Edenbrook Lakeside

Based on interview and record review, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 1 of 8 employees reviewed. The facility did not ensure their abuse policy was implemented when one employee's (Housekeeper-V) Integrated Background Information System (IBIS) background check was not obtained before the employee started working at the facility. Findings include:The facility policy and procedure titled Vulnerable Adult Abuse and Neglect Prevention last revised 3/25/25 documents::Purpose: To provide residents a safe environment t that is free from harm.1. Screening and Training of New Employees and Volunteers:A. Employees:i. Screen potential employees for a history of abuse, neglect, exploitation, or mistreatment. That includes . checking with the appropriate licensing boards and registries.iv. A criminal background check will be conducted on all prospective employees as provided by the facility's policy on criminal background checks, using…

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 did not ensure a comprehensive person-centered care plan was developed for 3 (R11, R77 & R85) of 22 residents reviewed. *R11 did not have an oxygen care plan. *R77 did not have a care plan for tubi grips. *R85 did not have a dehydration care plan. Findings include: The facility's policy titled, Care Plan – Baseline and Comprehensive and last revised 7/18/24 documents: To ensure that each resident care individualized to him or herself and that goals and approaches for care are communicated to all parties including caregivers, the resident, and the resident's representative. Under the Policy section it documents: The Interdisciplinary Team will develop an individualized, comprehensive care plan for each resident based on their medical condition, medical history, assessments from different members of the interdisciplinary team, lifestyle, and current resident goals. 1.) R11's diagnoses include acute respiratory failure (lungs cannot adequately exchange oxygen and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility did not update the comprehensive person-centered care plan for 1 (R10) of 22 residents to meet a resident's medical, nursing and psychosocial needs that are identified in the comprehensive assessment.R10's care plan was not updated after R10 was removed from hospice services.Findings include:The facility's policy and procedure titled Care Plan-Baseline and Comprehensive last revised 7/18/24, documents: Purpose- To ensure that each resident receives care individualized to him or herself and that goals and approaches for care are communicated to all parties including caregivers, the resident, and the resident's representative. Policy: The Interdisciplinary Team will develop an individualized, comprehensive care plan for each resident based on their medical condition, medical history, assessments from different members of the interdisciplinary team, lifestyle, and current resident goals.Procedure:7. Throughout the course of rehabilitation and the resident's stay…

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 did not ensure that 1 (R105) of 4 residents reviewed for ADL (Activities of Daily Living) assistance received the necessary services to maintain ability to practice good grooming and personal hygiene.*R105, whom requires assistance from facility staff, did not receive any showers in the last 30 days and was observed in the same clothes during survey. Findings include:The facility policy entitled, Activities of Daily Living (ADLs), last revised 2/25/2025 documents: 1. A resident will be given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living.2. The facility will provide care and services for the following activities of daily living:Bathing and hygiene: Assistance with bathing or showering and maintaining personal hygiene.Dressing: Helping residents put on or remove clothing.Based on the assessments, a personalized care plan is created. It outlines the level of assistance needed for each…

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 did not ensure that 2 (R5, R47 and R105) of 4 residents who are unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene.*R5, who is dependent on staff, only received 1 shower in 30 days, with no documented refusals. R5, who is also dependent on staff for toileting, was not checked or changed for incontinence and was observed with a saturated brief.*R47, who is dependent on staff, did not receive any showers in the last 30 days, with no documented refusals. R47, who is totally dependent on staff, was not checked or changed for incontinence per R47's care plan.Findings include:The facility policy entitled, Activities of Daily Living (ADLs), last revised 2/25/2025 documents: 1. A resident will be given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living.2. The facility will provide care and services for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility did not ensure residents received necessary care and treatment in accordance with professional standards of practice for 1 (R77) of 22 residents reviewed for quality of care.*R77's physician orders document that R77 is to wear bilateral tubi-grips during the day and off at night. Surveyor observed R77 not wearing bilateral tubi-grips during the survey process.Findings include:R77 was admitted to the facility on [DATE] with diagnoses of Peripheral Vascular Disease(circulatory condition in which narrowed blood vessels reduce blood flow to limbs), Cellulitis(bacterial skin infection affecting deep dermis and subcutaneous tissue) of Right Lower Limb, Essential Hypertension(chronic condition of persistently high blood pressure), Hypothyroidism(underactive thyroid), and Hyperlipidemia(high levels of fat particles in blood).R77's admission Minimum Data Set (MDS) completed 2/16/26 documents a Brief Interview for Mental Status (BIMS) score to be 14,…

