Windsor Grove Health and Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review the facility failed to ensure that activities of daily living (ADL) care related to toenail care was provided to one resident (Resident (R)80) out of a total sample of 55 residents. This failure had the potential to cause the resident foot problems. Findings include: Review of the facility policy titled Foot Care revised 08/23/17 included .Examine feet and report any unusual condition to nurse and/or physician . The policy did not indicate which department was responsible for toenail care. Review of R80's undated admission Record located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of dementia. Review of R80's quarterly Minimum Data Set (MDS) Assessment located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 03/23/25 included a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating 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 3. For Resident #55 the facility staff failed to have a signed copy of the DNR available in the clinical record. Resident # 55 was admitted to the facility on [DATE] with diagnoses that included, but we're not limited to hypertension, high cholesterol, dementia, depression, major depressive disorder, muscle, weakness, cognitive, communication, deficit, insomnia, and presence of a pacemaker. Resident # 55's most recent MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 3/3 25, scored the resident as having a BIMS (Brief Interview of Mental Status) score of 4 out of 15 indicating severe cognitive impairment. During the survey Resident #55 was observed to be unable to follow simple instructions by staff, feed herself or engage in meaningful conversations. On [DATE] during clinical record review it was found that Resident #55 had a DNR dated [DATE], this document was filled out to read as follows: 2. (box checked) The patient is INCAPABLE of making informed decision about providing, withholding or…

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 record review, interview and policy review, the facility failed to ensure that physician's orders were followed for one of 55 residents (Resident (R) 116) whose records were reviewed. This failure has the potential to negatively impact R116 and others that have similar orders that currently reside at the facility. Findings include: Review of facility policy titled, Administering Medications, revised 04/2019, indicated, Medications are administered in a safe and timely manner and as prescribed. Policy Interpretation and Implementation . 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Review of R116's admission Record, located under the Profile in the Electronic Medical record (EMR), indicated that R116 was admitted to the facility on [DATE] with diagnoses that included hypertension, chronic kidney disease (CKD), major depressive disorder (MDD), atrial fibrillation (a-fib), and vitamin b-12 deficiency.…

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 #87 the facility staff failed to schedule vision services for a resident with visual impairment. Resident # 87 was admitted to the facility on [DATE] with diagnoses that included, but we're not limited to dementia, schizophrenia, anemia, hypertension, psychotic disorder with delusions due to unknown physiological condition, and cognitive communication deficit. Resident number 87's most recent minimum data set with an ARD (Assessment Reference Date) of 4/16/25 coded Resident # 87 as having a BIMS (Brief Interview of Mental Status) score of 6 out of 15 indicating severe cognitive impairment. Resident number 87 could follow simple conversation. On 4/29/25 Resident #87 stated I need glasses, I can't see. When asked if she had an eye examination, she stated that she could not remember when the last time she had an eye examination. A review of the clinical record revealed that since admission she had not been seen by an optometrist for a routine vision examination. On 4/30/25 an interview with…

