Meadowview Healthcare And Rehab

Based on document review and interviews, the facility failed to provide required training to staff members for 1 of 1 facility. The findings are: Upon request of mandatory in-services, the surveyor received an Infection Control in-service and Resident Rights in-service. Upon reviewing the facility assessment there were no required trainings and/or in-services addressed. A review of an undated document titled, Required Annual State Inservices received by the Director of Nursing (DON), revealed that the in-services that the facility was going to provide were the following: Civil Rights, Disaster Preparedness, Fire Safety, Accident Prevention, Reporting Disaster/Outages, Utility Shut Off Demonstration, Oral and Dental Care, Restorative Nursing, Dignity, Death and Dying, Advanced Directives, Behavior Management, Assessments, Interventions, Medications, Documentation, Infection Control/Wound Management, Universal Precautions, Center of Disease Control, Tuberculosis Prevention, Nosocomial Infections, Treatments, Documentation, Abuse and Neglect, Types of Abuse and Neglect, Incident…

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 document review, and in-service reviews, the facility failed to provide communication training for staff members. Findings include: Upon review the surveyor did not observe a communication training/in-service to staff members. On 10/16/24 at 11:18 AM, during an interview with the Human Resource Director (HRD) she stated she was unsure what communications in-services would be, but she would look for that as well. On 10/16/2024 at 2:00 PM, the HRD brought in in-services, but there were no communication in-services and the HRD revealed that's all she could find. On 10/16/24 at 11:48 AM, during an interview with the Assistant Administrator she reported that there was no communication in-services performed for new hires or existing employees. On 10/16/24 at 11:49 AM, during an interview, the Administrator revealed that a communication in-service would be important to have one so that it would increase communication with staff. On 10/11/2024 at 2:30 PM, during an interview the Administrator reported that the they do not have all the required trainings, and it was 100% his fault.

Based on document review, and interviews, the facility failed to provide Quality Assurance and Performance Improvement (QAPI ) training upon hire and in services to direct staff for 1 of 1 facility. Findings include: A review of the undated policy titled, Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) Policy, revealed that all staff would be educated on the QAPI plan and the role in development and implementation of interventions. Upon record review there was no QAPI trainings or in services for new hire employees or current staff. On 10/11/2024 at 2:30 PM, during an interview with the Administrator, he reported that there was no QAPI training or in-services, for newly hired staff or current staff. The Administrator reported that they did not know that it had to be done. He stated it would be important to do so, because they want the employees to know when and how to report problems and so that the QAPI team could address issues within the facility. The Administrator also reported that they do not have all the required trainings. And…

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

Based on document review, and interviews, the facility failed to conduct a compliance/ethics training for staff members. The finds are: Upon observation no compliance/ethics training was observed. Om 10/11/24 at 10:44 AM, during an interview with the Human Resource Director (HRD) it was revealed that the Administrator does all the administrative training, and depending on what the in-service is about depends on who does the in-services. On 10/11/ 2024 at 2:30 PM, during an interview the Administrator reported that they do not have all the required training. And it was 100% his fault. He reported that the training was done, but the Administrator failed to document them. On 10/16/24 at 11:04 AM, during an interview with the HRD it was revealed that the Administrator has the spreadsheet/calendar that keeps up with the in-services and when they are due. The HRD does not keep up with the in-services, the Administrator does. The HRD reported that just recently the in-services were given back to the Administrator and there probably in the Administrator's new office. The HRD reported 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.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure staff was trained in behavioral health residents for 1 (Resident #49) of 2 residents reviewed for dementia care. Specifically, the facility had no formal dementia training for staff, this had the potential to affect 28 residents identified by the facility with an Alzheimer's/Dementia diagnosis. Findings include: A review of a certification titled, National Council of Certified Dementia Practitioners with a certification period of 08/08/2023 through 08/08/2025 revealed, Administrator had completed certification as a Certified Dementia Practitioner. A review of the facility document titled, Required Annual State Inservices, revealed a Behavior Management category and a Cognitive Impairment category noting assessments, interventions, medications, and documentation. No specific dementia training was identified, and the last dates entered were 09/01/2022 for Behavior Management and 02/02/2022 for Cognitive Impairment A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, it was determined that the facility failed to ensure a continent resident was able to call for toileting assistance to prevent incontinence for 1 (Resident #18) resident of 18 sampled residents; and the facility failed to ensure all residents were provided with similar dinnerware for 2 (Resident #25 and Resident #32) of 18 sampled residents. Specifically, residents requiring assistance with meals were served using (polystyrene foam) bowls. Findings include: A review of a facility document titled, Resident Rights, indicated residents have the right to be treated with dignity, privacy, respect, and to live in a safe, clean, and comfortable homelike environment. 1. A review of the admission Record, revealed the facility admitted Resident #18 with diagnoses that included blockage of blood flow to the brain, a decline in thinking skills due to condition that blocks blood flow to the [NAME] causing deprivation of oxygen, weakness on one side of the body,…

