Wind River Rehabilitation and Wellness

Based on observation, medical record review, policy and procedure review, and manufacturer recommendation review, the facility failed to ensure medication error rates were not greater than 5% during medication administration for 1 of 4 sample residents (#3) observed during medication administration. The medication error rate was 7.69%, 2 out 26 observations. The findings were: 1. Observation on 6/25/25 at 9:34 AM showed LPN #1 prepared 7 medications for resident #3 which included potassium chloride (mineral supplement) 20 meq (milliequivalents) tablet and duloxetine hydrochloride (antidepressant) 40 mg (milligrams) capsule. Further observation showed the LPN broke open the duloxetine capsule and placed it in a medication cup, then crushed the potassium chloride tablet with other medications before adding it to the medication cup. The LPN added applesauce and administered the medications to resident #3. Review of the physician orders for the resident showed an order May crush meds unless contraindicated dated 11/6/2014, duloxetine hydrochloride delayed release particles 40 mg give 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.

Based on medical record review, staff interview, and review of facility investigation and education documentation, the facility failed to ensure residents were free from physical abuse by other residents for 1 of 4 residents (#10) reviewed for allegations of abuse. The findings were: 1. Review of the 11/4/24 quarterly MDS assessment showed resident #11 (perpetrator) had a BIMS score of 6, indicating severe cognitive impairment. The resident exhibited physical behavioral symptoms 1-3 days during the assessment period. Review of a progress note dated 10/28/24 showed the resident was ambulating to his/her room and encountered another resident. Resident #11 reached over and pinched the other resident in the arm. Review of the care plan showed on 10/28/24 the care plan was updated to reflect the resident to resident altercation. The resident was placed on a 1:1 for supervision following the incident. 2. Review of the 9/6/24 quarterly MDS assessment showed resident #10 (victim) had a BIMS score of 3, indicating severe cognitive impairment. A progress note dated 10/28/24 showed 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 medical record review and staff and physician interview, the facility failed to ensure monitoring in accordance with physician's orders for 2 of 2 sample residents (#14, #16) with edema. The findings were: 1. Review of the 10/31/24 admission MDS assessment showed resident #16 had diagnoses including heart failure, renal insufficiency, pulmonary hypertension and localized edema. Review of a 10/29/24 progress note by physician #1 showed the resident had 2+ lower extremity edema up to the thighs. Review of physician orders showed on 10/29/24 daily weights were ordered. The following concerns were identified: a. Review of the medical record showed daily weights were not documented on 10/29, 10/30, 11/4, 11/7, 11/8 and 11/10 (the resident was discharged on 11/11/24). b. On 11/14/24 at 1:19 PM the administrator stated she was unable to locate any additional weights and confirmed the weights were not done per physician orders. During another interview on 11/14/24 at 3:08 PM the administrator stated the facility did not have a policy, but stated it was standard of practice 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.

Based on medical record review, staff and physician interview, and review of policies, the facility failed to provide care in accordance with physician's orders and professional standards of practice for 2 of 2 sample residents (#7, #8) with pressure ulcers. The findings were: 1. Review of the 10/7/24 annual MDS assessment showed resident #8 had one stage 3 and two stage 4 pressure ulcers. The 11/4/24 discharge MDS assessment showed the resident had 3 stage 4 pressure ulcers. Review of the 10/9/24 physician progress note showed the resident was bedbound due to myelopathy of the lower extremities and .recurring sacral pressure sores. despite best efforts to heal [his/her] wounds and work with pressure relief, the pressure sores keep recurring. Review of a progress note by the wound care nurse on 10/29/24 showed .Resident stage 3 on sacrum has developed into stage 4 pressure injury with coccyx palpable and visible. Large amount of drainage observed with slight odor; measuring 12x12x0.8 cm [centimeters] with undermining from 12 to 2 measuring 2.5cm Call made to MD making him aware 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 medical record review and staff interview, the facility failed to provide medications to meet the needs of the resident for 1 of 11 sample residents (#13). The findings were: 1. Review of the 9/3/24 admission MDS assessment showed resident #13 had diagnoses including abscess liver, CAD [coronary artery disease], hypertension, and diabetes mellitus. Review of a progress note by physician #1 dated 9/26/24 showed the physician documented the following medication changes: a. Start aspirin 81 milligrams (mg) every day for CAD. b. Start Ursodiol 300 mg, three times per day, for pericholecystic abscess. c. For primary hypertension, will stop Furosemide while we monitor volume status. d. For diabetes mellitus, will stop Glipizide and start Empagliflozin 25 mg once per day. The following concerns were identified: a. Review of the medication administration record (MAR) from 9/26/24 until discharge on [DATE] showed the medication changes from the 9/26/24 progress note were never implemented. b. On 11/14/24 at…