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, clinical record review and staff interviews, the facility staff failed to provide foot care for two (2) Residents (#65 and #90) of 55 residents, in the sample survey. The findings included: 1. Resident #65 was admitted to the facility on [DATE] with diagnoses of but not limited to hemiplegia and hemiparesis of right-side cerebral infarct, dysphagia, chronic congestive heart failure, and dementia. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 04/24/25. Resident # 65's BIMS (Brief Interview for Mental Status) Score was a 15 out of 15, indicating no cognitive impairment. Resident #65 required assistance with all ADL's (Activities of Daily Living). On 4/30/2025 during an afternoon tour, Resident # 65's was observed in bed on her back, sitting up. Resident # 65's toenails were thick, long with uneven edges. They were brown in color with some lighter brown to yellow areas. Resident #65 stated that she would see the podiatrist but that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to 1.) provide supervision for one of five residents (Resident (R) 35) identified as requiring one-to-one supervision for aggressive behaviors, 2) ensure potential hazardous items were not left unattended in the room of one (R) 2 and provide supervision for a resident (R) 114 with a known balance/gait issues, of 55 sampled residents. These failures had the potential for injury to other residents from R35's aggressive behavior and for injury related to exposure to unknown substances. Findings include: 1. Review of R35's admission Record located in the resident's electronic medical records section titled Profile revealed the resident was admitted to the facility on [DATE] with diagnoses that include cerebral infarction with left sided hemiplegia and hemiparesis, severe vascular dementia with agitation, and memory deficit. Review of the facility's Accident and Incident Log, dated 12/24/24 and provided by the facility, revealed R35 had an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and facility documentation the facility staff failed to ensure Residents received adequate nutrition to prevent weight loss for 1 Resident (#55) in a survey sample of 55 Residents. The findings included: For Resident #55 the facility staff failed to ensure adequate nutrition to prevent a weight loss of over 17% in five months since admission. Resident # 55 was admitted to the facility on [DATE] with diagnoses that included, but we're not limited to hypertension, high cholesterol, dementia, depression, major depressive disorder, muscle, weakness, cognitive, communication, deficit, insomnia, and presence of a pacemaker. Resident # 55's most recent MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 3/3 25, scored the resident as having a BIMS (Brief Interview of Mental Status) score of 4 out of 15 indicating severe cognitive impairment. During the survey Resident #55 was observed to be unable to follow simple instructions by staff, feed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility policy review, the facility failed to ensure medications were stored and labeled for three of four medication carts observed and one of two medication rooms observed. This had the potential for misappropriation of medications and possible unsafe medication administration. Findings include: Review of the facility policy titled Storage and Expiration Dating of Medications and Biologicals revised [DATE] revealed, .Facility should ensure medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding .Facility should ensure external use medications and biologicals are stored separately from internal use medications and biologicals .Facility should ensure all controlled substances are stored in a manner that maintains their integrity and security .Facility should ensure medications and biologicals for expired or discharged or hospitalized residents are stored separately, away from use,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure a resident visually impaired resident received training and assistance on infection prevention measures were followed while providing urinary catheter care self care for 1 of 55 residents (Resident #43), in the survey sample. The findings included: Resident #43 was originally admitted to the facility 11/05/22 and readmitted [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Neuromuscular Dysfunction of the Bladder. The quarterly revision, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/22/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #43 cognitive abilities for daily decision making were intact. In section B (Hearing, Speech and Vision) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, the facility staff failed to maintain an effective pest control program for 1 of 55 residents (Resident #65), in the survey sample. Resident #65 was admitted to the facility on [DATE] with diagnoses of but not limited to hemiplegia and hemiparesis of right-side cerebral infarct, dysphagia, chronic congestive heart failure, and dementia. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 04/24/25. Resident # 65's BIMS (Brief Interview for Mental Status) Score was a 15 out of 15, indicating no cognitive impairment. Resident #65 required assistance with all ADL's (Activities of Daily Living). On 4/29/2025 during the initial tour, Resident # 65's room was observed with a bag sitting in a folding chair beside the bed with a large number of ants crawling in around and on the bag, chair and wall. Resident # 65 stated she did not know what exactly was in the bag or that it had ants. The CNA (Certified Nursing…

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 observation and Resident interviews the facility failed to ensure residents are adequately equipped to allow residents to call for staff through a communication system for 2 of 7 residents in the survey sample, R#6 and R#7. The findings include: 1. Resident #6 was admitted to the facility on [DATE] with a diagnosis of Obesity, Chronic Respiratory Failure, Chronic Constructive Pulmonary Disease, Anxiety Disease, Congestive Heart Failure, and Dependence for Supplemental Oxygen. Resident #6's Care Plan dated 10/07/2024 documented the resident as having Full Code Status, Resident #6 is at risk for fall related to Gait/Balance problems history of falls. Resident #6's Minimum Data Set (MDS) assessment dated [DATE], Resident #1's Brief Interview for Mental Status (BIMS) summary score was as 15. Resident #6 asked to speak with the Surveyor on 11/13/2024 11:27AM. Resident #6 stated that her call bell system hasn't been working for a while and no one would come to assist. Resident #6 said she believes her call bell…

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 observations and Residents interviews the facility fail to ensure a safe, comfortable, and homelike for 3 residents out of 7 in the survey sample: Resident #1, Resident #2, and Resident #3 environment . The findings include: 1. Resident #1 was admitted to the facility on [DATE] with a diagnosis of Diabetes, Encephalopathy, Hematuria, Schizoaffective Disorder, Anxiety, Depression, Muscle Weakness, and Insomnia. Resident #1's Care Plan dated 07/25/2024 documented the resident as being independent for meeting, emotional, physical, and social needs. Resident #1's Minimum Data Set (MDS) assessment dated [DATE], the resident was coded as having no Mood or Behavioral symptoms presence. Resident #1's Brief Interview for Mental Status (BIMS) summary score was as 15 out of a possible score of 15 which indicated the resident was inatct with the cognitive skills for daily decision making. Resident #1 on 11/12/2024 at 10:30AM approached the surveyor during the start of entrance tour. Resident #1 stated he was the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and Residents interviews the facility fail to ensure a safe, comfortable, and homelike for 3 out of 7 residents in the survey sample (R#1, #2 and #3) . The findings include: 1. Resident #1 was admitted to the facility on [DATE] with a diagnosis of Diabetes, Encephalopathy , Hematuria, Schizoaffective Disorder, Anxiety, Depression, Muscle Weakness, and Insomnia. Resident #1's Care Plan dated 07/25/2024 documented the resident as being independent for meeting, emotional, physical, and social needs. The Minimum Data Set (MDS) assessment dated [DATE], the resident was coded as having no Mood or Behavioral symptoms presence. Resident #1's Brief Interview for Mental Status (BIMS) summary score was as 15 out of a possible score of 15, which indicated intact cognitive skills of daily decision making. Resident #1 on 11/12/2024 at 10:30AM approached the surveyor during the start of entrance tour. Resident #1 stated he was the Residents Council President. Resident was delighted to see someone show-up.…

