1. The findings included: For Resident #1 the facility staff failed provide personal privacy during incontinence care. Resident #1's face sheet listed diagnoses which included but not limited to cerebral infarction, chronic kidney disease, and chronic pain syndrome. Resident #1's most recent minimum data set with an assessment reference date of 01/1025 assigned the resident a brief interview for mental status score of 8 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Section H, Bowel and Bladder, coded the resident as being frequently incontinent of urine, and occasionally incontinent of bowel. Surveyor went to speak with Resident #1 on 04/07/25 at 9:55 am. Resident #1's room door was open, and room was darkened. Surveyor knocked on resident's door, and someone said, come in. Surveyor started in room, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and facility document review the facility staff failed to permit each resident to remain in the facility and not transfer or discharge the resident for one of 14 residents in the survey sample, resident # 454 (R454). R454's diagnoses according to the facility diagnoses sheet, included but were not limited to, other seizures, chronic obstructive pulmonary disease, hypertension, anxiety, heart failure, personal history of suicidal behavior, traumatic brain injury, major depressive disorder, and vascular dementia with psychotic disturbance. R454's minimum data set (MDS) assessment with an assessment reference date of 8/28/24 assigned the resident a brief interview for mental status score of 11 out of 15 indicating moderate cognitive impairment. There was no mood indicators captured on the assessment and the only behavior identified was wandering which occurred one to three days during the lookback period. Under the section for preferences for customary routine and activities, R454…

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 interviews, clinical record review, and facility document review, the facility staff failed to ensure a resident's medication needs were addressed as part of admission orders for one (1) of 55 sampled residents (Resident #153). The findings include: The facility staff failed to ensure Resident #153's admission documentation/orders addressed the medications included as part of Resident #153's hospital discharge information. Resident #153's admission minimum data set (MDS) assessment was not due and had yet to be submitted prior to the surveyor's review of the resident's clinical record. A medical provider assessment indicated Resident #153 was alert and oriented times three (3). Resident #153 was documented as having adequate vision. Resident #153's hearing was documented as being grossly intact. Resident #153's clinical record included an Internal Medicine Discharge Summary from the local hospital; this document had a date of service of 3/26/25. This document included information about medications and/or supplements Resident #153 was to start taking and/or continue…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. For Resident #93, the facility staff incorrectly coded the 2/15/25 minimum data set (MDS) assessment for the use of anticoagulant medication. Resident #93's diagnosis list indicated diagnoses, which included, but not limited to Cerebral Infarction, Metabolic Encephalopathy, Convulsions, Unspecified Psychosis, Major Depressive Disorder, and Generalized Anxiety Disorder. The most recent MDS with an assessment reference date (ARD) of 2/15/25 assigned the resident a brief interview for mental status (BIMS) summary score of 11 out of 15 indicating the resident was moderately cognitively impaired. The 2/15/25 MDS coded Resident #93 as taking an anticoagulant medication during the last seven (7) days. Surveyor reviewed Resident #93's clinical record and was unable to locate evidence of the resident receiving an anticoagulant medication during the seven-day period prior to the 2/15/25 MDS. On 4/07/25 at 9:08 AM, surveyor spoke with the MDS Coordinator regarding the anticoagulant coding on the 2/15/25 MDS. The MDS…

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.

2. For Resident #93, the facility staff failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) was completed. Resident #93's diagnosis list indicated diagnoses, which included, but not limited to Cerebral Infarction, Metabolic Encephalopathy, Convulsions, Unspecified Psychosis, Major Depressive Disorder, and Generalized Anxiety Disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/15/25 assigned the resident a brief interview for mental status (BIMS) summary score of 11 out of 15 indicating the resident was moderately cognitively impaired. The MDS was coded for the presence of delusions and wandering behavior. Surveyor reviewed Resident #93's clinical record and was unable to locate a Level I PASARR. Resident #93 had resided at the facility for approximately five (5) months. Surveyor requested and received the facility policy titled Resident Assessment - Coordination with PASARR Program with a reviewed/revised date of 2/20/23 which read in part .1. All applicants to this facility will be screened for serious mental…

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 facility document review, the facility staff failed to complete a discharge summary including a recapitulation of resident's stay and final summary of resident's status, to the continuing care provider and other authorized persons at the time of discharge for one of 14 residents reviewed, resident # 454 (R454). The findings included: R454's diagnoses included but were not limited to, R454's diagnoses according to the facility diagnoses sheet included but were not limited to other seizures, chronic obstructive pulmonary disease, hypertension, anxiety, heart failure, personal history of suicidal behavior, traumatic brain injury, major depressive disorder, and vascular dementia with psychotic disturbance. R454's minimum data set (MDS) assessment with an assessment reference date of 8/28/24 assigned the resident a brief interview for mental status score of 11 out of 15 indicating moderate cognitive impairment. According to the clinical record, R454 was issued a 30 day discharge notice on 9/4/24 that stated, 1. The facility is unable to meet your…

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 provide an on-going person-centered activity program to support resident choice, interests, and physical, mental and psychosocial well-being for 1 of 55 residents in the survey sample, resident #454 (R454) The findings included: R454's diagnoses according to the facility diagnoses sheet, included but were not limited to, other seizures, chronic obstructive pulmonary disease, hypertension, anxiety, heart failure, personal history of suicidal behavior, traumatic brain injury, major depressive disorder, and vascular dementia with psychotic disturbance. R454's minimum data set (MDS) assessment with an assessment reference date of 8/28/24 assigned the resident a brief interview for mental status score of 11 out of 15 indicating moderate cognitive impairment. There was no mood indicators captured on the assessment and the only behavior identified was wandering which occurred one to three days during the lookback period. Under the section for preferences for customary routine and activities, R454 had many…