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 review of the 2022 Food Code, the facility failed to store and prepare food in accordance with professional standards related to expired food, hair restraints, and hand hygiene/gloving during 3 of 3 observations in the kitchen and 1 of 1 observation of tray line service. The findings were: 1. The following concerns were identified related to hair restraints: a. Observation on 3/11/24 at 3:15 PM in the kitchen revealed the certified dietary manager (CDM) was wearing a hair restraint, but was not wearing a beard restraint to cover his beard. b. Observation on 3/13/24 at 12:21 PM revealed the CDM was assisting staff with tray line service (putting sour cream on the trays in the carts) and was not wearing a beard restraint to cover his beard. c. During an interview on 3/13/24 at 4:32 PM the CDM stated he had heard about beard restraints but had never worn one. Review of the 2022 Food Code, US Food and Drug Administration, showed .2-402 Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in ¶ (B) of this section, FOOD EMPLOYEES shall…

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 interview, the facility failed to ensure a safe environment for residents, staff, and public. The census was 56. The findings were: 1. Observation on 3/12/24 at 4:40 PM showed broken floor tiles outside the soiled utility room near room [ROOM NUMBER]. The area had built-up dirt and debris in the tile cracks which appeared black in color. In addition, the hand rails in the area were discolored and the sealant had been worn away, which created a porous surface, and the rails could not be effectively sanitized. 2. Observation on 3/12/24 at 4:43 PM showed an EZ Way sit to stand mechanical lift positioned in the hallway, outside room [ROOM NUMBER]. The lift had dirt and debris built-up on the standing platform which appeared black in color. 3. Observation on 3/12/24 at 4:46 PM showed a heater vent cover in room [ROOM NUMBER] which had visible rust and damaged brackets sticking out. The damaged brackets had sharp edges visibly noticeable. 4. Observation on 3/12/24 at 4:48 PM showed the…

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

Based on observation, review of the menu, and staff interview, the facility failed to ensure the menu was followed for 1 of 1 meals observed for meal preparation and tray line service. The findings were: 1. Review of the menu for the 3/13/24 lunch meal showed it included cranberry glazed pork loin, baked potato, beets, and a roll for the regular diet. However, the CCHO (consistent carbohydrate diet for diabetes) menu consisted of a baked pork loin, 1/2 baked potato, beets, and no roll. The following concerns were identified during tray line service on 3/13/24 from 12:03 PM through 12:59 PM: a. Resident #40 had a CCHO diet and was served cranberry sauce over the pork, a whole potato, beets, and a roll. b. Resident #39 had a CCHO diet and was served cranberry sauce over the pork, half a potato, beets, and a roll. c. Resident #28 had a CCHO diet and puree texture and was served pureed pork with the cranberry sauce, pureed beets, mashed potatoes, and pureed bread. d. Resident #34 had a CCHO diet and soft and bite sized texture and was served ground pork with cranberry sauce, mashed…

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, staff interview, resident representative interview, and resident rights review, the facility failed to ensure 1 of 25 sample residents (#54) was treated with dignity and care in a manner that promoted quality of life. The finding were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #54 had severely impaired cognition. The diagnoses included medically complex conditions, wound infection, other fracture, non-Alzheimer's dementia, and depression. The resident required extensive assistance with dressing, toileting, and personal hygiene. The following concerns were identified: a. Review of the 11/21/23 at 9:59 PM progress note showed Communication with Family/NOK/POA, resident's daughter, expressed her dissatisfaction with resident's haircut. I told them to let me know when [s/he] needs a haircut. I have someone hired to come in and cut [his/her] hair. I don't want [his/her] head buzzed like this. b. Review of the 11/22/23 at 3:16 PM progress note showed…