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 obtain written authorization from the residents or their legal representatives for 2 of 6 residents (Resident #9 and Resident #21) personal funds. Findings include: On 10/14/2024 at 10:55 AM, the Administrator stated the facility did not have a policy for resident funds. A review of the admission Agreement in Resident #9's admission Packet 1 signed by Resident #9's representative on 02/16/2017, revealed a written request for the management of the resident's personal funds was required. For the question, Do you wish the facility to manage your funds, No was circled. A review of Resident #9's Trust Transaction History for the dates 10/01/2023-10/09/2024 revealed a running balance with deposits and withdrawals entered by the facility. The current balance as of 10/09/2024 was $1,645.34. A review of Resident #9's admission Packet Section 2 and electronically signed by the Medical Director on 09/24/2019 revealed Resident #9 had dementia and was usually…

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 quarterly trust fund statements to the residents or their legal representatives for 2 of 6 residents (Resident #9 and Resident #21) and failed to ensure generally accepted accounting practices were followed for 2 of 6 residents (Resident #7 and Resident #28) reviewed for personal funds. Findings include: On [DATE] at 10:55 AM, the Administrator stated the facility did not have a policy for resident funds. 1. A review of the admission Agreement in Resident #9's admission Packet Section 1, signed by Resident #9's representative on [DATE], revealed the nursing facility agreed to maintain written records of all financial transactions with the resident or legal representative including quarterly statements. A review of Resident #9's Trust Transaction History for the dates of [DATE]-[DATE] revealed a running balance with deposits and withdrawals entered by the facility. All deposits are either from Resident #9's federal benefits or interest paid. All…

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 provide residents who used the shower hallway with a safe, clean, homelike environment. The findings include: Review of facility provided Maintenance Log, dated 03/04/2024 stated outside of the double shower, the floor is leaking. During the initial facility rounding on 10/7/2024 at 11:05 AM, this Surveyor noted a section of the facility hallway that had the flooring removed exposing the concrete foundation with non-skid tracks laying down and three blankets rolled up and pressed to the far-right wall. During an interview on 10/7/2024 at 5:00 PM, Certified Nursing Assistant (CNA) #9 stated the flooring had been removed due to a leak from the far-right wall. CNA #9 stated that it was difficult to get residents into the shower room due to the flooring being removed and stated staff had to remain vigilant when transporting residents into the shower rooms due to the holes in the door frames to the shower room. During an interview on 10/7/2024 at 5:30 PM, the Environmental Director stated the flooring was removed…