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 nursing staff failed to complete a provider ordered treatment to a pressure ulcer for 1 of 55 sampled residents, Resident #34. The findings include. The facility nursing staff failed to complete a provider ordered treatment to Resident #34's left buttock. This treatment was for a pressure ulcer. Resident #34's diagnoses included paranoid schizophrenia, diabetes, and chronic pain syndrome. Section C (cognitive patterns) of Resident #34's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 01/07/25 included a brief interview for mental status (BIMS) score of 9 out of a possible 15 points. Per the MDS manual a 9=moderately impaired in cognitive skills for daily decision making. Section M (skin conditions) was coded to indicate the resident was at risk for developing pressure ulcers and had no unhealed pressure ulcers. This MDS was coded to indicate Resident #34 used a pressure reducing device for chair and bed and had application of dressings to feet. Resident…

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

Based on observation, staff interview, clinical record review, and facility document review the facility staff failed to ensure resident environment remains free of accident hazards and failed to provide adequate supervision to prevent accident for 1 of 55 residents, Resident #36. The findings of included: For Resident #36 the facility staff failed to provide an environment free of accident hazards and failed to provide adequate supervision to prevent accidents. Resident #36's face sheet listed diagnoses which included but not limited to suicidal ideations, major depressive disorder, and bipolar disorder, severe, with psychotic features. Resident #36's most recent minimum data set with an assessment reference of 02/04/25 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 #36's comprehensive care plan was reviewed and contained plans for ADL (activities of daily living) self-care deficit r/t (related to) impaired mobility and weakness, The resident has 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 a therapeutic diet to one (1) of fifty-five (55) sampled residents, (Resident #454). For Resident #454, the facility staff failed to provide evidence the resident received or refused a therapeutic diet as ordered by the medical provider during evening meals on 8/21/24, 9/9/24, and 9/10/24. Resident #454's diagnosis list indicated diagnoses that included, but were not limited to, Atrial Fibrillation, Glaucoma, Seizures, Hypertension, Chronic Obstructive Pulmonary Disease, History of Falls, Dementia with Agitation, Depression, Anxiety Disorder, Heart Failure, Vascular Dementia-severe with Psychotic Disturbance, Traumatic Brain Injury, History of Suicidal Behavior, and Thyrotoxicosis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 8/28/24, assigned the resident a brief interview for mental status (BIMS) summary score of 11 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and clinical record review, the facility staff failed to provide ordered respiratory care and/or treatments for two (2) of 55 sampled residents (Resident #90 and Resident #100). The findings include: 1. The facility staff failed to ensure Resident #90's incentive spirometer was correctly ordered and/or provided. (An incentive spirometer is a handheld device used to improve lung function.) Resident #90's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of [DATE], was signed as completed on [DATE]. Resident #90 was assessed as able to make self understood and as able to understand others. Resident #90's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact or borderline cognition. Resident #90's clinical record included orders for the use of an incentive spirometer. The incentive spirometer orders were dated as being created/revised on [DATE] but scheduled to be started on [DATE] at 7:00 a.m. The incentive…

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 coordinate care with the dialysis center for 1 of 1 dialysis residents in the survey sample. Resident #255. The findings include. The facility staff failed to coordinate care with the dialysis center. The facility staff failed to obtain pre and post dialysis weights. Resident #255's diagnosis included end stage renal disease. There was no completed minimum data set assessment on this resident. This resident was alert and orientated to person and place. Resident #255's care plan included the focus area of dialysis due to end stage renal disease. Interventions included coordinate plan of care with dialysis as needed The clinical record included provider orders for dialysis 3 times a week. On 04/04/25 at 10:15 a.m., Licensed Practical Nurse (LPN) #4 provided the surveyor with a copy of their policy titled, Care Planning Special Needs-Dialysis. This policy read in part, .Interventions will include Pre-and post-weights .If no written report is received upon return from dialysis,…

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 interviews and clinical document review, the facility's medical providers failed to ensure resident's orders addressed the resident needs for two (2) of 55 residents (Resident #90 and Resident #153). The findings include: 1. A medical provider failed to identify concerns with the start date of Resident #90's incentive spirometer orders. (An incentive spirometer is a handheld device used to improve lung function.) Resident #90's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/18/25, was signed as completed on 1/30/25. Resident #90 was assessed as able to make self understood and as able to understand others. Resident #90's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact or borderline cognition. Resident #90's clinical record included orders for the use of an incentive spirometer. The incentive spirometer orders were dated as being created/revised on 3/25/25 but scheduled to be started on 4/13/25 at 7:00 a.m. The incentive spirometer orders were signed by a medical provider on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to review the resident's total program of care, including medications and treatments for one (1) of fifty-five (55) sampled residents (Resident #77). The findings include: For Resident #77 the facility staff failed to ensure the attending physician reviewed the hospital discharge summary for a hospital stay ending on 1/12/24. This lack of review of the resident's total program of care, including medications and treatments resulted in the resident not receiving a review of orders for diabetic medications essential to the resident's medical treatment and care for a diagnosis of Type 2 Diabetes Mellitus. Resident #77's diagnosis list indicated diagnoses that included, but were not limited to, Atrial Fibrillation, Morbid Obesity, Obstructive Sleep Apnea, Hypertension, Hyperlipidemia, Peripheral Vascular Disease, Edema, Polyneuropathy, Dementia-Moderate with Mood Disturbance, Adjustment…

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 the necessary health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 55 residents in the survey sample, resident # 454. The findings included: For resident # 454 (R454) the facility staff failed to involve the resident's family or hospice team in the comprehensive assessment, failed to develop a comprehensive care plan with individualized interventions, and failed to follow the care plan. R454's diagnoses according to the facility diagnoses sheet, included but were not limited to, other seizures, chronic obstructive pulmonary disease, hypertension, anxiety, heart failure, personal history of suicidal behavior, traumatic brain injury, major depressive disorder, and vascular dementia with psychotic disturbance. R454's minimum data set (MDS)…

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 medical provider ordered medications were available for administration for 3 of 55 sampled residents (Resident #354, Resident #356, and Resident #9). The findings included: 1. For Resident #354, the facility staff failed to ensure the antibiotic Rocephin (Ceftriaxone Sodium) was available for administration. Resident #354's diagnosis list indicated diagnoses, which included, but not limited to Neuropathy, Type 2 Diabetes Mellitus, Alzheimer's Disease, and Atrial Fibrillation. The minimum data set (MDS) with an assessment reference date (ARD) of 1/13/25 assigned the resident a brief interview for mental status (BIMS) summary score of 13 out of 15 indicating the resident was cognitively intact. A review of the clinical record revealed Resident #354 was seen by the medical provider on 3/03/25, the progress note read in part .Staff concerned that patient is more lethargic today .Plan: Lethargic rule out urinary tract infection. Patient has history of urinary tract…

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.