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 did not ensure 2 (R74 & R2) of 6 residents with limited range of motion receive appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. *R74 was observed not wearing the right palm guard and left-hand carrot during the survey. *R2 was observed not wearing bilateral palm guards during the survey. Findings include: The facility's policy titled, Orthotics and dated 12/8/25 documents under purpose To ensure safe, clinically appropriate, person-centered use of hand splints and braces that support function, prevent/mitigate contracture or deformity, protect healing tissues, and reduce pain while maintaining resident rights, dignity, and freedom from unnecessary restraint. 1.) R74 was admitted to the facility with diagnoses that include nontraumatic intracerebral hemorrhage (a life threatening type of stroke caused by a ruptured blood vessel), chronic kidney disease (kidneys are damaged 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 did not ensure the environment remained free of accident hazards with smoking materials for 1 (R82) of 2 residents reviewed for smoking and that residents received adequate supervision to prevent accidents for 2 (R22 and R106) of 3 residents reviewed for falls. * R82 was seen vaping in R82's room for the duration of the survey. * R22 was observed not to have fall interventions in place the duration of the survey. R22 also had multiple falls that were not thoroughly investigated. * R106 had multiple falls that were not thoroughly investigated. Findings Include: The facility's policy and procedure titled Smoking and E-Cigarettes revised on [DATE] documents: When the resident requests to smoke (includes smoking of any material, including but not limited to tobacco, marijuana, saliva (sage), etc). Smoking will only be allowed in designated outdoor area(s) in the facility that are not near flammable substances or where oxygen is in use. - Smoking -…

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 did not ensure 1 (R4) of 6 residents reviewed for nutrition received therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.* R4 was not provided with a meal supplement per R4's plan of care.Findings include:R4 was admitted the facility on 12/18/24 with diagnoses of Unspecified protein calorie malnutrition (A deficiency of protein and calories leading to weakened immunity), Gastroparesis (chronic digestive disorder causing delayed stomach emptying causing nausea and vomiting), and Dependence on Renal Dialysis (the person requires dialysis to remove toxins from the body due to the kidneys not functioning properly).R4's nutritional care plan initiated 12/18/24 and revised on 2/26/26 documents under the Interventions section:- Provide supplements with Med pass as ordered: Nepro BID (2 times a day) daily. Document and monitor acceptance. Initiated 11/25/2025, revised 2/8/26- Honor resident's food…

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 did not ensure that 1 (R5) of 1 residents reviewed with a gastronomy tube (G-tube) received appropriate treatment and services. *R5 has a physician order to measure R5's G-tube to check for placement, indicating R5's tube length should be 16 inches plus or minus 1. This order was not transcribed into the R5's Medication Administration Record (MAR)/ Treatment Administration Record (TAR) so that nursing staff could accurately monitor placement of R5's G-tube. Findings include:The facility's policy titled: Verifying Placement of Feeding Tubes, last revised 9/8/2023, documents: 1. Gastrostomy tube will be marked with a permanent marker at the exit sit of tube. 2. Upon admission or with placement of new tube, the length is measured from exit site to end of tube and documented in clinical record. 3. Tube length will be visually inspected by checking initial mark on tube prior to accessing tube. 4, If external tube length has changed or mark on tube is…

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 did not provide the necessary respiratory care and services for 1 (R11) of 1 resident receiving oxygen therapy.R11's oxygen concentrator did not have a humidification bottle according to physician orders.Findings include:R11's diagnoses include acute respiratory failure (lungs cannot adequately exchange oxygen and carbon dioxide) with hypoxia (low level of oxygen), congestive heart failure (heart doesn't pump enough blood to meet the body's needs) and hypoxemia (abnormally low level of oxygen in the blood), and hypertension (high blood pressure).R11's physician order dated 10/24/25 documents: Change oxygen humidifier bottle weekly and prn (as needed).On 3/23/26, at 9:52 a.m., Surveyor observed R11 in bed on his back with the head of the bed elevated. Surveyor observed R11 is receiving oxygen via nasal cannula at 1.5 liters per minute. Surveyor observe R11's oxygen concentrator did not have a humidifier bottle.On 3/23/26, from 10:59 a.m. to 11:21 a.m., Surveyor observed Certified Nursing Assistant (CNA)-Y and CNA-Z…