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 the facility failed to ensure a resident with colostomy received care consistent with professional standards of practice for 1 out of 7 residents in the survey sample, Resident #4. The findings include: Resident #4 was admitted to the facility on [DATE] with a diagnosis of Diabetes, Congestive Heart Failure, Chronic Kidney Disease, Heart Failure, Below the Knee Bilateral Amputation and Colostomy. Resident #4 Care Plan dated 03/08/2024 documented the resident as having an indwelling foley catheter as well as colostomy related to Diabetes. Resident #4's Minimum Data Set (MDS) assessment dated [DATE], resident's Brief Interview for Mental Status (BIMS) summary score was a 15 out of a possible score of 15, which indicated intact cognitive skills of daily decision making. Surveyor conducted a meeting with Resident #4 on 11/13/2024 at 11:45PM. Resident #4 stated the facility's nurses have not been changing his colostomy bag according to his doctor's order. Resident said the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and Resident interview the facility failed to ensure sufficient fluid intake to maintain proper hydration and health for 2 out 7 residents in the survey sample, R#2 and R#3. The findings include: 1. Resident #2 was admitted to the facility on [DATE] with a diagnosis of Hypertension, Diabetes , Heart Disease, Anemia, Hyperlipemia, Congestive Heart Failure, Atherosclerotic Heart Disease and Dependence on Wheelchair. Resident #2 Care Plan dated 09/16/2024 documented the resident as being independent for meeting, emotional, physical, and social needs. Resident #2 is a risk for falls relate to Deconditioning, Gait/Balance problems, Incontinence, Morbid Obesity. Resident #2's Minimum Data Set (MDS) assessment dated [DATE], the resident was coded as having adequate Vision and Hearing. Resident #2's Brief Interview for Mental Status (BIMS) summary score was 15 out of a possible score of 15, which indicated intact cognitive skills of daily decision making. Surveyor observed Resident #2 on 11/13/2024…

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, clinical record review, staff interview, and facility documentation, the facility staff failed to provide dignity and respect for 1 Resident (Resident #47) of 35 residents in the survey sample. The facility staff failed to provide Resident #47 dignity and respect during wound care as evidenced by writing on the resident's wound dressing after applying it to the resident's right upper buttock. The findings included: Resident #47 was admitted to the nursing facility on 01/22/21. Diagnosis included but not limited to Pressure Ulcer of Right Upper Buttock, Stage 3 and Muscle Weaknesses. The current Minimum Data Set (MDS) an admission Assessment MDS with an Assessment Reference Date (ARD) of 01/28/21 coded the resident with a 5 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS). This indicated Resident #47's cognitive abilities for daily decision making were severely impaired. In addition, the Minimum Data Set coded Resident #47 as requiring extensive assistance of two persons for bed mobility, extensive assistance of one person 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 a facility reported incident, resident personal funds review, resident interviews, staff interviews and facility document review the facility staff failed to ensure that 2 of 35 residents in the survey sample were allowed to manage their own financial affairs/facility personal funds account in regards to a Covid Stimulus Check, Resident #14 and Resident #100. The findings included: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses to include but not limited to Hypertension, Chronic Obstructive Pulmonary Disease and Congestive Heart Failure. The most recent MDS (Minimum Data Set) for Resident #14 was a Quarterly Assessment with a ARD (Assessment Reference Date) of 12/18/20. Resident #14's BIMS (Brief Interview for Mental Status) score was a 14 out of a possible 15 indicating the resident was cognitively intact and capable of daily decision making. A Facility Reported Incident (FRI) received at the Office of Licensure and Certification(OLC on 8/13/20 was reviewed and is documented 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.

Based on responses from six residents during a group interview and general observations, the facility staff failed to ensure the residents were aware of the contact information for all State regulatory and informational agencies to include email, mailing addresses and telephone numbers in a font large enough to be read by residents. The findings included: On 3/24/21 at 1:30 p.m., a group interview was conducted with 6 residents that represented all units. During the group interview, Resident Council President (RCP)-Resident #100 and the remaining 5 residents expressed that they were not aware of where the State Regulatory and informational agencies contact information posting was located within the facility. It was asked of the group if in-house procedures for filing a grievance failed to resolve a complaint regarding care and services, abuse, neglect, exploitation and or misappropriation of property, what other recourse would they have? They all stated no one had ever given them the information and they did not know where the information was posted. This surveyor was also unable to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a facility reported incident, resident personal funds review, resident interviews, staff interviews and facility document review the facility staff failed to prevent the misappropriation of resident federal stimulus check funds for 2 of 35 residents in the survey sample, Resident #14 and Resident #100. The findings included: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses to include but not limited to Hypertension, Chronic Obstructive Pulmonary Disease and Congestive Heart Failure. The most recent MDS (Minimum Data Set) for Resident #14 was a Quarterly Assessment with a ARD (Assessment Reference Date) of 12/18/20. Resident #14's BIMS (Brief Interview for Mental Status) score was a 14 out of a possible 15 indicating the resident was cognitively intact and capable of daily decision making. A Facility Reported Incident (FRI) received at the Office of Licensure and Certification(OLC on 8/13/20 was reviewed and is documented in part, as follows: Report Date: 8/13/2020 Resident involved:…