2.For Resident #86 the facility staff failed to provide evidence of the 2/24/25 medication regimen review being reported to and acted upon by the medical provider in a timely manner. Resident #86's diagnosis list indicated diagnoses that included but were not limited to Progressive Multifocal Leukoencephalopathy, Anorexia, Chronic Kidney Disease, Acute Kidney Failure, Anxiety Disorder, Repeated Falls, Ataxia, Acute Respiratory Failure with Hypoxia, and Wasting Disease Syndrome. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 3/23/25, did not assign the resident a brief interview for mental status (BIMS) summary score for cognitive abilities, but a review of the clinical record revealed resident was assigned 15 out of 15 on the BIMs, which indicated the resident was cognitively intact. Progress notes within R86's clinical record indicated medication regimen reviews (MRRs) were completed by a pharmacist on 2/24/25 and on 3/25/25 with recommendations. Surveyor was unable to locate the 2/24/25 recommendation report in the resident's clinical record.…

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

Based on staff interview, clinical record review and facility document review the facility staff failed to ensure that 1 of 55 residents was free from unnecessary medications, Resident #85. The findings included: For Resident #85 the facility staff failed to ensure that resident was free of unnecessary medications. Resident #85's face sheet listed diagnoses which included but not limited to cerebral infarction, type 2 diabetes mellitus, and hypertension. Resident #85's most recent minimum data set (MDS) with an assessment reference date of 02/24/25 assigned the resident 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 #85's comprehensive care plan was reviewed and contained a plan for The resident has Diabetes Mellitus. Interventions for this plan include Diabetes medication as ordered by doctor . Resident #85's clinical record was reviewed and contained a physician's order summary which read in part, Lantus Solution 100 unit/ml (Insulin Glargine). Inject 12 units subcutaneously…

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 (2) two of fifty-five (55) sampled residents were free from unnecessary psychotropic medications (Resident #455 and Resident #86). The findings included: 1.For Resident #455 the facility staff failed to monitor the resident for behaviors or side effects related to psychotropic medications in March 2025. Resident #455's diagnoses included diagnosis but were not limited to, Bipolar Disorder, Other Seizures, Insomnia, Chronic Kidney Disease, Borderline Personality Disorder, and Atrial Fibrillation. The MDS (minimum data set) had not been completed related to the resident being a new admission to the facility. A facility document titled, MDS Data Collection with an effective date of 3/13/25 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 indicating the resident was cognitively intact. Review of the March 2025 medication administration record (MAR) revealed Resident #455 was prescribed Effexor 150 mg (milligrams) one time a day…

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 the facility staff failed to ensure a medication error rate of less than 5%. There were two (2) medication errors in 28 opportunities for a medication error rate of 7.14%. These medication errors affected Resident #253 (R253). The findings included: R253's diagnoses included but were not limited to atrial fibrillation, heart failure, bradycardia and gastroesophageal reflux disease (GERD). On 04/02/25 at 08:13 AM during a medication pass and pour observation, this surveyor observed Licensed Practical Nurse (LPN) #13 administer R253's morning medications. LPN #13 administered Eliquis 5 mg, Entresto 24-26 mg, famotidine 10 mg, and potassium ER 20 meq. LPN #13 took R253's pulse and stated to the resident, Your pulse is 60 so I am going to hold your metoprolol. R253's physician's orders were reviewed for morning medication regimen and included; Eliquis 5 mg give one tab by mouth twice daily, famotidine (used to treat GERD) 20 mg give one tablet by mouth, metoprolol succinate ER oral tablet extended release 50 mg give one…

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 and facility document review, the facility staff failed to ensure that residents are free of any significant medication errors for (1) one of fifty-five (55) sampled residents (Resident #86). The findings included: For Resident #86, the facility staff failed to follow provider orders for the administration of the medication, Levofloxacin one time a day for infection for five days. (Levofloxacin is an antibiotic that is utilized to kill bacteria or prevent their growth in certain infections). Resident #86's diagnosis list indicated diagnoses that included but were not limited to Progressive Multifocal Leukoencephalopathy, Anorexia, Chronic Kidney Disease, Acute Kidney Failure, Anxiety Disorder, Repeated Falls, Ataxia, Acute Respiratory Failure with Hypoxia, and Wasting Disease Syndrome. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 3/23/25, did not assign the resident a brief interview for mental status (BIMS) summary score for cognitive abilities. Further review of the clinical record provided documentation 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 and staff interview, the facility staff failed to dispose of expired medications and/or biological's in 1 of 2 medication rooms, the [NAME] side medication room. The findings include. The facility staff failed to dispose of expired medication/biological's in the [NAME] side medication room. On 04/04/25 at 8:40 a.m., the surveyor and the Assistant Director of Nursing (ADON) completed an observation of the medication room on the [NAME] side. The surveyor identified 16 red top laboratory tubes with expiration dates of 12/31/24 and 11/30/24. A box of opened green top tubes with an expiration date of 03/31/25, 4 bottles of expired D3 medication with an expiration date of 03/2025, and 4 boxes of Influenza vaccine labeled 2023-2024 formula with an expiration date of 06/30/24 each box contained 10 syringes of the influenza vaccine. The ADON reviewed all these items, confirmed the items were expired, and disposed of the items. On 04/04/25 at 10:35 a.m., during a meeting with the Administrator, Director of Nursing, and Regional Director of Clinical Services the issues…