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 interview, the facility did not provide all the required transfer notice information for a resident transfer out of the facility. This was observed with 1 (R6) of 1 resident transfer reviews. * R6 was transferred to the hospital from the facility. There is not documentation they were provided the required transfer notice information. Findings include: The facility's policy and procedure titled Admission, Readmission, Bed Hold, and Transfer/Discharge dated 10/12/21, documents . Transfer/discharge: Before the facility transfer or discharges a resident, the facility must - * Notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand.; Include in the notice - * The reason for transfer or discharge. * The location to which the resident is transferred or discharged . * A statement of the resident's right to appeal including the name, address (mailing and email) and telephone number of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not permit a resident to be readmitted to the facility immediately following hospitalization. This was observed with 1 (R6) of 1 resident reviewed for readmission. * R6 was transferred from the facility to the hospital on [DATE]. On 12/13/24 R6 was transferred from the hospital back to the facility however the facility denied readmission. R6 was sent back to the hospital. R6 did not have a change in their clinical status to be denied readmission to the facility. R6 was readmitted to the facility on [DATE] from the hospital. Findings include: The facility's policy and procedure titled Admission, Readmission, Bed Hold, and Transfer/Discharge dated 10/12/21 documents .readmission: * A resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, will be re-admitted to the facility to their previous room (if available) or to the first available bed in a semi-private room if the resident; - Requires the services provided by…

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 did not ensure 2 (R82 and R31) of 18 residents reviewed had an individualized comprehensive plan of care. * R82 did not have a comprehensive care plan for R82's foley catheter that was inserted on 9/23/2024. * R31 was assessed to be incontinent of bowel and bladder and did not have a care plan in place with relevant interventions. Findings include: The facility policy entitled Care Plan- Baseline and Comprehensive revised on 6/20/2023 documents, Purpose: To ensure that each resident receives care individualized to him or herself and that goals and approaches for care are communicated to all parties including caregivers, the resident, and the resident's representative. Policy: The Interdisciplinary Team (IDT) will develop an individualized, comprehensive care plan for each resident based on their medical condition, medical history, assessments from different members of the IDT, lifestyle, and current resident goals. Procedure: 1. The care plan is…

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 did not ensure 1 (R55) of 1 residents receiving medications through G (Gastronomy Tube ) tube received the care necessary to meet professional standards. * On 10/24/24, Surveyor observed LPN (Licensed Practical Nurse)-C administer medications to R55 via G tube. LPN-C did not check G tube placement prior to instilling medication. Findings include: The facility's Tube Feeding: Administering Medications Policy and Procedure with revision date of 9/8/23 documents: 9. Verify placement of feeding tube: Verifying Placement of Feeding Tube Policy The facility's Verifying Placement of Feeding Tubes Policy and Procedure with revision date of 9/8/23 indicate . 1. Gastronomy Tube will be marked with a permanent marker at the exit site of tube. 2. Upon admission or with placement of new tube, the length is measured from exit site to end of tube and documented in clinical record. 3. Tube length will be visually inspected by checking initial mark on tube prior to accessing tube. 4. If external tube length has changed or mark on tube is…

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 did not ensure residents received post fall assessments as indicated in the Facility policy in order to guarantee a resident received treatment and care in accordance with professional standards of practice for 1 (R56) of 5 residents reviewed for falls. R56 did not have post fall assessments completed per policy of once per shift for 3 days for falls that occurred on June 6/29/24 and 8/30/2024. Findings include: The Facility Policy and Procedure titled Post Fall Policy revised 10/13/23, documents (in part): Monitoring and Re-evaluation -Document on resident's condition at a minimum of every shift for 72 hours. -Staff should document relevant post-fall clinical findings, such as vital signs, pain, swelling, bruising and changes in function or cognitive status. -Staff will have increased awareness that the resident has recently fallen and report any changes in function, increased pain, and changes in cognition to the nurse for further evaluation. -Monitor 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 interview and record review, the Facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, including the ongoing communication with the dialysis center before and after dialysis treatments for 1 (R43) of 2 residents reviewed for dialysis. R43 has a physician order for dialysis at Fresenius on Capitol on Tuesday, Thursday and Saturday. Communication between the Facility and the dialysis center was not being shared with each visit. Findings include: The Facility Policy and Procedure titled Care of Hemodialysis Resident last revised on 6/28/2021 documents (in part): Procedure . -Facility will have ongoing communication and collaboration with the dialysis facility . Post Dialysis -Review communication documents for any pertinent information . 1.) R43 was admitted to the facility on [DATE] with a diagnoses that includes sepsis, alcoholic cirrhosis of liver, end stage renal disease and dependence on renal dialysis. R43's quarterly…