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, clinical record review and facility documentation review the facility staff failed to send a copy of the Resident's Care Plan to include their goals after being transferred and admitted to the hospital for two residents (Resident #91 and #94) in survey sample of 35 residents. The findings included: 1. The facility staff failed to send a copy of Resident #94's Plan of Care summary to include plan care goals was sent upon transfer/discharge to the hospital on [DATE]. Resident #94 was re-admitted to the facility 02/02/21. Diagnosis for Resident #91 included but were not limited to Hypertension, Diabetes - Type 2, Bipolar Disorder and Heart Failure. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 12/02/20 coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS). A nursing note dated 1/25/21 indicated: Resident #94 was discharged from the facility and transferred to the hospital. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review, staff interviews and facility document reviews, the facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of discharges for two residents (Resident #43 and #94) in the sample of 35 residents. The findings included: 1. The facility staff failed to notify the Office of the State Long - Term Care Ombudsman in writing when Resident #94 was transferred to the hospital on 1/25/21. Resident #94 was re-admitted to the facility 02/02/21. Diagnosis for Resident #91 included but were not limited to Hypertension, Diabetes - Type 2, Bipolar Disorder and Heart Failure. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 12/02/20 coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS). A nursing note dated 1/25/21 indicated: Resident #94 was discharged from the facility and transferred to the hospital. A phone interview was conducted with the Social Worker…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. The facility staff failed to ensure that Resident #91 was provided a written copy of the facility's bed-hold and reserve bed payment policy upon transfer/discharge to the hospital on [DATE]. Resident #91 was originally admitted to the facility on [DATE]. Diagnosis for Resident #91 included but not limited to Chronic Obstructive Pulmonary Disease (COPD.) The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 03/01/21 coded the resident with a 06 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The Discharge MDS assessments was dated for 08/09/20 - discharged with return anticipated. On 08/09/20, according to the facility's documentation read in part, Resident #91, was observed ambulating out of her room towards nurse's station and was met by staff member, noted facial drooping to left side of face, drooling from the mouth and mumbling her words. The on call physician made aware with new orders to…

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

Based on observation, resident interview, staff interview, and clinical record review, the facility's staff failed to accurately code the 2/18/21 quarterly MDS assessment at sections H0100 Bowel and Bladder Appliances and H0300 Urinary continence for 1 of 35 residents (Resident #70), in the survey sample. The findings included: Resident #70 was originally admitted to the facility 8/29/20 and had never been discharged from the facility. The current diagnoses included; stroke, hemiparesis, an enlargement of the prostate gland, and a neurogenic bladder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/18/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #70's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with toileting. In section H the resident was coded for no appliances such as an indwelling catheter, an intermittent catheter, and at 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 clinical record review, staff interview and facility documentation, the facility staff failed to provide supervision and implement interventions to reduce environmental hazards for one resident (Resident #4) in the survey sample of 35 residents. The findings included: Based on observations, clinical record review, staff interviews and Past- Non- Compliance Plan of Corrections the facility staff failed to provide supervision and implement interventions to reduce environmental hazards for one resident (Resident #4) in the survey sample of 35 residents. The findings included: The facility staff failed to provide supervision and implement interventions to reduce environmental hazards for one resident (Resident #4). The facility presented evidence of Past-Non-Compliance in response to an elopement of Resident #4. Resident #4 was admitted to the facility on [DATE] with diagnoses that included the following: Alzheimer's Disease, Peripheral Vascular Disease, Exfoliative dermatitis, Pruritus, Psoriasis, Disorder…

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's staff failed to ensure appropriate care and services were provided to prevent/reduce trauma to the urethra and bladder, and other complications while utilizing an indwelling catheter for 1 of 35 residents (Resident #70), in the survey sample. The findings included: Resident #70 was originally admitted to the facility 8/29/20 and had never been discharged from the facility. The current diagnoses included; stroke, hemiparesis, an enlargement of the prostate gland, and a neurogenic bladder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/18/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #70's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with toileting. In section H the resident was coded for no appliances such as an indwelling catheter, an intermittent…

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 record record review, staff interviews and facility document review the facility staff failed to ensure a gradual dose reduction for Trazadone was followed through for 1 of 35 Resident's in the survey sample, Resident #88. The findings included: Resident #88 was admitted to the facility on [DATE] with diagnoses to include but not limited to Schizoaffective Disorder, Bipolar Disorder and Major Depressive Disorder. The most recent MDS (Minimum Data Set) for Resident #88 was a Quarterly Assessment with a ARD (Assessment Reference Date) of 3/2/21. Resident #88's BIMS (Brief Interview for Mental Status) score was a 15 out of a possible 15 indicating the resident was cognitively intact and capable of daily decision making. Under Section NO410 Medications Received, C. Medication received Days: Antidepressant-7. Resident #88's Pharmacy Consultation Report for 10/1/20 through 10/30/20 was reviewed and is documented in part, as follows: Recommendation date 10/10/20. Comment: Name (Resident #88) Trazadone…