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, resident interview, clinical record review and facility document review the facility staff obtained laboratory test without a physician's order for 1 of 55 residents, Resident #85. The findings included: For Resident #85 the facility staff obtained physician ordered international normalized ratio (INR) laboratory tests more times than it was ordered. An INR is used to indicate how well the blood can clot. Resident #85's face sheet listed diagnoses which included but not limited to cerebral infarction, type 2 diabetes mellitus, and presence of prosthetic heart valve. Resident #85's most recent minimum data set with an assessment reference date of 02/24/25 assigned the resident 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 #85's comprehensive care plan was reviewed and contained a plan for The resident has altered cardiovascular status r/t (related to) HTN (hypertension), HLD (hyperlipidemia) and Mechanical aortic valve and Resident is on Anticoagulant…

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

Based on observation, staff interview, resident interview, clinical record review and facility document review the facility staff failed to provide food to accommodate the resident's preferences for 1 of 55 residents, Resident #1. The findings included: For Resident #1 the facility staff failed to honor resident's food preferences. Resident #1's face sheet listed diagnoses which included but not limited to cerebral infarction, chronic kidney disease, chronic pain syndrome, and anxiety. Resident #1's most recent minimum data set with an assessment reference date of 01/10/25 assigned the resident a brief interview for mental status score of 8 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Surveyor spoke with Resident #1 on 04/01/25 at 8:15 am. Resident was seated in bed, with breakfast tray on overbed table. Surveyor asked resident if they had a good breakfast and resident stated, I'm supposed to get boiled eggs for breakfast. I want boiled eggs every day. I have ate boiled eggs since I was a child. Surveyor observed…

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 family interview, staff interview, clinical record review, and facility document review the facility staff failed to ensure the timeliness of radiology services furnished by an agency outside the facility under an arrangement for (1) one of fifty-five (55) sampled residents (Resident #453). The findings include: For Resident #453 the facility staff failed to ensure the timeliness of radiology services furnished by an outside mobile radiology agency under an arrangement for a left hip x-ray ordered for 3/8/25. Resident #453's diagnosis list indicated diagnoses that included, but were not limited to, Hypertension, Atrial Fibrillation, Diverticulosis, Macular Degeneration, Unsteadiness on Feet, Depression, Difficulty Walking, Weakness, Polyosteoarthritis, Dementia, Alzheimer's, Chronic Kidney Disease-Stage 2, and Nightmare Disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/19/25, assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating the resident was…

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

Based on staff interviews and clinical record review, the facility staff failed to obtain the Medical Director's assistance when having trouble scheduling a surgical consult/appointment for one (1) of 55 sampled residents (Resident #55). The findings include: The facility staff failed to have the Medical Director assist with obtaining Resident #55's surgical consult to address a rectal prolapse. Resident #55's diagnoses included, but were not limited to: rectal prolapse, Barrett's Esophagus, Gastro-Esophageal Reflux Disease, and dementia. Resident #55's minimum data set (MDS), with an assessment reference date (ARD) of 12/20/24, had the resident's brief interview for mental status (BIMS) summary score documented as a 15 out of 15 (this indicated intact or borderline cognition). Resident #55 was seen by the physician assistant (PA) on 9/19/24, the progress note read in part .asked to be seen per nursing staff due to rectal bleeding and tissue protruding from rectum .Rectal exam: Rectal prolapse evident. Unable to reduce .Attempted reduction, not successful-No evidence 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 staff interview, clinical record review and facility document review, the facility staff failed to meet the requirements set forth in the Nursing Facility Services Agreement to designate a member of the nursing home's interdisciplinary team to coordinate care with the hospice provider for 1 of 55 residents in the survey sample, resident 454 (R454). The findings included: R454's diagnoses according to the facility diagnoses sheet, included but were not limited to, other seizures, chronic obstructive pulmonary disease, hypertension, anxiety, heart failure, personal history of suicidal behavior, traumatic brain injury, major depressive disorder, and vascular dementia with psychotic disturbance. R454's minimum data set (MDS) assessment with an assessment reference date of 8/28/24 assigned the resident a brief interview for mental status score of 11 out of 15 indicating moderate cognitive impairment. There was no mood indicators captured on the assessment and the only behavior identified was wandering which…

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

Based on observation, staff interview, clinical record review and facility document review the facility staff failed to follow established infection control guidelines for 1 of 55 residents, Resident #13. The findings included: For Resident #13 the facility staff failed to don proper personal protective equipment (PPE) and failed to follow infection control guidelines for the handling of trash and soiled clothing. Resident #13's face sheet listed diagnoses which included but not limited to spastic quadriplegic cerebral palsy, gastrostomy status, and dysphagia. Resident #13's most recent minimum data set with an assessment reference date of 02/07/25 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 #13's most recent minimum data set with an assessment reference date of 02/07/25 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 GG,…

