Willow Springs Care And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure culturally competent, trauma-informed care, related to assessing for trauma and identifying trigger-specific (a psychological stimulus that prompts recall of a previous traumatic event) interventions for residents with a history of trauma for 1 of 3 residents (Resident 14) reviewed for trauma informed care. This failed practice placed the resident at risk for unidentified triggers, re-traumatization and psychological harm. Findings included . Review of the facility's undated policy titled Trauma Informed Care Purpose, showed that social services staff were trained on screening, trauma assessment and how to identify triggers associated with re-traumatization. <Resident 14> Review of Resident 14's medical record showed the resident was admitted to the facility on [DATE] with diagnoses including insomnia (trouble sleeping) and Post Traumatic Stress Disorder [(PTSD) a mental health condition that's triggered by a terrifying…

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 record review the facility failed to ensure a medication error rate of less than five percent. Three medication errors were identified for 2 of 6 residents (Residents 21 and 43) observed during 25 medication administration opportunities that resulted in an error rate of 12%. The failed practice had the potential to place residents at risk for not receiving the full therapeutic effect of the medication and possible adverse side effects. Findings included . Review of the policy titled, Medication and Flexible Pass Time, dated 10/2023, showed nurses would follow the general guidelines for safe and accurate medication administration. Review of the Instructions for use (IFU) by the U.S. Food and Drug Administration (USFDA) revised 07/2023, stated to prime the insulin pen (a pre-filled disposable device containing insulin) with a new needle prior to each injection administration. To prime the insulin pen was to turn the dose knob to two units, hold pen and needle upright, tap pen…

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 and record review, the facility failed to send a copy of a notice of transfer/discharge to the representative of the Office of the State Long Term Care (LTC) Ombudsman (a person that advocates for residents in nursing homes) for 3 of 3 residents (Residents 2, 3, and 4) reviewed for notice of transfer/discharge. This failed practice placed the residents at risk for lack of access to an advocate that could inform them of their options and rights, and to ensure the resident advocacy agency was aware of the facility practices and activities related to a transfer or discharge. Findings included . Review of a policy titled, Admission, Transfer and Discharge - Facility Initiated Transfers and Discharges, undated, showed the facility would send a copy of the notice of transfers or discharges to a representative of the Office of the State Long-Term Care Ombudsman. <Resident 2> Review of the medical record showed Resident 2 was admitted to the facility with diagnoses of chronic obstructive pulmonary…

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 and record review, the facility failed to develop and implement an effective discharge planning process that addressed the resident's goals and needs, that involved the resident and the interdisciplinary team [(IDT) a group of healthcare professionals from different disciplines to help residents receive the care they need] for 1 of 3 residents (Resident 5) reviewed for discharge planning process. The failure to develop and implement a plan consistent with the resident's needs and expressed discharge goals, placed the resident at risk for decreased self-worth and dissatisfaction with their living situation. Findings included . <Resident 5> Review of the medical record showed Resident 5 was admitted to the facility with diagnoses including a stroke, diabetes (a group of diseases that result in too much sugar in the blood), and anxiety. The 05/14/2024 comprehensive assessment showed Resident 5 required moderate/maximum assistance of one staff member for activities of daily living. The assessment also showed Resident 5 had a moderately impaired cognition. During 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 and record review the facility failed to ensure the food was palatable, attractive, and at a safe and appetizing temperature for 7 of 7 residents (Residents 5, 38, 54, 32, 55, 46, and 27) interviewed about meal satisfaction during the Resident Council meeting, and 2 of 4 residents (Residents 49 and 30) reviewed for meal palatability. Additionally, Resident 49 was served eggs for breakfast routinely even though eggs were listed as a dislike. This failure placed the residents at risk for weight change, less than adequate nutritional intake, and dissatisfaction with meals. Findings included . Record review of the facility's policy titled, Food and Nutrition Services, dated 07/2023, showed that food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. <Meal Satisfaction> Record review of Resident Council Meeting Minutes, dated…