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 representative and staff interview, medical record review, facility grievance log review, and policy and procedure review, the facility failed to ensure the grievance procedure was followed for 1 of 6 sample residents (#104) reviewed for reported grievances. The findings were: 1. Review of the Discharge Transition Plan dated 2/9/24 and timed 8:10 AM showed resident #104 had a planned discharge scheduled for 2/10/24. Further review showed the resident's representative and social services director signed the plan on 2/10/24. Review of the Recapitulation of Resident Stay dated 2/12/24 showed the resident discharged from the facility on 2/10/24. The following concerns were identified: a. Interview with the resident's representative on 3/14/24 at 8:33 AM confirmed the resident discharged from the facility on 2/10/24 and revealed she reported concerns of missing items to the social services director at the time of discharge. The resident's representative revealed the missing items reported included a pair of swim shoes, 2 white shirts, a pair of pajamas, and a glasses…

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, medical record review, and staff and resident interviews, the facility failed to provide necessary treatment to promote healing for 2 of 5 sample residents (#50, #105) with pressure ulcers. The findings were: 1. Review of the 3/3/24 admission MDS assessment showed resident #50 had diagnoses including renal insufficiency and was at risk for pressure ulcers, but did not have any. Review of a progress note dated 3/5/24 showed therapy called the nurse to assess the resident's heel when blood was observed on the resident's left sock. A 5 x 4.5 x 0.1 cm serosanguinous filled blister was observed to the left heel. Review of a progress note dated 3/12/24 showed the pressure ulcer to the left heel was 4.5 x 4.5 x 0.1 cm and new epitheliazation was observed around the wound edges. Observation on 3/12/24 at 10:40 AM showed RN #1 provided wound care to the left heel. Review of physician orders showed on 3/5/24 the physician ordered for the wound to be cleaned with wound cleanser, covered with skin prep, a non adherent foam applied and then covered with mepilex. The order…

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, medical record review, and staff interview, the facility failed to ensure therapeutic diets were provided in accordance with physician's orders during 1 of 3 meal observations. Random observations showed thickened liquids were not appropriately provided for resident #28 and resident #43. The following concerns were identified: 1. Observation on 3/11/24 at 5:03 PM showed CNA #2 obtained a small container of white powder which was not covered, labeled, or dated, she referred to as thickener, from on top of the book shelf in the dining room. The CNA dumped the contents of the container into a plastic cup, then poured hot cocoa into the cup. The CNA stirred the contents briefly and provided to the cup of fluid to resident #28. The resident took a drink of the fluid and coughed several times after drinking. Continued observation throughout the meal showed the resident did not drink any more of the hot cocoa during the meal. 2. Review of the medical record for resident #28 showed s/he had an active physician's order for .puree texture, mildly thick liquid consistency…

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 professional reference review, the facility failed to ensure infection prevention techniques were followed for 1 of 5 sample residents (#50) during wound care. The findings were: 1. Observation of wound care for resident #50 on 3/12/24 at 10:40 AM showed RN #1 cleaned a surgical wound on the resident's abdomen, below the umbilical, with wound cleanser and gauze. Without removing her gloves or performing hand hygiene, the RN opened a package of xeroform impregnated gauze and placed it over the site, opened a second package of xeroform impregnated gauze and placed it over the site, and opened an abdominal (ABD) dressing and applied over the xeroform. At that time, the RN removed her gloves, used some scissors from her pocket, cut a strip of medifix tape, and applied it to the top of the ABD dressing. The RN tucked the lower bottom portion of the ABD dressing into the resident's incontinence brief. The RN applied clean gloves and got on her hands and knees in a position 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, resident, resident representative and staff interview, medical record review, and staffing log review, the facility failed to ensure adequate staff to meet the needs of the residents. The census was 59. The findings were: 1. Review of the staffing logs from 12/1/22 to 12/8/22 showed the facility required 1 nurse or medication aide per unit on each shift, which would result in 4 nurses and/or medication aides for each day. Further review showed the facility required 8 CNAS (3 CNAs on the front unit, 3 CNAs on the back unit, and 2 CNAs on the secure unit) from 6 AM to 2 PM (day shift), 6 CNAs (2 CNAs on the back unit, 2 CNAs on the front unit, and 2 CNAs on the secure unit) from 2 PM to 10 PM (evening shift), and 3 CNAs (1 CNA on the back unit, 1 CNA on the front unit, and 1 CNA on the secure unit) from 10 PM to 6 AM (night shift), and 1 restorative aide daily. Interview with the ED on 12/7/22 at 10:30 AM confirmed staffing identified on the staffing logs was the required staffing to ensure…