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 offer a pneumococcal vaccine in accordance with nationally recognized standards for 2 of 5 residents reviewed for immunizations, Resident #47, and Resident #68. The findings included: 1. For Resident #47, the facility staff failed to offer the resident a pneumococcal conjugate vaccine 20 (PCV120) or a pneumococcal conjugate vaccine 21 (PCV20) following admission to the facility. Review of the Centers for Disease Control (CDC) guideline entitled Adult Immunization Schedule by Age-2025 read in part, Age 50 years or older who have: Previously received only PCV 13: 1 dose PCV 20 or 1 dose PCV 21 at least 1 year after the last PCV 13 dose. Resident #47's face sheet listed diagnoses which included but not limited to peripheral vascular disease, end stage renal disease, viral hepatitis, and Alzheimer's disease. Resident #47's most recent minimum data set with an assessment reference date of 02/27/25 assigned the resident a brief interview for mental status score of 9 out of 15 in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and facility document review the facility staff failed to ensure resident call bells were accessible to residents on 1 of 3 halls on [NAME] unit of the facility. The findings included: For 1 of 3 halls on the [NAME] unit of the facility, calls bell push buttons were inaccessible to residents in 5 out of 12 resident rooms on the hall. During a tour of the facility on 12/03/24 at 10:30 am, surveyor observed the call bell lying in the floor beside resident bed in room [ROOM NUMBER]-A, and the nightstand in room [ROOM NUMBER]-A and B, and lying in the floor in room [ROOM NUMBER]-B, and behind the nightstand in room [ROOM NUMBER]-A. This Surveyor observed rooms again on 12/03/24 at 12:05 pm. The call bell was observed in the floor beside the bed in room [ROOM NUMBER]-A, no resident in bed at the time. The call bell was observed on the nightstand in room [ROOM NUMBER]-A. The call bell was observed behind the nightstand in room [ROOM NUMBER]-A, no resident in bed at the time. This…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility document review the facility staff failed to ensure a safe, clean, comfortable, and homelike environment for 1 of 3 halls on the [NAME] wing of the facility. The findings included: For 1 of 3 halls on the [NAME] wing of the facility, staff failed to ensure a clean environment. During a tour of the facility on 12/03/24 at 10:30 am surveyor observed a used disposable glove and used tissue lying on the floor in room [ROOM NUMBER], food debris on the floor around and under the bed in room [ROOM NUMBER], debris on the floor in rooms [ROOM NUMBER]. This Surveyor observed rooms again on 12/03/24 at 12:05. There was debris on the floor around and behind beds in rooms [ROOM NUMBER]. This Surveyor, along with director of nursing (DON) observed rooms on 12/04/24. Food and other debris were observed on floors of several rooms. DON asked staff to call housekeeping to come clean the area, and stated, I'll talk to the girls. Surveyor later observed housekeeping staff cleaning…

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 ensure residents receive treatment and care in accordance with the comprehensive person-centered care plan and medical provider orders for 1 of 9 sampled residents, Resident #104. The findings included: For Resident #104, the facility staff failed to administer Humalog insulin as ordered by the medical provider. Humalog is a fast-acting insulin used to lower blood sugar. Resident #104's diagnosis list indicated diagnoses, which included, but not limited to Paranoid Schizophrenia, Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and Alzheimer's Disease. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 1/07/25 assigned the resident a brief interview for mental status (BIMS) summary score of 9 out of 15 indicating the resident was moderately cognitively impaired. Resident #104's current person-centered comprehensive care plan included a focus area stating in part The resident has diabetes Mellitus . with an intervention dated 11/10/21 for Diabetes…

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 medical provider ordered medications were available for administration for 1 of 9 sampled residents, Resident #103. The findings included: For Resident #103, the facility staff failed to ensure over the counter Biotin (vitamin supplement), Omega 3 (fatty-acid supplement), and Tylenol Arthritis (pain reliever) were available for administration. Resident #103's diagnosis list indicated diagnoses, which included, but not limited to Pain in Right Shoulder, Type 2 Diabetes Mellitus, Essential Hypertension, and Dementia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 1/06/25 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 indicating the resident was cognitively intact. Resident #103's current comprehensive person-centered care plan included a focus area stating The resident has nutritional problem or potential nutritional problem r/t [related to] dx [diagnosis] Cellulitis,…

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 residents were free of significant medication errors for 1 of 17 sampled residents (Resident #10). The findings included: For Resident #10, the facility staff failed to administer Insulin Lispro (a fast-acting insulin) according to the provider ordered sliding scale on two (2) separate occasions on 10/26/24. Resident #10's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus and Dementia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 10/31/24 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 indicating the resident was cognitively intact. Resident #10's comprehensive person-centered care plan included a focus area stating the resident has diabetes mellitus with an intervention for diabetes medication as ordered by the doctor. Resident #10's medical provider orders included an order dated 10/25/24 for Insulin Lispro per sliding scale four (4) times a day (scale…

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 follow facility established infection control procedures for 3 of 17 residents, Resident #5, Resident #16, and Resident #17. The findings included: 1. For Resident #5 the facility staff failed to ensure oxygen tubing was not resting on the floor. Resident #5's face sheet listed diagnoses which included but not limited to acute and chronic respiratory failure. Resident #5's most recent minimum data set with an assessment reference date of 11/12/24 coded the resident as having both long- and short-term memory problems with severely impaired cognitive skills for daily decision making. Resident #5's comprehensive care plan was reviewed and contained a plan for The resident has altered respiratory status/difficulty breathing r/t (related to) acute resp failure and dysphagia. Interventions for this care plan included Oxygen per MD order. Maintain all 02 safety precautions. Resident #5's physician's order summary was reviewed contained an order which read in part, Oxygen at 2 LPM (liters per…

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

Based on staff interview and facility document review, the facility staff failed to complete a review of every nurse aide at least every 12 months and failed to provide regular in-service education based on the outcome of these reviews. The findings included: The facility administrative staff failed to complete a review of every nurse aide at least every 12 months and failed to provide regular in-service education based on the outcomes of reviews/evaluations. 08/10/23 8:20 a.m., the Assistant Director of Nursing (ADON) was given 5 names of Certified Nursing Assistants(C.N.A.) that would be reviewed for performance reviews/evaluations. 08/10/23 9:25 a.m., the current Director of Nursing (DON) provided the survey team with a document titled, Job Description and Performance Standards dated 11/2018. This document had been signed by C.N.A. #3. The DON stated they could not find anything further, they would expect performance evaluations to be completed annually, and they had been the DON approximately 3 or 4 weeks. 08/10/23 2:20 p.m., during a meeting with the DON and ADON these staff…

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 interviews and clinical record review the facility staff failed to maintain a complete medical record on each resident for all residents with a medical regimen review without recommendations and also for two of 29 residents in the survey sample. 1. While conducting medication regimen reviews, surveyors were unable to locate routine monthly medication regimen reviews after December 2022. Some residents had documented recommendations. No regimen reviews without recommendations were recorded in the clinical records. Surveyors asked nursing staff where medication regimen reviews without recommendations were documented. The pharmacy was changed in January 2023. The current pharmacy sends an e-mail to the director of nursing with the list of residents reviewed and recommendations. The recommendations are placed in the clinical record after the physician acts on them. There is no note made in the clinical record if there are no recommendations. 2. For Resident #45, facility staff failed to act on medication regimen review recommendations. Resident #45 was admitted to the…