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

Based on interview and record review, the facility failed to periodically review resident rights with residents during their stay at the facility for 7 of 7 sampled residents (Residents 5, 27, 32, 38, 46, 54, and 55). This failure placed residents at risk of not understanding their rights and a reduced ability to self-advocate. Findings included . Record review of the facility's undated policy titled, admission Agreement - appendix D [facility name] Resident Rights, showed this policy did not address the review of resident rights. During an interview on 07/18/2023 at 9:09 AM, Representatives of the Resident Council (Residents 5, 27, 32, 38, 46, 54, and 55), stated that they were not aware of staff reviewing resident rights. During an interview on 07/19/2023 at 11:15 AM, Staff D, Activity Director, stated that they did not review resident rights at the Resident Council meetings. During an interview on 07/19/2023 at 11:35 AM, Staff A, Administrator, stated that the Social Services Director reviewed resident rights with residents. During an interview on 07/19/2023 at 11:44 AM, Staff E,…

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, interview and record review, the facility failed to ensure current state survey results were available for 7 of 7 sampled residents (Residents 5, 27, 32, 38, 46, 54, and 55) to examine. This failure prevented residents, family members, and visitors from exercising their rights to examine these documents. Findings included . Record review of the facility's undated policy titled, admission Agreement - appendix D [facility name] Resident Rights, showed residents had the right to examine the most recent results of the facility's state survey or inspections. During an interview on 07/18/2023 at 9:09 AM, Resident Council Representatives (Residents 5, 27, 32, 38, 46, 54, and 55), stated that they did not know where state survey results were available to them to read. Observation on 07/19/2023 at 11:16 AM, showed a hard covered three-ring binder located outside of the business office. The most recent copy of state survey results in this binder was dated 03/30/2023. There were other state survey investigations, dated 05/18/2023 and 06/02/2023, that were not included 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 interview and record review, the facility failed to document, periodically review, and revise Advanced Directives related to residents' wishes for 9 of 9 sampled residents (Residents 1, 7, 8, 21, 26, 30, 31, 44 and 213), reviewed for Advanced Directives. This failure prevented residents from having their health care decisions and preferences known in advance, and when they were unable to communicate this information. Findings included . Record review of the facility's undated policy titled, Advance directives (legal documents that provide instructions for medical care when a person is unable to communicate their own wishes) will be respected in accordance with state law and facility policy, showed: 1. A copy of residents' Advance Directives would be placed in their medical record. 2. The residents' decision to accept or decline an Advance Directives would be documented in the medical records. 3. The Interdisciplinary Team would conduct an annually review, with the resident, their Advance Directives. Record review of the 9 sampled residents' Electronic Health Records 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 observation and interview, the facility failed to provide a clean and comfortable homelike environment for 7 of 10 resident rooms (rooms 2, 3, 4, 20, 32, 35 and 55), 3 of 3 shower rooms (Team 1 shower room, Team 2 shower/bath room and Team 3 shower room), and missing/damaged wood panel flooring were also observed in one of five hallways (Team 2 hallway) all reviewed for safe, comfortable, and sanitary environment, 2 of 5 hallways in resident care areas (Middle and Kitchen hallways) reviewed for comfortable sound levels. These failures placed residents at risk for a diminished quality of life. Findings included . Resident rooms An observation on 07/16/2023 at 2:10 PM, in room [ROOM NUMBER], showed a six-drawer dresser was missing the third drawer on the left side of the dresser. The drawer front face was off and in the corner of the room with missing particle/pressed board and sharp pieces were exposed. An observation on 07/16/2023 at 2:46 PM in room [ROOM NUMBER], showed gouges (grooves or holes) 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 observation, interview, and record review, the facility failed to ensure the coordination of care conferences for 3 of 4 residents (Residents 20, 30 and 44); and failed to update or revise care plan changes for fall interventions and resident preferences for 2 of 4 residents (1 and 30) reviewed for care plan timing and revision. This failure placed the residents at risk for unmet and unidentified care needs and decreased quality of life. Findings included . Review of the facility's policy, dated 07/2023, titled Care Conferences showed there were no procedure or processes for implementing the policy. The policy did not list the physician (or delegated Non-Physician Practitioner) as part of the Interdisciplinary Team (IDT), nor did it show how the physician would be involved. The policy listed the Nursing Assistant (NA) would be included only if applicable the policy showed no documentation how the facility would involve the resident or Resident Representative (RR). The policy further showed no…