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, resident and staff interview, and policy and procedure review, the facility failed to ensure baths or showers were provided routinely for 3 of 4 sample residents (#7, #42, #56) who required assistance with bathing. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #7 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and diagnoses which included seizure disorder or epilepsy, depression, arthritis, unsteadiness on feet, and other lack of coordination. Further review showed the resident required total physical assistance of 1 person for bathing. Review of the ADL care plan last revised on 10/28/22 showed .BATHING/SHOWERING: The resident requires limited-extensive assist by 1 staff with showering or bathing 2-3X [two to three times] weekly and as necessary . The following concerns were identified: a. Interview with the resident on 12/8/22 at 11:35 AM revealed s/he had received a shower on that day and it 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 observation and staff interview, the facility failed to ensure water did not reach hazardous temperatures for residents on 3 of 3 units (front unit, back unit, secure unit). The findings were: 1. Observation on 12/8/22 at 10:29 AM with the maintenance director showed the hot water temperature at the handwashing sink in room [ROOM NUMBER] was 130 degrees Fahrenheit. The maintenance director verified the temperature at that time. 2. Observation on 12/8/22 at 10:34 AM with the maintenance director showed the hot water temperature at the handwashing sink in room [ROOM NUMBER] was 124.5 degrees Fahrenheit. The maintenance director verified the temperature at that time. 3. Observation on 12/8/22 at 10:38 AM with the maintenance director showed the hot water temperature at the handwashing sink in room [ROOM NUMBER] was 136 degrees Fahrenheit. The maintenance director verified the temperature at that time. 4. Observation on 12/8/22 at 10:40 AM with the maintenance director showed the hot water temperature at…

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 failed to ensure food was properly stored in 1 of 1 kitchen. The findings were: 1. Observation on 12/5/22 at 2:27 PM of the walk-in refrigerator showed one opened carton of thickened cranberry juice with a received date of 11/16/22; four open cartons of lemon-flavored thickened water with received dates of 9/14/22, 10/26/22, and 11/23/22; and one open carton of thickened apple juice with a received date of 11/23/22. None of the cartons were marked with an open or use-by date. Review of the Sysco Imperial Thickened liquid cartons showed After opening can be kept for 7 days. 2. Observation on 12/5/22 at 2:27 PM of the walk-in refrigerator showed two cases containing 75 four fluid ounce cartons of Sysco Imperial strawberry-flavored and vanilla-flavored shakes. In addition to the boxes of shakes multiple loose cartons of the shakes were stored in plastic tubs. None of the cartons were marked with a date they were removed from the freezer and made available for resident consumption. Review of the Sysco Imperial shakes cartons showed…

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, review of facility reportable incidents, staff interview, review of the facility's COVID surveillance documentation, Centers for Disease Control (CDC) guidelines and policy and procedure review, the facility failed to ensure infectious disease outbreaks were reported as required, and failed to ensure infection control practices were implemented for 5 random observations. The census was 59. The findings were: Regarding reporting of the infectious disease outbreaks: 1. Review of the COVID-19 OUTBREAK STRATEGY ACTION PLAN dated 11/10/22, provided by the facility at the time of entrance, showed one staff member tested positive for COVID-19 on 11/10/22 and a second staff member was sent home on [DATE]. Review of the resident testing records showed 14 residents tested positive on 11/28/22; 2 residents tested positive on 11/30/22; and 5 residents tested positive on 12/2/22. 2. Review of the facility reportable incidents from 10/1/22 through 12/1/22 showed no evidence the facility had reported 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 review of the facility's resident immunization documentation, medical record review, and staff interview, the facility failed to ensure documentation related to the education, administration, refusal, or medical contraindication of immunizations was included in the medical record for 3 of 5 residents (#18, #34, #40) reviewed for immunizations. The findings were: 1. Review of the medical record for resident #18 showed s/he had declined the influenza vaccine on 10/5/22. Review of the facility's immunization documentation showed the resident had declined the SARS-CoV-2 vaccine. There was no evidence of documentation, signed by the resident or the resident's representative, of the education provided and the refusal of the vaccine in the resident's medical record. 2. Review of the medical record for resident #34 showed s/he had received the first dose of the SARS-CoV-2 primary series, however had refused the second dose. There was no evidence of documentation, signed by the resident or the resident's representative, of the education provided and the refusal of the vaccine in 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 medical record review, resident and staff interview, review of facility grievances, and policy and procedure review, the facility failed to ensure grievances were resolved for 1 of 2 sample residents (#56) reviewed for grievances. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #56 had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact. Further review showed the resident had diagnoses which included unspecified head injury and torticollis. Review of the activity care plan last revised on 11/3/22 showed the resident had little or no activity involvement due to disinterest, physical limitations, and desire to not participate. Interventions included .prefers the following radio stations: Country and Western .preferred activities are: .music. The following concerns were identified: a. Interview with the resident on 12/6/22 at 1:40 PM revealed the resident recently went to the hospital and upon his/her return, s/he identified some…