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

Based on staff interview and facility document review, the facility staff failed to provide 12 hours of in-service training for nurse aides. The findings included: The facility staff failed to provide nurse aides with 12 hours of in-service training. During the task sufficient and competent nurse staffing the surveyor requested information regarding in-service training. 08/09/23 4:15 p.m., the Director of Nursing (DON) stated they were unable to find training for employees that was requested. The DON stated the former Staff Development Coordinator (SDC) left without notice, they were unable to find their records, and they were in the process of hiring an SDC. 08/11/23 12:28 p.m., the Assistant Director of Nursing (ADON) stated they had 3 different DON's and Administrators in the last 6 months. 08/11/23 12:38 p.m., the Assistant Director of Nursing provided the survey team with a copy of their policy titled, Training Requirements. This policy read in part, It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing…

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 interviews and facility document reviews the facility staff failed to prevent misappropriation of resident funds for 7 residents residing at the facility at the time of the incident. The findings were: During a review of recent Facility Reported Incidents (FRIs) with the administrator, regional director of clinical services (RDCS), and director of operations (DOO) on 08/09/2023 at 1:32 p.m., the DOO reported a FRI which read that on 07/05/23, the facility discovered their business office manager (BOM) diverted funds from resident trusts and the cash box. The director of operations reported that on 07/05/23, a resident requested his funds that were in the facility safe. The BOM was not working, and facility staff discovered the money was not in the safe. The administrator at the time contacted the BOM who eventually acknowledged she had the money in her purse for safe keeping. The administrator notified the regional director of clinical services and director of operations. Facility staff determined the cash contents of the safe, which totaled $572.16, was missing. 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, resident interview, family interview, clinical record review, and facility document review, the facility staff failed to provide activity of daily living (ADL's) care for 2 of 29 dependent care residents, Resident #44 and #71. The findings included: 1. For Resident #44, the facility staff failed to provide ADL care. Resident #44 was observed to have long fingernails and facial hair. Resident #44's diagnoses included, but were not limited to Parkinson's disease, unspecified dementia, major depressive disorder, difficulty in walking, and muscle weakness. Section C (cognitive patterns) of Resident #44's significant change minimum data set (MDS) assessment with an assessment reference date (ARD) of 07/25/23 included a brief interview for mental status (BIMS) summary score of 3 out of a possible 15 points. Resident #44's comprehensive care plan included the focus areas resident and/or family have chosen comfort care, impaired visual function, ADL self-care performance deficit, communication problem, and impaired thought processes. 08/08/23 during…

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 care and services as ordered for 3 of 29 residents records reviewed. (Res #359, #44, #71) The findings include: 1. For resident #359, the facility staff failed to obtained weights three times weekly as ordered by the physician. Resident #359's demographic sheet listed diagnoses that included but was not limited to, acute on chronic systolic congestive heart failure, hyponatremia, hypertension, mild protein calorie malnutrition, obesity, depression and anxiety. The admission minimum data set (MDS) with an assessment reference date (ARD) of 6/3/2023 assigned resident #359 a brief interview for mental status (BIMS) score of 15 indicating they were cognitively intact. Under Section K, Swallowing and Nutrition of the MDS, resident #359 was coded as having a weight loss prior to admission. Under Section N, resident #359 was coded as receiving diuretics. Resident #359's physician orders included an order dated 6/1/2023 for weights to be obtained three times weekly. 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, resident interview, staff interview, and clinical record review, the facility staff failed to anchor an indwelling foley catheter for 1 of 29 residents, Resident #85. The findings included: The facility staff failed to anchor Resident #85's foley catheter. Resident #85's diagnoses included but were not limited to, obstructive and reflux uropathy and retention of urine. Section C (cognitive patterns) of Resident #85's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 07/18/23 included a brief interview for mental status (BIMS) summary score of 14 out of a possible 15 points. Section H (bladder and bowel) was coded to indicate Resident #85 had an indwelling foley catheter. Resident #85's comprehensive care plan included the focus area obstructive uropathy and urinary retention catheter, readmitted with foley catheter (04/11/23). 08/09/23 8:25 a.m., Resident #85 was observed resting on bed, foley catheter on side of bed. When asked if the foley catheter was strapped/secured/anchored Resident #85 stated it had never been…

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 the facility staff failed to remove an IV access per policy for 1 of 29 sampled residents. (Resident #209). Resident #209 was admitted to the facility with multiple diagnoses including encephalopathy, diabetes mellitus, morbid obesity, hypertension, dysphagia, atherosclerotic heart disease, chronic obstructive pulmonary disease, sepsis, cerebral infarction, and heart failure. On the Minimum Data Set assessment with assessment reference date 5/4/2022, the resident scored 3/15 on the brief interview for mental status, indicating the resident had impaired cognitive function. Clinical record review revealed a physician order dated 5/5/2022 for Sodium chloride 0.9% use 1 liter one time only for dehydration for 1 day 300 ml (milliliter) bolus then run at 125 ml per hour until complete. A nursing Health Status Note dated 5/5/2022 at 18:51: Note Text: IV placed by this nurse, to left AC X 1 attempt without difficulties. Flushes and is patent, IV fluids initiated. A nursing skilled note dated 5/5/2022 at 23:46 noted under Special Care: IV…

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 ensure medical supervision of care for 1 of 29 residents review. (Res #96) The findings included: For resident #96 the facility staff failed to ensure the physician was notified of and addressed a significant weight loss. Resident #96's demographic sheet listed diagnoses that included but was not limited to, paroxysmal atrial fibrillation, morbid severe obesity due to excess calories, obstructive sleep apnea, type 2 diabetes mellitus, unspecified dementia, adjustment disorder with depressed mood and gastro-esophageal reflux disease. A review of resident #96's clinical record revealed that in April of 2023 their weight was 238.6 pounds and in August their weight was 205.2 pounds for a 14% loss in 6 months. On 8/10/2023 at 8:46 AM surveyor interviewed resident #96. They stated that they knew they had lost weight and stated, it's probably a good thing. They stated that they ate but not as much as they might have in the past, I don't get hungry much. They stated no one had…