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 record review, the facility failed to initiate gradual dose reductions (GDR- stepwise tapering of a dose to determine if symptoms, conditions, or risks could be managed by a lower dose or if the dose or medication could be discontinued) or obtain a rationale from the physician or prescribing practitioner that a GDR was clinically contraindicated for 2 of 5 residents (Residents 12 and 25) reviewed for unnecessary medication; and the facility failed to ensure as-needed (PRN) psychotropic medications (medications capable of affecting the mind, emotions, and behavior) were limited to 14 days without providing a physician-documented rationale or duration for 1of 2 residents (Resident 7) reviewed for PRN psychotropic medication use. These failures placed residents at risk of being over medicated, medical complications related to the side effects, and diminished quality of life. Findings included . Record review of the facility's undated policy titled, Antipsychotic (a class of…

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

Based on observation, interview, and record review, the facility failed to ensure medications, biologicals, and testing supplies were labeled, dated, or discarded when expired for 1 of 1 medication room and 1 of 1 treatment cart reviewed for medication storage. These failures placed residents at risk of receiving compromised or ineffective medications. Findings included . Review of the facility's 07/2021 policy, titled Medication Storage in the facility showed, medications dispensed by the pharmacy will be kept in the container they were dispensed in with the pharmacy label. The policy further showed outdated medications will be disposed of according to the facility procedures for destroying medications. An observation on 07/20/2023 at 10:39 AM, with Staff K, Licensed Practical Nurse Care Manager in attendance, of the medication room showed: • 66- bottles of hand sanitizer, 4 fluid ounces (oz) each that expired on 03/2023. • 16 fluid oz bottle, half full bottle of hydrogen peroxide (a mild antiseptic used on the skin to prevent infection of minor cuts, scrapes, and burns) 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, interview and record review, the facility failed to ensure implementation of infection prevention and control practices for for 1) hand hygiene was completed and gloves were changed by staff between soiled and clean tasks for 2 of 3 residents (Resident 40 and 59) observed for personal care, 2) hand hygiene that was not appropriately performed by 7 of 10 staff, observed during meal services, 3) failure to perform hand hygiene wound care for 1 of 2 residents (Resident 24) observed during a wound care procedure and, 4) failure to follow contact precautions for 1 of 1 resident (Resident 28) reviewed for compliance with Transmission Based Precautions. These failures placed the residents at risk for acquiring infectious diseases and a diminished quality of life. Findings included . <Soiled to Clean Task> Record review of the facility's policy titled, Catheter (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag) Care, dated 08/10/2023, showed 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, interview and record review the facility failed to provide a dignified dining experience during two of two dining observations. On 07/16/2023, during the lunch service, the facility failed to provide meals to all residents at a table at the same time for 6 residents (Residents 33, 9, 15, 47, 31 and 1) who waited 10 minutes after Resident 42 and Resident 27 were served; and the facility failed to ensure 1 of 3 staff (Staff G) observed talked with the resident for whom they were providing assistance rather than conducting social conversations with other staff, Staff G fed Resident 33 without engaging the resident and had a conversation with Staff L, NA, that did not include the residents. On 07/19/2023 during dinner service, the facility failed to provide meals to all residents at a table at the same time for 4 o4 residents (Residents 5, 7, 32, and 55.) This failure placed residents at risk to feel diminished and disrespected. Findings included . Review of CMS §§483.10(a)-(b)(1)&(2) 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 observation, interview, and record review the facility failed to protect the personal privacy for 2 of 3 residents (Resident 40, and 31) observed for urinary catheter (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag) care or incontinent care. This failure placed the resident at risk for loss of the right to personal privacy. Findings included . Record review of the facility's policy titled, Catheter Care (a process to clean a urinary catheter tube where it exits the body), dated 07/10/2023, showed that staff were to provide privacy, cover the resident with a sheet, exposing only the perineal (the area of the body between the anus and the genitals) area. Record review of the facility's undated resident admission Packet showed that the resident had the right to personal privacy that included personal care. Resident 40. Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses to include obstructive uropathy…