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 the observation of 3 medication carts and 2 medication rooms; the facility staff failed to dispose of expired medications for two units. The facility staff failed to dispose of expired medications on the Peach Unit and The [NAME] 300 Unit. The findings included: On 03/23/21 at approximately 2:25 PM an inspection of the Medication Cart on the Peach Unit was made with LPN (Licensed Practical Nurse) #3. Upon visual inspection of the medication cart one Glucagon ER Kit was found with an expiration date of 12/2020. LPN #3 stated, I should have looked in the stat box and called the pharmacy to re-order. On 03/24/21 at approximately 10:13 AM an inspection of the Medication Cart on the [NAME] Unit 300 was conducted with LPN (Licensed Practical Nurse) #4. Upon visual inspection of the medication cart one Glucagon Kit was found with an expiration date of 06/2020. LPN #4 stated, That's way past due. We need to get a new one. Policy: Facility's Pharmacy Services and Procedures Manual. Policy Title: Storage and…

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

Based on clinical record review and staff interviews, the facility's staff failed to promptly notify the physician of laboratory results which fell outside of the clinical range for administration of an antibiotic for 1 of 35 residents (Resident #36), in the survey sample. The findings included: Resident #36 was originally admitted to the facility 12/27/18 and had never been discharged from the facility. The current diagnoses included; mild intellectual disabilities and dementia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/16/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 7 out of a possible 15. This indicated Resident #36's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as required supervision of one person with dressing and independent after set-up with transfers, eating, toileting, personal hygiene and bathing and independent with bed mobility, walking with a walker and locomotion in room. Review of 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 clinical record review and staff interviews, the facility's staff failed to have laboratory results obtained 1/30/21, on the clinical record for 1 of 35 residents (Resident #36), in the survey sample. The findings included: Resident #36 was originally admitted to the facility 12/27/18 and had never been discharged from the facility. The current diagnoses included; mild intellectual disabilities and dementia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/16/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 7 out of a possible 15. This indicated Resident #36's cognitive abilities for daily decision making were severely impaired. In sectionG(Physical functioning) the resident was coded as required supervision of one person with dressing and independent after set-up with transfers, eating, toileting, personal hygiene and bathing and independent with bed mobility, walking with a walker and locomotion in room. Review of the clinical record revealed on 1/29/21 at 5:30 a.m. 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 clinical record review and staff interviews, the facility's staff failed to ensure unnecessary administration of an antibiotic for seven days (use of an antibiotic when an infection wasn't diagnosed) for 1 of 35 residents (Resident #36), in the survey sample. The findings included: Resident #36 was originally admitted to the facility 12/27/18 and had never been discharged from the facility. The current diagnoses included; mild intellectual disabilities and dementia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/16/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 7 out of a possible 15. This indicated Resident #36's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as required supervision of one person with dressing and independent after set-up with transfers, eating, toileting, personal hygiene and bathing and independent with bed mobility, walking with a walker and locomotion in room. Review of 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 observations, record review, staff interviews, resident interview, and facility document review the facility staff failed to ensure that shower preferences were followed for one of 57 residents in the survey sample, Resident #108. The facility staff failed to ensure that Resident #108's shower preferences were followed as indicated in the comprehensive care plan. The findings included: Resident #108 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to, Spina Bifida, Mild Intellectual Disabilities and Bipolar Disorder. Resident #108's most recent Minimum Data Set (MDS) was an Annual with an Assessment Reference Date (ARD) of 5/30/19. The Brief Interview for Mental Status was a 15 out of a possible 15 indicating the resident was cognitively intact and capable of daily decision making. Under Section G Functional Status G0120 Bathing Resident #108 was coded as requiring total dependence with one person physical assist. Resident #108's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to conduct an investigation and keep residents free from further abuse for two of 57 residents in the survey sample, Resident #5 and Resident #82. 1. Facility staff failed to investigate a sexual encounter between Resident #5 and Resident #107 on 3/6/19; and failed to protect Resident #5 from a second sexual encounter with Resident #107 on 3/20/19. 2. For Resident #82, facility staff failed to investigate a resident to resident altercation between Resident #82 and Resident #107; and failed to prevent further potential abuse from Resident #107. The findings include: 1a. Resident #5 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Pick's Disease (1), muscle weakness, difficulty walking, and major depressive disorder. Resident #5's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference…