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

Based on staff interview and facility document review the facility staff failed to ensure licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. The findings were: During a review of recent Facility Reported Incidents (FRIs) with the administrator, regional director of clinical services (RDCS), and director of operations (DOO) on 08/09/2023 at 1:32 p.m., the RDCS reported an incident which occurred on 06/30/23 and 07/01/23. The facility discovered their business office manager (BOM) who reported to be a registered nurse (RN) and presented the facility with an RN license verification document, was not a licensed RN. The BOM worked as a nurse on 06/30/23 and 07/01/23. The regional director of clinical services reported facility staff realized the BOM who had worked as a nurse on orientation (with another nurse) passing medications for approximately four hours on 06/30/23 did not actually possess a nursing license. That BOM worked as a nurse, passing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility document review, the facility staff failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The findings include: On 8/9/2023 at 2:20 PM Surveyor entered the East wing nutrition room to check the residents refrigerator. In the door of the refrigerator, a jar of Great Value Thick and Chunky Salsa with an expiration date of April 1, 2023, was observed. The salsa had initials written in permanent marker and had been opened. There was no date to indicate when the jar had been opened. On 8/9/2023 at 2:36 PM Surveyor checked the [NAME] wing nutrition room refrigerator and observed a bottle of [NAME] French Dressing with an expiration of 8/9/22. This bottle had been opened. There were no initials written on the bottle and there was no date to indicate when the bottle had been opened. On 8/9/2023 at 2:24 PM surveyor interviewed LPN #3 who discarded the salsa and stated that dietary is responsible for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and facility document review the facility staff failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for one staff member employed by the facility. The findings were: During a review of recent Facility Reported Incidents (FRIs) with the administrator, regional director of clinical services (RDCS - regional nurse), and director of operations (DOO) on [DATE] at 1:32 p.m., the RDCS reported an incident which occurred on [DATE] and [DATE]. Facility staff discovered on [DATE] that their business office manager (BOM) who reported to be a registered nurse (RN) and presented the facility with an RN license verification document, was not a licensed RN. The BOM worked as a nurse on [DATE] and [DATE]. The regional director of clinical services reported facility staff realized the BOM who had worked as a nurse on orientation (with another nurse) passing medications for approximately four hours on [DATE] did not actually possess 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 and [NAME] Report review, the facility staff failed to electronically submit staffing information to The Centers for Medicare & Medicaid Services (CMS) for 2 quarters. The findings included: The facility staff failed to electronically submit staffing information to CMS for January 1-March 31 and April 1-June 30 2022. 08/08/23 3:32 p.m., the current Administrator confirmed to the survey team that there was no payroll based journal (PBJ) documentation submitted to CMS for these 2 quarters. 08/11/23 4:38 p.m., during an end of the day meeting with the Administrator and Regional Director of Operations. The Regional Director of Operations stated the former company did not submit the PBJ documentation. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation and staff interview the facility staff failed to meet safety requirements by storing food that reflected expired use by dates and boxes of unfrozen ice cream. The findings included: During initial tour of the facility, the surveyor observed food in the active food supply with expired use by dates and observed two boxes of ice cream in the freezer that were not frozen. 06/29/21 11:00 a.m., the surveyor checked the nourishment refrigerator with the accounts manager in dietary. The surveyor observed almond milk with an open date of 05/27/21 and a use by date of 06/03/21, five bottles of lemon juice with an open date of 05/13/21 and a use by date of 06/13/21, one bottle of thousand island dressing open date 05/28/21 use by date 06/04/21, a silver deep dish tray that contained smuckers topping (no open date), raspberry topping with an open date of 05/05/21 and a use by date of 06/05/21, caramel topping and chocolate topping with no open date. The outside of this tray had a sticker that read open date 05/07/21 use by date 06/07/21. The accounts manager identified…

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, facility document review, and during a medication pass and pour observation, the facility staff failed to ensure the residents receive treatment and care in accordance with the comprehensive person-centered care plan for 5 of 28 residents in the survey sample, Residents #58, #49, #57, #61, and #9. The findings included: 1. For Resident #58, the facility staff failed to follow the physician's order for the administration of the oral antibiotic, Vacomycin to treat c. diff (clostridioides difficile). Resident #58's diagnosis list indicated diagnoses, which included, but not limited to End Stage Renal Disease, Chronic Diastolic Congestive Heart Failure, Type 2 Diabetes Mellitus without Complications, and Bipolar Disorder Unspecified. The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of 5/26/21 assigned the resident a BIMS (brief interview for mental status) score of 13 out of 15 in section C, Cognitive Patterns. A nursing progress note dated 5/31/21 6:04 pm states in part, positive for CDIFF, (name…

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 an effective infection control program for 3 of 28 residents (Resident #57, Resident #75, and Resident #58) and 1 of 2 units. The findings included: 1. For Resident #57 the facility staff failed to maintain contact precautions after the resident was diagnosed with MRSA (methicillin resistant staphylococcus aureus) infection. Resident #57's face sheet listed diagnoses which included but not limited to pyelonephritis, ESBL (extended spectrum beta lactamase) resistance, urinary tract infection, hypertension, atrial fibrillation, type II diabetes mellitus, depression, sepsis, MRSA (methicillin resistant staphylococcus aureus) and chronic kidney disease. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 05/20/21 assigned the resident a BIMS (brief interview for mental status) 12 out of 15 in section C, cognitive patterns. This indicates that 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 staff interview and clinical record review, the facility staff failed to ensure the resident's right to formulate an advanced directive by failing to complete a DDNR (durable do not resuscitate) order form for 1 of 28 residents in the survey sample, Resident #79. The findings included: For Resident #79, the facility staff failed to complete the resident's DDNR order form. Resident #79's diagnosis list indicated diagnoses, which included, but not limited to Acute Respiratory Failure with Hypoxia, Vascular Dementia without Behavioral Disturbance, Unspecified Atrial Fibrillation, Chronic Obstructive Pulmonary Disease Unspecified, and Chronic Kidney Disease Stage 3 Unspecified. The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of 6/07/21 coded the resident as being moderately impaired in cognitive skills for daily decision making with short-time and long-term memory loss. The resident was unable to complete the BIMS (brief interview for mental status) interview.…