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 interviews, it was determined that the facility failed to ensure established abuse policies and procedures were implemented after receiving an allegation of abuse for 2 (Resident #21 and Resident #23) of 18 residents sampled for the implementation of abuse prohibition policies and procedures, that resulted in facility and contract staff, involved in allegations of abuse, to remain in the facility and to have continued contact with residents. Findings include: A review of a facility document titled, Employee Handbook, dated 2023, indicated, Grounds for Immediate Dismissal 1. Verbal or physical abuse of anyone while at the facility. A review of a facility policy, included in the employee handbook, titled, Patient Ause/Neglect, with a policy change effective date of 09/25/2017, page 21 indicated the facility will report to state agencies as required by state and federal law within 2 hours and The facility will immediately send home the accused employee. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation,…

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 interviews, it was determined that the facility failed to ensure staff involved in abuse allegations had no further contact with residents after the facility received an allegation of abuse for 2 (Resident #21 and Resident #23) of 18 sampled residents. Specifically, the facility allowed Certified Nursing Assistants (CNA) #1, CNA #2, CNA #3 and Phlebotomist, involved in the abuse allegations, to remain in the facility and to have continued contact with residents after the allegation of abuse was made. Findings include: A review of a facility document titled, Employee Handbook, dated 2023, indicated, Grounds for Immediate Dismissal 1. Verbal or physical abuse of anyone while at the facility. A review of a facility policy included in the employee handbook, titled, Patient Ause/Neglect, with a policy change effective date of 09/25/2017, page 21 indicated, The facility will immediately send home the accused employee. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical…

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

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure comprehensive assessments were accurately completed for 3 (Resident #1, Resident #10, and Resident #20) of 18 residents reviewed for assessments. The facility failed to accurately assess Resident #1 and Resident #10's use of bed rails and identify that the residents were at high risk for the use of bed rails on the annual Minimum Data Set (MDS) and to accurately assess Resident #20's current diagnosis status on the quarterly MDS assessment, which resulted in inaccurate care plans. Findings include: 1. A review of the admission Record, indicated the facility admitted Resident #1 on 08/11/2020 with diagnoses that included hemiplegia/hemiparesis, convulsions, restlessness/agitation, psychosis, and delusional disorder. A review of Resident #1's Order Summary Report revealed, Resident #1 had an order for full bilateral bedrails, to enable repositioning in bed, make sure they are up and tightly secured every shift, dated 05/17/2023.…

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, it was determined that the facility failed to ensure care plans accurately reflected the resident's needs and interventions for care of 5 (Residents #10, #20, #21, #23, and #25) of 18 sampled residents. Findings include: 1. A review of the admission Record, indicated the facility admitted Resident #10 with diagnoses that included a brain disorder that causes memory loss, language and thinking problems, kidney disease and depression. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/26/2024, revealed Resident #10 had a Brief Interview for Mental Status score of 3 which indicated the resident had severe cognitive impairment. Resident #10 required substantial to maximal assistance with dressing, showering/bathing, sitting to lying and lying to sitting, from sitting to standing, transferring from chair to bed and bed to chair; required partial to moderate assistance for personal hygiene and to roll left to right; and required…

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 services provided or arranged by the facility did not meet professional standards of quality for 1 (Resident #23) of 1 sampled resident. The findings include: Review of Resident #23's Medical Diagnosis, reported multiple sclerosis, weakness, other motor neuron disease, a condition that causes sudden and uncontrollable laughing or crying, wheelchair dependence, dementia, anxiety, insomnia, and depression. A review of Resident #23's Order Entry, on 10/9/2024 at 3:00 PM reported, THC Gummies 25mg (milligrams) 1 gummy every 2 hours as needed, not to exceed 5 gummies in 24 hours verbal order per Medical Director dated 9/2/2024. Previous orders included: 15 mg/1000 mg may have 1-2 gummies every 2 hours as needed up to 10 per day on 8/11/24. THC gummies 600mg THC/15 mg [brand] may have two gummies each shift if 25 mg is not available, every 8 hours for pain/anxiety, not to exceed 6 gummies per day on 8/1/24. During a concurrent observation and interview on 10/9/2024 at 3:30 PM, THC gummies were observed in Licensed Practical Nurse…