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, clinical record review and facility documentation review the facility staff failed to send a copy of the Resident's care plan to include their goals for six of 57 residents (Resident #317, #32, #41, #265, #65 and #108) after being transferred to the hospital. The findings included: 1. The facility staff failed to ensure that Resident #317's Plan of Care Summary to include their care plan goals was sent upon transfer/discharge to the hospital on [DATE]. Resident #317 was originally admitted to the facility on [DATE]. Diagnosis for Resident #317 included but not limited to acute respiratory failure with hypoxia. The current Minimum Data Set (MDS), an admission assessment with an Assessment Reference Date (ARD) of [DATE] coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The Discharge MDS assessments was dated for [DATE]-discharge return anticipated. On [DATE], according to the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, facility documentation review and clinical record review the facility staff failed send a copy of the Bed-Hold Policy upon discharge/transfer for five of 57 resident's (Resident #317, 32, 41, 65 and 108) after being transferred to the local hospital. The findings included: 1. The facility staff failed to provide the Resident #317 or their representative a copy of the bed hold policy upon discharge/transfer to the hospital on [DATE]. Resident #317 was originally admitted to the facility on [DATE]. Diagnosis for Resident #317 included but not limited to acute respiratory failure with hypoxia. The Discharge MDS assessments was dated for 04/01/19 - discharge return anticipated. On 06/13/18, according to the facility's documentation, per family request, Emergency Services was called to transport Resident #317 to the local emergency room (ER) due to resident complained of being dizzy, nauseous, extreme weakness and had vomited several times (unwitnessed). On 06/25/19 at approximately 1:40…

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 complainant investigation, observation, resident interviews, staff interviews, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice for three out of 57 residents (Residents #55, #32 and #465) in the survey sample. 1. The facility staff failed to follow the physician orders for the treatment of the following wounds: right below the knee *amputation site (surgical incision) and skin tear to right elbow for Resident #55. 2. The facility staff failed to follow physician orders and administer treatments to a right BKA (Below the Knee Amputation) for Resident #32. 3. The facility failed to justify treatment with elimite cream for Resident #465. The findings included: 1. Resident #55 was originally admitted to the facility on [DATE]. Diagnosis for Resident #55 included but are not limited to Right below the knee amputation. Resident #55's Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of [DATE] coded 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 record review and staff interviews, the facility staff failed to provide physician ordered medications and treatments for 3 of 57 residents in the survey sample, Resident #6, #465, & #265. 1. The facility staff failed to provide Resident #6 with medications as ordered by the physician. 2. The facility staff failed to provide wound care for Resident #465. 3. The facility staff failed to provide treatment for a venous stasis ulcer wound for Resident #265. The findings included: 1. Resident #6 was re-admitted to the facility on [DATE] with diagnoses which included type two diabetes, long term use of insulin, dysphagia, depression, anxiety, congestive heart failure, hyperlipidemia, and COPD. The facility staff failed to provide physician ordered insulin and anti-anxiety medication to Resident #6. Resident #6 was assessed on a Quarterly Minimum Data Set (MDS) dated [DATE] as having minimum hearing difficulty and wears glasses. In the area of Cognitive Patterns this resident was assessed as having scored a 15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to notify the responsible party and physician after a resident to resident abuse incident for two of 57 residents in the sample, Resident #5 and #107; and failed to notify the physician of medications not administered per order for Resident #6. 1. For Resident #5 and Resident #107, facility staff failed to notify the responsible parties and physician after a sexual encounter had occurred on 3/6/19. 2. For Resident #6, facility staff failed to notify the physician of missed doses of insulin. The findings include: 1a. Resident #5 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Pick's Disease (1), muscle weakness, difficulty walking, and major depressive disorder. Resident #5's most recent MDS (Minimum Data Set) assessment was a quarterly assessment with an ARD (assessment reference date) of 3/11/19. Resident #5 was coded as being severely impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a medical record review, facility document review and staff interviews the facility staff failed to ensure a Notice of Medicare Non-Coverage was given timely prior to the last covered skilled day of 1/23/19 for one of 57 residents in the survey sample, Resident # 92. This is cited as Past Non-Compliance. The findings included: Resident #92 is a [AGE] year old admitted to the facility on [DATE] with diagnoses to include but not limited to Acute Bronchitis, Dysphagia and Generalized Muscle Weakness. Resident #92's Notice of Medicare Non-Coverage (NOMNC) document with Skilled Nursing Services ending on 1/23/19 was reviewed and is documented in part, as follows: Telephone Notification: 1/22/19 at 3:20 P.M. spoke with son about mother's last covered day for therapy being 1/23/19. QIO (Quality Improvement Organization) phone number given, appeal rights and timeframe provided/explained: No. On 06/25/19 at 12:47 PM an interview was conducted with the current facility Social Worker regarding the timeframe as to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews the facility staff failed for one resident (Resident #55), in the survey sample of 57, to ensure privacy was maintained during a wound care dressing change for Resident #55. The findings included: Resident #55 was originally admitted to the facility on [DATE]. Diagnosis for Resident #55 included but are not limited to right below the knee amputation. Resident #55's Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 04/26/19 coded the resident with an 11 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. In addition, the MDS coded Resident #55 as extensive assistance of one with bathing and toilet use and limited assistance of one with dressing and personal hygiene for Activities of Daily Living care. Section M-skin condition was coded for surgical wound care. Resident #55 resided in a private room; the room did not have a privacy curtain. During a wound dressing…