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 record review the facility failed to ensure three of the seven required components (identification, investigation, and reporting) in of the prevention of abuse and neglect policy were consistently implemented for 2 of 4 residents (Residents 26 and 213) reviewed for abuse/neglect. This failure prevented the facility from identifying the extent and nature of the occurrence, interview all individuals involved, and placed the residents at risk for unidentified abuse and/or neglect. Findings included . Review of the facility's policy, titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, dated 09/21/2022, showed the facility would .identify and assess all possible incidents of abuse .Investigate and report any allegations of abuse . Resident 213. Review of the resident's Electronic Health Record (EHR) showed, the resident was admitted to the facility on [DATE] with diagnoses to include an infection in their urine, and alcoholism (any drinking of alcohol…

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 and record review, the facility failed to issue a written transfer notice to a resident and/or legal representative and to the state Ombudsman for 2 of 3 residents (Resident 49 and 59) reviewed for hospitalizations. This failure placed residents at risk of not being informed of their condition, unmet care needs and a diminished quality of life. Findings included . Record review of the facility's policy titled, Transfer/Notification of Ombudsman, dated 07/2023, showed residents will be given written transfer information and reason for the transfer upon leaving the facility if they are able to understand the information. If hospitalized and they are unable to understand or family is not able to be reached, the admission Coordinator will visit the resident in the hospital the next day to review the reason for the discharge. The social service department will be responsible for notifying the state ombudsman office of all of the discharges and transfers out to include discharge to hospital .…

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 and record review, the facility failed to provide a written bed-hold notice, at the time of transfer or within 24 hours of transfer to the hospital, for 2 of 3 Residents (Resident 49 and 59), reviewed for hospitalization. This failure placed the resident or their representative at risk for a lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . Record review of the facility's policy titled, Bed-Holds and Returns, dated 07/2023, showed all resident will be given transfer / bed hold information upon leaving the facility if they are able to understand the information. If they are unable to understand or family is not able to be reached, the admission coordinator will visit the resident in the hospital the next day to review the hold policy. Record review of the facility's undated resident admission Packet showed for bed holds and readmission the facility will hold the resident's bed at no charge for up to 24 hours. Should the resident wish to have…

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 record review the facility failed to accurately assess 3 of 5 residents (Residents 49, 17, and 20) whose Minimum Data Sets (MDS - an assessment tool) were reviewed. Failure to ensure accurate assessments related to Vision (Residents 49 and 17) and Communication (Resident 20), placed residents at risk for unidentified and/or unmet needs. Findings included . <Vision> Resident 49. Electronic Health Record (EHR) review showed the resident was admitted to the facility on [DATE] with diagnoses to include Diabetes Mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of the 06/23/2023 Minimum Data Set comprehensive assessment showed the resident had adequate vision (sees fine detail, such as regular print in newspapers/books), did not have corrective lenses and had moderate cognitive impairment. Review of the preference section of the MDS showed Resident 49 indicated it was somewhat important to have stuff to read. During 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 interview and record review, the facility failed to review the Pre-admission Screening and Resident Review (PASARR, a tool used to identify if a person may have an intellectual disability (ID) or related condition (RC), or a serious mental illness [SMI]) for accuracy upon admission for 1 of 6 residents (Resident 7) reviewed for PASARR services. Additionally, the facility failed to ensure a resident received a PASARR Level I ( an inital assessment to determine whether an individual might have (SMI) or (ID)) which was required prior to admission to the facility. This failure placed the residents at risk for unidentified mental health needs. Findings included . Resident 7. Review of the Electronic Health Record (EHR) showed the resident admitted to the facility on [DATE] with multiple serious mental health diagnoses to include dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), paranoid schizophrenia (a pattern of behavior where a person feels…

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 record review, the facility failed to implement a Care Plan related to wearing a hearing aid for 1 of 1 sampled residents (Resident 14). This failure resulted in Resident 14 having unmet care needs and was at risk for a diminished quality of life. Findings included . Resident 14. Review of the 05/25/2023 comprehensive assessment showed that the resident was admitted to the facility with diagnosis including Anxiety and hemiparesis ( partial / complete loss of strength to one side of the body), and the resident's cognition was moderately impaired. Observation on 07/16/2023 at 9:14 AM, showed Resident 14 sat in their wheelchair watching television (TV). Resident 14 could not hear the surveyor during the survey screening process. When asked if they wore hearing aids, Resident 14 did not answer. Resident 14's roommate said Resident 14's hearing aid was at the nurse's station. Observation and interview on 07/17/2023 at 8:59 AM, showed Resident 14 was not wearing their hearing aid…