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

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure assessments, proper bedrail placement and safety precautions for 2 (Resident #1 and Resident #10) of 2 residents reviewed for bedrails. Specifically, at-risk residents were not properly assessed for risks associated with the use of bedrails, and the facility did not perform or maintain documentation of assessments, measurements, or inspections of entrapment zones. Findings include: 1. A review of the admission Record, indicated the facility admitted Resident #1 on 08/11/2020 with diagnoses that included hemiplegia/hemiparesis, convulsions, restlessness/agitation, psychosis, and delusional disorder. A review of Resident #1 Order Summary Report revealed, Resident #1 had an order for full bedrails, to enable repositioning in bed, make sure they are up and tightly secured every shift, dated 05/17/2023. On 10/15/2024 at 3:12 PM, the Administrator stated the facility did not have a policy for side rails/bedrails/full rails,…

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

Based on observations and interviews, it was determined that the facility failed to provide food items as listed on the menu and follow the recipe during food preparation to meet the needs of the residents in 1 kitchen reviewed for food preparation and service. Specifically, the facility ran out of food on the designated menu due to serving staff meals prior to serving the residents; allowing food to cook down on the steam table for two hours and forty-five minutes for lunch on 10/07/2024; not following the menu for lunch on 10/10/2024, and not taking measurements verify serving size. Findings include: 1. A review of the facility menu, Spring/Summer 2024, Week 4, for Monday, 22, the menu indicated the lunch meal was to include ham & beans, squash, cornbread, margarine, sour cream pound cake, chilled peaches, and coffee or tea. During a concurrent observation and interview on 10/07/2027 at 10:55 AM, Dishwasher (DW) #21 was serving staff lunch from the steam table line including squash. DW #21 stated the staff lunch was served from 11:00 AM - 11:30 AM During an observation 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.

Based on observations, interviews, and facility document review, it was determined that the facility failed to ensure nutritive value and appearance was maintained for food preparation in 1 of 1 kitchen reviewed for food preparation and services. Specifically, the squash served for lunch on 10/07/2024 was on the steam table for two hours and twelve minutes prior to the start of resident lunch services resulting in overcooked watered-down squash. Findings include: During an observation on 10/07/2024 at 12:58 PM, the Kitchen Manager (KM) was plating the squash with a perforated spoon. In the pan there was mainly yellow water with pieces of limp squash. During an interview on 10/07/2024 at 1:05 PM, the KM stated, five bags of squash was used in preparation for lunch but when it cooks so much it turns to liquid. The KM stated the squash was put on the steam table at 10:15 AM, prior to the staff's lunch being served. It was calculated that the squash had been on the steam table for two hours and twelve minutes prior to the start of the first resident's tray being served. A 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 observations, interviews, facility document review, and facility policy review, it was determined that the facility failed to prepare and serve food in a way to reduce food borne illnesses and ensure dishes were washed and stored in a sanitary manner with the potential to effect 48 residents served from the 1 of 1 kitchen reviewed for food preparation and service. Specifically, the facility left uncooked breaded chicken strips uncovered sitting on top of the commercial oven for one hour and fifteen minutes, failed to perform and maintain good hand hygiene during food service and preparation, failed to maintain safe food temperatures for pureed foods during preparation time, did not use soap/detergent to wash utensils during food preparation and allow for proper sanitation time, or store the ice scoop in a clean, dry container. Findings include: A review of a facility policy titled, Self Survey Module revised in September of 2007 stated, the intent was to prevent food borne illnesses and reduce practices that result in food contamination and compromised food safety to all…