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

Based on observation and staff interview, the facility staff failed to provide a homelike environment during the dining observation from 06/24/19 to 06/27/19 on the Peach Unit (Memory Care Unit). Facility staff served resident meals on trays during the dining observation on the Peach Unit. The findings include: On 06/24/19 at approximately 7:05 PM all nineteen residents sitting at the dining table on the Peach unit were served dinner on their trays. On 06/25/19 at approximately, 11:56 AM all nineteen residents sitting at the dining table with their meals on their trays. On 06/26/19 at approximately 12:20 PM all residents sitting at the table had their meals left on trays. On 06/27/19 at approximately 12:23 PM all nineteen residents sitting at the dining table had their meals served on trays. On 6/27/19 at approximately 9:00 AM an interview was conducted with Other Staff #9 (Food Service Director) concerning leaving the resident's meals on their trays. She stated that It's not a fine dining experience on the Peach Unit. Only in main Dining. We've tried to leave the trays on 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, facility document review and clinical record review, it was determined that facility staff failed to ensure a resident was free from abuse for one of 57 residents in the survey sample, Resident #5. Facility staff failed to ensure Resident #5 was separated and protected from Resident #107 after a sexual encounter on 3/6/19 between the two residents; another sexual encounter occurred on 3/20/19. The findings include: 1a. Resident #5 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Pick's Disease (1), muscle weakness, difficulty walking, and major depressive disorder. Resident #5's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 3/11/19. Resident #5 was coded as being severely impaired in cognitive function scoring 99 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #5 was coded as requiring extensive assistance from one staff member with ADLs (activities…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to implement abuse policies and report and investigate allegations of abuse; and failed to ensure resident safety after abuse had occurred for four of 57 residents in the survey sample, Resident #5, #82, #107 and #41. 1. For Resident #5, facility staff failed to implement abuse policies and report, investigate and ensure Resident safety after a sexual encounter with Resident #107 on 3/6/19. 2. For Resident #82, facility staff failed to implement abuse policies and report, investigate and ensure Resident safety after a physical altercation with Resident #107 on 6/24/19. 3. The facility staff failed to implement the written policy and procedure to report allegation of abuse to the Administrator in a timely manner for Resident #41. The findings include: 1a. Resident #5 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Pick's Disease (1),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to report an allegation of abuse to the appropriate state agencies for four of 57 residents in the survey sample, Resident #5, #82, #107 and #41. 1. Facility staff failed to report a sexual encounter that had occurred between Resident #5 and Resident #107 on 3/6/19 to the appropriate state agencies. 2. Facility staff failed to report a resident to resident altercation that had occurred between Resident #82 and Resident #107 on 6/24/19 to the appropriate state agencies. 3. The facility staff failed to report allegation of abuse in a timely manner for Resident #41. The findings include: 1a . Resident #5 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Pick's Disease (1), muscle weakness, difficulty walking, and major depressive disorder. Resident #5's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment…

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 medical record review, facility document review and staff interviews the facility staff failed to ensure that a Comprehensive Minimum Data Set, dated [DATE] was accurately coded to include a Level II PASRR (Preadmission Screening and Resident Review for one of 57 residents in the survey sample, Resident #108. The facility staff failed to ensure that Resident #108's Annual Minimum Data Set, dated [DATE] was accurately coded to include a Level II PASRR (Preadmission Screening and Resident Review). The findings included: Resident #108 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to Spina Bifida, Mild Intellectual Disabilities and Bipolar Disorder. Resident #108's most recent Minimum Data Set (MDS) was an Annual with an Assessment Reference Date (ARD) of 5/30/19. The Brief Interview for Mental Status was a 15 out of a possible 15 indicating the resident was cognitively intact and capable of daily decision making. Under Section A 1500…

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 observations, resident interview, staff interview and clinical record review the facility staff failed to develop a comprehensive care plan for one of 57 residents in the survey sample, Resident #97. The facility staff failed to include care area 'falls on the comprehensive care plan when Resident #97 was identified as a fall risk. The findings included: Resident #97 was admitted to the facility on [DATE]. Diagnosis included but were not limited to, Chronic Obstructive Pulmonary Disease and Diabetes Mellitus. Resident #97's Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 06/03/2019 was coded with a BIMS (Brief Interview for Mental Status) score of 11 indicating moderate cognitive impairment. In addition, the Minimum Data Set coded Resident #97 as requiring total dependence of 1 for transfer, toilet use and bathing, extensive assistance of 1 for bed mobility, dressing and personal hygiene and supervision with set up help only for eating. On 06/27/2019 review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to revise the care plan after resident to resident altercations for three of 57 residents in the survey sample, Residents #5, #107 and #7. 1. Facility staff failed to revise the care plan after a sexual encounter had occurred between Resident #5 and Resident #107 on 3/6/19. 2. Facility staff failed to revise the care plan after a resident to resident physical altercation had occurred between Resident #7 and Resident #107. The findings include: 1a. Resident #5 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Pick's Disease (1), muscle weakness, difficulty walking, and major depressive disorder. Resident #5's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 3/11/19. Resident #5 was coded as being severely impaired in cognitive function scoring 99 out of 15 on the BIMS (Brief…