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 did not ensure its medication error rates are not 5 percent or greater. The facility medication error rate was 41.67%. On 10/24/24, R55 was administered medications via G (gastronomy) tube. LPN-C did not flush the G tube with water before or/and after instilling medications. R55 received 15 medications via G tube. Due to LPN-C not flushing with water after instilling medications, all 15 medications are medication errors which resulted in medication error rate of 41.67%. Findings include: The facility's Tube Feeding: Administering Medications Policy and Procedure with revision date of 9/8/23. 10. Insert syringe (without plunger) and flush tube with 30 ml (milliliters) water or as ordered; do not use cold water which may induce abdominal cramping. R55 physician order dated 11/27/23 documents May combine medications to give all at once during G tube administration with flushes as ordered. On 10/24/24 at 7:59 a.m., Surveyor observed LPN (Licensed Practical Nurse)-C prepare and administer R55 medications via G tube. R55 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure one (Resident (R)2) out of five reviewed for medications received ordered medications upon admission. This had the potential for the resident to have unmet care and health needs. Findings include: Review of the Census tab of the electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE] at 5:45 PM. Review of the Diagnosis tab located in the EMR revealed diagnoses of presence of right artificial knee joint, end stage renal disease, and kidney transplant status. Review of R2's Medication Administration Record (MAR) for December 2023 with the Director of Nursing (DON) revealed the following physician ordered medications were not given as ordered the evening of 12/21/23 or 12/22/23 due to not being available and there was no evidence the physician was notified the medications were not available: 1. Belsomra Oral tablet 10 MG [milligrams] 1 tablet at bedtime for insomnia to be given at 8:00 PM. A…

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

Based on record review, interview, and facility policy review, the facility failed to administer one (Resident (R) 1) out of five residents insulin in a timely manner, in accordance with the physician's order. This had the potential for the resident to have unmet health care needs. Findings include: Review of R1's Medication Administration Record (MAR) located in the Orders tab of the electronic medical record (EMR) revealed an order for insulin Regular Human Injection solution Pen-injector 100 UNITS/ML. Inject as per sliding scale. The order included how much insulin she should receive depending on the results of her finger stick [blood sugar]. According to MAR at 7:30 AM the resident's blood sugar was 215 and she received three units of the insulin and at 11:30 AM her blood sugar was 234 and she received three units of insulin. During an interview on 03/25/24 with R1 at 12:30 PM revealed her lunch tray was on the overbed table. Some of her food was gone and she stated she had finished eating. During the interview she was asked if she received her medications in a timely manner 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 record review and interview, the facility did not ensure the physician wrote, signed, and dated progress notes at each visit for 4 (R1, R2, R3 and R4) of 4 residents reviewed for MD visit notes. Resident visit notes were not available in Electronic Medical Records (EMR) for R1, R2, R3 and R4 and when requested by Surveyor, were reviewed and signed by the Medical Director on the day requested instead of the visit day. Findings include: Surveyor reviewed facility's Medical Director Policy & Procedure with a revision date of 3/26/20. Documented was: Policy The facility must designate a physician to serve as medical director. The medical director is responsible for: - Implementation of resident care policies. - Coordination of medical care in the facility. Support services include: 1. Assisting in development of staff education programs. 2. Communicating to the medical staff additions and revisions to policies, rules, and regulations. 3. Conducting periodic reviews of resident medical records 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, record review and interview, the facility did not ensure a resident with pressure injuries received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure injuries from developing for 1 of 3 (R19) residents reviewed for pressure injuries. Findings include: R19 admitted to the facility on [DATE] with multiple pressure injuries including a stage 4 pressure injury to the right hip and a deep tissue injuries (DTI) to his right proximal medial and right distal medial foot. R19's diagnosis include Autistic Disorder, severe protein-calorie malnutrition, pneumonia, Respiratory Syncytial Virus, dysphagia, Myocardial Infarction, UTI (urinary tract infection), contractures, and anemia. R19's Quarterly Minimum Data Set (MDS) dated [DATE] documents Functional Limitation Range of Motion: Impairment both sides upper and lower extremities. Ability to roll from lying on back to left and right side and return 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 resident and staff interview and record review, the facility did not ensure grievances or recommendations from resident council meetings were investigated, considered and/or provide follow up for 4 (R70, R93, R88, R63) of 4 Resident in attendance for Resident Council. The facility did not investigate, consider suggestions and/or provide follow up to resident council participants' (R70, R93, R88, R63) grievances and/or concerns that staff were not wearing name tags, staff using personal cell phone in resident care areas, ramp to go outside is hard to get up and door to outside closes too quickly. These concerns were documented several months in a row in the Resident Council Meeting minutes without documented follow up. The grievance documents do not identify how the grievances were investigated, if interviews with staff/residents were completed, or the outcome of the investigation. Resident Council Minutes did not include actions taken regarding the concerns voiced by residents. Findings include: The facility policy, entitled Resident Council, dated 2/26/20, states: 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 interview and record review the facility did not ensure that 4 (R206, R13, R451 and R452) of 7 Residents reviewed for falls received treatment and care based upon assessment of individual needs. * R206 had a fall on 4/16/23 and post fall monitoring which included vital signs each shift for 72 hours was not always completed. * R13 had a falls on 2/28/23 and 5/9/2. Post fall monitoring which included a Registered Nurse assessment and/or vital signs each shift for 72 hours was not always completed. * R451 had a fall on 7/19/23 and post fall monitoring which included vital signs each shift for 72 hours was not always completed. A Registered Nurse assessment was not completed immediately after the fall. * R452 had a falls on 2/7/23, 2/17/23, 4/6/23, 4/7/23, 4/17/23, 4/23/23 and 4/26/23. Post fall monitoring which included a Registered Nurse assessment and/or vital signs each shift for 72 hours was not always completed. Findings include: On 9/18/23 Surveyor reviewed the facilities policy titled Post Fall…