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 and staff interview, the facility failed to ensure a comprehensive care plan was developed for 3 of 15 sample residents (#15, #28, #49). The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #15 had a BIMS score of 4 out of 15, which indicated severe cognitive impairment, and diagnoses which included Alzheimer's disease, non-Alzheimer's dementia, and anxiety disorder. Further review showed the resident had a depression score of 0 and no behaviors were exhibited. Review of the physician's orders showed the resident received trazodone (antidepressant) 100 mg by mouth one time per day related to insomnia and duloxetine (antidepressant) 20 mg by mouth twice per day for anxiety. The following concerns were identified: a. Review of the MAR for December 2022 showed the resident had 2 orders for target symptoms monitoring; however, there was no indication which symptoms were being monitored for which psychotropic medication. b. 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 medical record review and staff interview, the facility failed to revise the care plan to reflect the resident's needs after a comprehensive assessment for 1 of 15 (#34) sample residents reviewed. The findings were: 1. Review of the 10/21/22 significant change MDS assessment showed resident #34 had a BIMS score of 3 out of 15 (cognitively impaired) and required the extensive assistance of one staff member for eating. Review of a 10/16/22 nurse's note showed the resident had returned from the hospital with a diagnosis of inoperable left hip fracture. The following concerns were identified: a. Observation on 12/5/22 at 6:08 PM showed the resident was in bed and CNA #1 was assisting him/her with the evening meal. Interview with CNA #1 at that time revealed the resident required the assistance of staff with eating. b. Interview on 12/8/22 at 8:57 AM with CNA #2 revealed staff had assisted the resident with eating either in his/her room or at the table since the resident broke his/her hip. c. Review of the resident's ADL care plan, last revised on 3/18/21, showed the resident…

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

Based on medical record review, and resident representative and staff interview, the facility failed to ensure residents received services to maintain range of motion for 2 of 2 residents (#19, #37) reviewed for range of motion. The findings were: 1. Review of the 10/5/22 annual MDS assessment showed resident #19 had a BIMS score of 8 out of 15 (moderate cognitive impairment) and was admitted with diagnoses which included left artificial knee joint, generalized muscle weakness, pain in the right shoulder, joint disorder of the right knee, lack of physical exercise, osteoarthritis in the right hand, and dementia. Review of the care plan, revised on 3/17/22, showed the resident was to receive restorative nursing rehabilitation, which included stationary pedaling for the arms and legs, free weights, and tension band exercises. The following concerns were identified: a. Review of the care conference notes dated 12/5/22 and timed 10:36 AM, showed the resident participated in restorative therapy exercises; however, review of the medical record failed to show documentation of restorative…

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, medical record and policy and procedure review, the facility failed to ensure PRN (as needed) orders for anti-psychotic medications were limited to 14 days for 1 of 5 sample residents (#34). In addition the facility failed to ensure the physician provided a rationale for contraindication to a dose reduction for 1 of 5 sample residents (#43) reviewed for psychotropic medications. The findings were: 1. Review of the physician orders for resident #34 showed s/he was prescribed 25 mg of Seroquel (antipsychotic) every 12 hours as needed for agitation with a start date of [DATE]. The following concerns were identified: a. Review of the Consultant Pharmacist Recommendation to Physician, dated [DATE], showed the pharmacist recommended the discontinuation of the PRN Seroquel on or before [DATE] and noted the resident had used 2 doses during the month of April. The physician responded on [DATE] to Renew order for PRN antipsychotic Seroquel prescribed for agitation for 14 days, as the benefit…

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.