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 notify residents or their legal representatives when their personal fund account balances approached limits for Medicaid eligibility for 2 of 6 residents (Resident #9 and Resident #21) for personal funds. Findings include: On 10/14/2024 at 10:55 AM, the Administrator stated the facility did not have a policy for resident funds. A review of the admission Agreement in Resident #9's admission Packet Section 1 signed by Resident #9's representative on 02/16/2017, revealed the nursing facility agreed to maintain written records of all financial transactions with the resident or legal representative. A review of Resident #9's Trust Transaction History for the dates 10/01/2023-10/09/2024 revealed, on 11/29/2023, a balance of $1,843.25, and remained above $1,800 until 02/02/2024. On 07/03/2024 a balance of $2,472.02 was posted and remained above $1,800 until 09/30/2024. A review of Resident #9's admission Packet Section 2 and electronically signed by 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, interview, and record review, the facility failed to notify the medical provider of a significant change in Resident 14's dental health resulting in pain when dental care was provided. The findings include: During a concurrent observation and interview on 10/08/2024 at 9:00 AM, the Surveyor was speaking to Resident #14 in the facility common room. When Resident #14 smiled at the Surveyor, the Surveyor noted what appeared to be blood coming from Resident #14's upper gums. The Surveyor interviewed the Certified Nursing Aid (CNA) #4 who touched Resident #14's lip. Resident #14 pulled away and stated that it hurt. CNA #4 stated it appeared to be blood on Resident #14's gums. During an interview on 10/09/2024 at 10:00 AM, Certified Nursing Aid (CNA) #9 stated Resident #14's gums bleed often, and dental care had become very painful for Resident #14. CNA #9 stated the blood and pain with dental hygiene had been reported to Registered Nurse (RN) #13. During an interview on 10/09/2024 at 10:30 AM, Registered Nurse (RN) #12 stated no one had reported a change in 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 observations and interviews, it was determined that the facility failed to provide privacy for 1 of 1 Resident (Resident #47). Findings included: After a request for a dignity policy. It was reported that the facility did not have a dignity policy. A review of Resident #47's admission Record, revealed the resident's medical diagnoses included: dementia and generalized anxiety disorder. On 10/11/2024 at 9:00 AM, this surveyor was standing beside the nurses' desk when the residents' main bathroom door was opened by Certified Nursing Assistant (CNA) #7 asking for the surveyor to get help. Upon opening the door wide, the resident was exposed with pants and brief pulled down standing in front of the toilet in eyesight of this surveyor. The CNA then shut the door. On 10/11/24 at 10:25 AM, during an interview, the Environmental Director revealed that there had been a bell attached to the emergency call light, in the resident's bathroom. The surveyor then observed a bell attached to the string hanging from the call light string. On 10/11/24 at 10:40 AM, during an interview CNA #7…

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

Based on interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure a resident was free from chemical restraint for 1 (Resident #49) of 1 resident reviewed for chemical restraint. Findings include: A review of the facility's undated policy titled, Your Rights and Protections as a Nursing home Resident, indicated nursing homes can't use chemical restraints (like drugs) to discipline you for the staff's own convenience. A review of the admission Record, indicated the facility admitted Resident #49 with diagnoses that included dementia, generalized anxiety disorder, and delusional disorders. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/06/2024, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident was had severe cognitive impairment. A review of Resident #49's care plan initiated on 07/30/2024 and revised on 08/31/2024, revealed the resident was disoriented to place, had impaired safety awareness, wandering behaviors, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Resident #23 was free from unnecessary medications. The findings include: A review of Resident #23's care plan dated 07/10/2023, did not report any use of marijuana or THC products. A review of Resident #23's Minimum Data Set, dated [DATE]; Section J reported no documentation of Resident #23's marijuana use. A review of Resident #23's Medical Diagnosis, reported the resident had diagnoses to include multiple sclerosis, weakness, asthma, motor neuron disease, chest pain, dependence on wheelchair, dementia, anxiety, insomnia, and depression. A review of Resident #23's Physician Orders, reported barbiturates, oxygen, muscle relaxers, narcotics, a mixed drink as needed, and tetrahydrocannabinol (THC). During a concurrent observation and interview on 10/9/2024 at 3:30 PM, THC gummies were observed in the medicine cart for the 500 Hall. Licensed Practical Nurse (LPN) #6 stated the THC Gummies belonged to Resident #23 and were brought 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 observation, interview, and record review, the facility failed to operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility The findings include: Review of Resident #23 Medical Diagnosis, reported the resident had diagnoses to include: multiple sclerosis, weakness, other motor neuron disease, a condition that causes sudden and uncontrollable laughing or crying, wheelchair dependence, dementia, anxiety, insomnia, and depression. A review of Resident #23's Order Summary Report on 10/9/2024 at 3:00 PM, reported THC Gummies 25mg 1 gummy every 2 hours as needed, not to exceed 5 gummies in 24 hours verbal order per Medical Director order dated 9/2/2024. Previous orders include 15 mg/1000 mg may have 1-2 gummies every 2 hours as needed up to 10 per day on 8/11/24. THC gummies 600mg THC/15 mg delta may have two gummies each shift if 25 mg not available, every 8 hours for pain/anxiety, not to exceed 6…