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, record review, and interview, the facility did not store drugs and biologicals in locked compartments affecting three of three floors of the facility potentially affecting mobile residents. Observations on the first, second, and third floor during the survey process showed medication carts to be unlocked and unsupervised with other unauthorized staff and residents in the vicinity of the carts. Findings include: The facility policy and procedure entitled Medication Storage dated 9/21/2019 states: General Guidelines: . 7. Compartments containing medications should be locked when not in use. Trays or carts used to transport such items should not [sic] left unattended. (Note: Compartments include, but are not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes.) . 11. All controlled drugs are stored under double lock and key. On 9/14/2023 at 8:40 AM, Licensed Practical Nurse (LPN)-Q was observed passing medications on the third floor. LPN-Q gathered the medications for a resident, pushed in the locking mechanism of the cart without engaging 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 did not develop a comprehensive resident centered care plan for 1 (R13) of 1 residents reviewed for elopement and the use of a wanderguard. The facility did not develop a plan of care related for elopement precautions and monitoring related to the use of a wanderguard for R13. Findings Include: The facility policy, entitled Elopement Risk and Prevention, dated 6/2022 states: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for wandering/elopement. All residents so identified will have these issues addressed in their individual care plan. R13 was admitted to the facility on [DATE] with diagnoses of Type 2 diabetes, altered mental status, chronic kidney disease stage 3, unsteady on feet, repeated falls, cognitive communication deficit and encephalopathy. R13's Quarterly MDS (Minimum Data…

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 did not ensure 1(15) of 7 residents with pressure injuries received the necessary services for healing. R15 was admitted to the facility on [DATE] with six pressure injuries. Four of the pressure injuries were assessed to be unstageable and the other 2 pressure injuries were assessed to be stage 4. The medical record indicates on 1/31/23 R15's pressure injuries were assessed by Wound Physician-M who wrote treatment orders for daily dressing changes. The medical record reveals the treatment orders were transcribed and completed on 2/2/23. R15 did not have treatments completed on 2/1/23. There is no evidence the pressure injuries worsened. Findings include: R15 was admitted to the facility on [DATE] with diagnoses of paraplegia, schizophrenia and pressure injuries. On 9/19/23, at 8:04 a.m. Surveyor observed pressure injury treatment being completed on R15. Wound Physician-M, Director of Nursing (DON)-B and Assistant Director of Nursing (ADON)-L took…

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 did not ensure the physician acted upon recommendations by the pharmacist for 2 (R40, R38) of 5 Residents reviewed for unnecessary medications. *On 7/19/23, Pharmacy recommendations were given for R40 and not followed up upon. *On 8/28/23, Pharmacy recommendations were given for R38 and not followed up upon in a timely fashion. Findings include: 1. R40 was admitted to the facility on [DATE]. R40's diagnoses include Diabetes Mellitus, Hyperlipidemia and venous insufficiency. Surveyor requested to review R40's Pharmacist MRR (Medication Regimen Reviews) from March 2023-August 2023. Pharmacy recommendations were noted for R40 to receive lab work including a Hemoglobin A1C level and Lipid panel for next scheduled lab day on 7/19/22. Surveyor reviewed R40's medical record and noted lab testing has not yet been completed. On 9/19/23 at 2:00 PM, Surveyor conducted interview with NHA (Nursing Home Administrator)-A. Surveyor asked NHA-A when a physician should be made…

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.