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 record review the facility failed to ensure that 2 of 5 residents (Resident's 59 and 6) reviewed for dental care received goods and services to maintain their ability to perform oral care. The facility did not ensure the resident's oral care equipment was consistently set up for the residents to participate in this aspect of Activities of Daily Living (ADLs, activities related to personal care). This failure placed residents at risk for unmet care needs and a deterioration in their oral health status. Findings included . Resident 59. Review of the residents Electronic Health Record (EHR) showed the resident was admitted to the facility on [DATE] with diagnosis of a recent stroke (a condition in which the blood supply is cut off from the brain). As a result of the stroke the resident had left sided weakness and dysphagia (impaired ability to swallow). Review of Resident 59's most current comprehensive assessment, dated 07/05/2023, showed the resident was cognitively intact and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a one-to-one individualized activity program for cognitive stimulation for 1 of 1 sampled resident (Resident 1). This failure placed Resident 1 at risk of decreased cognitive ability and diminished quality of life. Findings included . Record review of Resident 1's Minimum Data Set, dated [DATE], showed Resident 1 had memory problems and their skills for making daily decisions was moderately impaired. Record review of Resident 1's Care Area Assessment, dated 07/21/2023, showed Resident 1 had cognitive loss. Record review of Resident 1's Care Plan, dated 08/02/2013, showed Resident 1 had impaired cognitive functioning related to a medical condition, and that the facility was to offer an ongoing structured activity program for intellectual stimulation. Observation on 07/16/2023 at 11:24 AM, showed Resident 1 sat in their wheelchair and watched television (TV). Observation on 07/17/2023 at 8:41 AM and at 10:00 AM, showed Resident 1 sat…

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 record review the facility failed to consistently follow physician ordered eating recommendations for 1 of 1 resident (Resident 59) reviewed for safe swallowing guidelines. This failure placed the resident at risk for choking, aspiration (a condition where food or liquids are breathed into the lungs), and an overall decline in their health status. Findings included . Resident 59. Review of the resident's Electronic Health Record (EHR) showed the resident was admitted to the facility on [DATE] following a stroke (damage to the brain from an interruption in blood flow) and dysphagia (impaired ability to safely swallow). The EHR showed the resident had a gastrostomy tube (GT a tube inserted into the abdomen) placed on 06/23/2023 while at the hospital to maintain their hydration and nutritional status and their inability to safely swallow food and liquids. The most current comprehensive assessment, dated 07/05/2023, showed the resident was cognitively intact and required total…

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 record review, the facility failed to ensure residents received proper treatment and assistive devices to maintain their vision for 2 of 3 residents (Resident 49 and 59) reviewed for vision. Failure to assist residents to obtain vision services/devices, placed the residents at risk for decreased self-care, social interaction and participation in activities. Findings included . Resident 49. Electronic Health Record (EHR) review showed the resident was admitted to the facility on [DATE] with diagnoses to include Diabetes Mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of the 06/23/2023 comprehensive assessment showed the resident had adequate vision (sees fine detail, such as regular print in newspapers/books) and moderate cognitive impairment. During an interview on 07/17/2023 at 8:54 AM, Resident 49 was in bed with the head of bed elevated. There were several facility handouts on the resident's overbed table 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 interview and record review the facility failed to ensure pharmacy recommendations were followed up on for 1 of 5 resident (Resident 25), reviewed for unnecessary medications. This failure placed the resident at risk of inaccurate dosing of medication, adverse side effects, and receiving a medication longer than medically necessary. Findings included . Review of the facility policy titled Medication Regimen Review (MRR) dated July 2021, showed the MRR involved reporting of findings with recommendations for improvement. Recommendations are acted upon and documented by the facility staff and/or the prescriber. Resident 25. Review of the resident's Electronic Health Record (EHR) showed, the resident admitted to the facility on [DATE] with multiple diagnoses which included depression and psychotic disorder. Review of the comprehensive assessment, dated 06/23/2023, showed the resident's cognition was moderately impaired. Review of the pharmacy recommendation, dated 6/19/2023, showed the pharmacist…

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.