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 foods were utilized prior to the use by date, stored in a manner to prevent cross contamination, hair coverings were worn when entering the kitchen and hand hygiene was performed to prevent cross contamination. The findings are: During observation on 10/09/23 at12:36 PM, CNA #9 coughed used the gloved right hand to cover her mouth. CNA #9 removed the paper covering from a straw and placed the straw into Resident #25 ' s plastic mug. CNA #9 did not perform hand hygiene. During interview on 10/09/23 12:49 PM, CNA #9 said hand hygiene should be performed before and after resident care, and confirmed she should have not used her gloved hand that covered her mouth to handle the resident ' s straw. The following observations were made on 10/10/23: a. At 11:59 AM, Certified Nursing Assistant (CNA) #5 served a meal tray from the tray cart to Resident #19. CNA #5 did not perform hand hygiene prior to removing the room tray from the tray cart and did not perform hand hygiene after exiting Resident #19 ' s room.…

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 ensure resident's environment was safe, free of hazards, and promoting a home like environment. The findings are: The following observation were made: On 10-9-23 at 12:12 PM, room [ROOM NUMBER]'s door protector was loose with a hard plastic cover on the lower half of the door and splinters. During observation on 10/12/23 at 2:03 PM, room [ROOM NUMBER] ' s door had a loose protector gaping open with sharp screws. On 10/09/23 at 12:20 PM, the baseboard approximately 12 inches in length in room [ROOM NUMBER] was pulled away from the wall and protruded outward. A hole approximately 3 inches deep was in the wall with sheet rock and insulation exposed behind the baseboard. On 10/10/23 at 12:17 PM, a hole in the wall of room [ROOM NUMBER] had approximately 12 inches of base board detached from the wall and protruding outward. On 10/12/23 11:48 AM, a hole in the wall approximately 3 inches deep and approximately 12 inches of base board was detached from the wall…