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 reviews the facility staff failed to provide a nutritional supplement per physician orders for one of 57 Residents in the survey sample (Resident #63). The facility staff failed to provide the nutritional supplement, Mighty Shake, on 6/25/19. The findings included: Resident #63 was originally admitted to the facility 9/27/18 and readmitted on [DATE]. The current diagnoses were Alzheimer's Dementia and feeding difficulties. The Significant Change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/09/19 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview coded the resident with long and short term memory problems as well as severely impaired decision making abilities. On 06/25/19 at approximately 11:42 AM Resident #63 was observed sitting at a table waiting for lunch. The lunch trays arrived at 11:56 AM. Resident #63 was observed touching her food but not eating until…

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 facility information obtained during the Complaint investigation, Sufficient and Competent Nurse Staffing task, and staff interviews, the facility staff failed to staff an Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. 1. The facility staff failed to staff an RN , for at least 8 consecutive hours on 06/16/19 and utilized the Director of Nursing as a charge nurse with a resident census greater than 60. 2. The facility staff failed to ensure RN coverage eight hours in a twenty-four hour period on 4/14/18, 4/15/18 and 6/24/18. The findings included: 1. A review of the as work schedules from April 2019 through June 26, 2019, were reviewed which resulted in further review of the Registered Nurse (RN) weekend coverage. During the review of the as worked schedule for 06/16/19 it revealed the Director of Nursing (DON) worked on the Blue Unit as the floor nurse passing medications. The current census on 06/16/19 was 108. The review concluded there was no RN supervisor/charge nurse other than the DON for at least 8 hours consecutive hours on 06/16/19. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility staff failed to provide pharmaceutical services for one resident (Resident #6) in the survey sample of 57 residents. For Resident #6, facility staff failed to ensure medications were available for administration per physician's order. The findings included: Resident #6 was re-admitted to the facility on [DATE] with diagnoses that included congestive heart failure, hyperlipidemia, COPD, type two diabetes, dysphagia, depression, anxiety and long term use of insulin. Resident #6 was assessed on a Quarterly Minimum Data Set (MDS) dated [DATE] as having minimum hearing difficulty and wears glasses. In the area of Cognitive Patterns this resident was assessed as having scored a 15 in the area of Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. Resident #6 was assessed in the area of Activities of Daily Living (ADL's) as requiring supervision with set-up only in the areas of transfer and dressing with limited assistance with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility staff failed to ensure two of 57 residents were free from significant medication errors. 1. The facility staff failed to ensure Resident #6 received insulin per physician's order. 2. The facility staff failed to ensure that Resident #32 received his insulin per physician's order. The findings included: 1. Resident #6 was re-admitted to the facility on [DATE] with diagnoses which included congestive heart failure, hyperlipidemia, COPD, type two diabetes, dysphagia, depression, anxiety and long term use of insulin. The facility staff failed to provide physician ordered insulin and anti-anxiety medications to Resident #6. Resident #6 was assessed on a Quarterly Minimum Data Set (MDS) dated [DATE] as having minimum hearing difficulty and wears glasses. In the area of Cognitive Patterns this resident was assessed as having scored a 15 in the area of Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. In the area of Medications 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, it was determined that facility staff failed to secure medications on one of four medications carts; a medication cart on the blue unit. And failed to ensure one of two medication rooms were free from expired biologicals; the green unit medication storage room. 1. Facility staff failed to ensure the medication cart on the Blue Unit was locked when it was left unattended. 2. The facility staff failed to dispose of multiple expired influenza vials stored in the refrigerator in the medication room located on the [NAME] Unit. The findings include: 1. On [DATE] at 11:20 a.m., the medication cart on the blue unit was observed to be unlocked. The keys to the medication cart sat on top of the cart. Licensed Practical Nurse (LPN) #5 was at the nurse's station at the time and in view of the cart. LPN #5 then walked away from the station with the cart unlocked and keys on the cart. The medication cart was left unattended for approximately 14 minutes.…

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 follow infection control practices, increasing the chances of infection, illnesse and disease for one of 57 residents in the survey sample (Resident #10.) The facility staff failed to cover an open wound on Resident #10's left lower extremity in a timely manner. The findings included: Resident #10 was originally admitted to the facility 02/07/18. Resident #10's diagnoses included Major Depressive Disorder and Muscle Weakness. The Annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/11/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 6 out of a possible 15 which indicated Resident #10's cognitive abilities for daily decision making were not intact. On 06/25/19 at approximately 10:30 AM, Resident #10 was observed showing activity staff an uncovered wound on her left lower extremity as she was sitting. The staff commented, I will tell (Licensed Practical Nurse-LPN#1). On 06/25/19 at 11:33 AM the area was still exposed on Resident #10's…

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