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 notify the facility physician of a change in condition for 1 of 28 residents, Resident #57. The findings included: For Resident #57 the facility staff failed to verify a medication change and failed to verify contact precaution orders with the resident's physician. Resident #57's face sheet listed diagnoses which included but not limited to pyelonephritis, ESBL (extended spectrum beta lactamase) resistance, urinary tract infection, hypertension, atrial fibrillation, type II diabetes mellitus, depression, sepsis, MRSA (methicillin resistant staphylococcus aureus) and chronic kidney disease. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 05/20/21 assigned the resident a BIMS (brief interview for mental status) 12 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Resident #57's comprehensive care plan…

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, facility staff failed to provide for confidentiality of personal and medical records by not securing resident identifiable information on one of six resident care halls. On 07/01/21 at 2:10 PM, the surveyor walked up to the medication cart on the 400 hall. The laptop was open to a resident's file, a clipboard with the resident names and room numbers and notes was face up on the medication cart, and reorder stickers were on the border of the display. The nurse came out of a resident room and stated she had been trying to draw some blood before 2 PM. When asked about resident information being visible, the nurse apologized and covered the information. The surveyor notified the administrator and director of nursing of the concern during a summary meeting on 7/1/2021.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. For Resident #79, the facility staff failed to initiate treatment to a DTI (deep tissue injury) to the right heel on admission on [DATE]. Resident #79's diagnosis list indicated diagnoses, which included, but not limited to Acute Respiratory Failure with Hypoxia, Vascular Dementia without Behavioral Disturbance, Unspecified Atrial Fibrillation, Chronic Obstructive Pulmonary Disease Unspecified, and Chronic Kidney Disease Stage 3 Unspecified. The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of 6/07/21 coded the resident as being moderately impaired in cognitive skills for daily decision making with short-time and long-term memory loss in section C, Cognitive Patterns. The resident was unable to complete the BIMS (brief interview for mental status) interview. In section M, Skin Conditions, the resident was code for the presence of one unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar present on admission and one unstageable pressure injury…

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, facility staff failed to offer the therapeutic diet indicated by the speech therapy assessment for 1 of 28 residents in the survey sample (Resident #203). Resident #203 was admitted to the facility with diagnoses including cerebral infarction, essential thrombocytopenia, pneumonia, atherosclerotic heart disease, acute kidney failure, dysphagia, oropharyngeal phase, hypertension, and hemiplegia. The resident did not have a minimum data set assessment on file. On 6/29/ 2021, the resident reported that being unable to feed self due to inability to move arms. The resident's tray had a pureed diet, set up by staff. The surveyor asked the nurse if someone would help the resident and the nurse said the resident could use one arm to self feed. The resident was absent from the building on 6/30/21 from 7:30 AM to late evening. On 7/01/21 at 11:30 AM, a second nurse was unable to tell the surveyor how the resident eats or to find an assessment. On 07/01/21 at 12:09 PM, the surveyor spoke with the occupational therapist who said…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and clinical record review, the facility staff failed to provide pharmaceutical services by obtaining physician ordered medications for 2 of 28 residents in the survey sample (Resident #2 and #33) and failed to ensure a medication was ingested prior to leaving the resident's room for 1 of 28 residents in the survey sample (Resident #11). 1. For Resident #2, the facility staff failed to ensure the medication Briviact (an anticonvulsant drug used to treat partial-onset seizures) was available for administration. Resident #2's diagnosis list indicated diagnoses, which included, but not limited to Epilepsy Unspecified Not Intractable without Status Epilepticus, Urinary Tract Infection Site Unspecified, Schizoaffective Disorder Depressive Type, Type 2 Diabetes Mellitus without Complications, Heart Failure Unspecified, and Bipolar Disorder. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 3/11/21 assigned the recent a BIMS (brief interview…

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 that residents were free of significant medication errors for 2 of 28 residents in the survey sample, Residents #49 and #5. 1. For Resident #49, the facility staff failed to follow physician's orders for the administration of Novolog (a rapid-acting insulin) on five separate occasions. Resident #49's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus without Complications, Cerebral Palsy Unspecified, Unspecified Dementia without Behavioral Disturbance, Schizophrenia Unspecified, and Barrett's Esophagus without Dysplasia. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 5/13/21 assigned the resident a BIMS (brief interview for mental status) score of 3 out of 15, indicating severe impairment, in section C, Cognitive Patterns. In section I, Active Diagnoses, Resident #49 was coded for the diagnosis of Diabetes Mellitus. Resident #49's active physician's orders included the following…

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

Based on interviews and the review of documents, it was determined the facility staff failed to assess pneumococcal immunization status and/or address pneumococcal immunization needs for two (2) of five (5) residents sampled for immunization review (Resident #17 and Resident #70). The findings include: The facility staff members failed to address Resident #17's and Resident #70's pneumococcal immunization status and/or pneumococcal immunization needs. Review of Resident #17's and Resident #70's clinical documentation failed to reveal evidence of the residents' pneumococcal status being assessed by facility staff members. Resident #17's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 4/12/21, had the resident assessed as able to make self understood and as able to understand others. Resident #17's Brief Interview for Mental Status (BIMS) summary scare was documented as five (5) out of 15. Resident #17 was documented as requiring assistance with transfers, bed mobility, dressing, toilet use, and personal hygiene. Resident #17's diagnoses included, but…

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.