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 drugs and biologicals used in the facility were labeled appropriately and disposed of past the expiration date when applicable. The findings are: The following observations were made on 10/11/23 at 9:59 AM of the medication cart on 400 hall and 500 hall. a. One box of nasal strips containing 19 strips with no resident ' s name. b. A tube of topical anesthetic with no resident ' s name. c. One tube of eye drops with no resident ' s name. d. Two cups of a white powder with no label with the contents. e. 1 tube of eye ointment with an expiration date of 7/2023. During interview on 10/11/23 at 10:05 AM, Licensed Practical Nurse (LPN) #1 said, medications should be left on the cart in the original container or box and labeled.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure infection control precautions were followed during wound care for 2 (Resident #25 and #27) residents, failed to ensure that bed pans were stored properly when not in use for Resident #21, and clothing and linens were processed in a manner to minimize cross contamination. The findings are: On 10/11/23 at 1:40 PM, Surveyor observed LPN #2 perform wound care on two of Resident #25 wounds. CNA #2 and CNA #10 assisted LPN #2. LPN #2, CNA #2, and CNA #10 did not perform hand hygiene or change gloves during the wound care process. During observation on 10/11/23 1:54 PM, LPN #2 entered Resident #25's room donned in an isolation gown and gloves. LPN #2 lifted the Resident's heels off the bed and applied a heel protector to each heel. LPN #2 manually raised Resident #25 head of bed up, and pulled the sheets up to the Resident's chest and applied a cream to the Resident's shoulders. LPN #2 did not change gloves. On 10/12/23 at 1:25 PM 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 observations, record review, and interviews, the facility failed to ensure staff did not stand over the resident while assisting with meals to promote dignity for 1 (Resident #25) of 1 sampled resident who required assistance with meals; and the facility failed to ensure residents were not referred to as a feeder to promote dignity to residents who required assistance with meals. The findings are: Resident #25 at 12:31PM was sitting up in bed, and Certified Nursing Assistant (CNA) #9 was standing next to the bed and gave Resident #25 a drink of tea. At 12:36 PM and 12:34 PM, CNA #9 was standing next to Resident #25 while giving her a drink of tea from a glass using a straw. During interview CNA #9 said she usually sits in a rolling chair if they are a feeder. The Surveyor asked CNA #9 was asked, what is a feeder? CNA #9 stated, Residents that have to be fed. During interview on 10/13/23 10:02 AM, Licensed Practical #3 said a residen's dignity is maintained when assisting them with meal by talking with them and sitting eye level. On 10/13/23 at 10:35 AM, the Surveyor asked…

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 interview the facility failed to ensure that a call light was within reach for one (Resident #4) of one sampled resident who requires a call light for assistance. The findings are: On 10/09/23 at 2:48 PM, Resident #4 was observed lying in bed with the call light in the chair next to the bed out of the resident's reach. In the adjacent bed the call light was hanging over the headboard of the bed, out of reach of the resident. Resident #4 was asked do you ever use the call light for assistance? He nodded his head up and down and looked at each side rail. On 10/09/23 at 2:51 PM, Certified Nursing Assistant (CNA) #1 confirmed Resident #4 ' s call light was on the chair and out of reach. On 10/12/23 at 1:00 PM Licensed Practical Nurse (LPN) #2 confirmed Resident #4 had the ability to use his call light.

Based on interview and record review the facility failed to ensure that 1 (Resident #2) of one sampled resident had completed an Advance Directive upon entry. The findings are: Review on 10/9/23 at 3:13 PM, of Resident #2's medical record revealed no information concerning an Advance Directive 10/13/23 at 2:05 P.M, the Administrator reported that Resident #2's Advance Directive could not be located and said the document might be located with the Resident's original admission record from 2013 in storage.

Based on observation, record review and interview, the facility failed to ensure facial hair was removed in a timely manner to maintain dignity for 2 (Resident #25 and #42) of 2 sampled who required assistance for personal hygiene. The findings are: Review of Resident #25's care plan with a revision date of 8/14/23 showed Resident is totally dependent of 1 staff to provide a bath/shower. Review of the activities of daily living self-care performance bathing task showed Resident #25 was provided a bath/shower on 10/9/23, 10/5/23, and 10/2/23. On 10/10/23 at 8:54 AM, Resident #25 was observed lying in bed with facial hair/whiskers approximately 0.25 in to 0.5 inches in length on/under chin and on neck. On 10/10/23 at 2:49 PM Resident #25 was observed lying in bed with facial hair/whiskers approximately 0.25 inches to 0.5 inches in length on/under chin and neck. On 10/11/23 at 8:38 AM Resident #25 was observed lying in bed with facial hair/whiskers approximately 0.25 inches to 0.5 inches in length on/under chin and neck. During interview on 10/12/23 at 9:39 AM, Certified Nursing…

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

Based on observation, interview and record review the facility failed to ensure that nebulizer masks were stored in a manner to prevent cross contamination of 1 of 1 (Resident #21) of 3 (Resident #21, #48, and #15) sampled residents. The findings are: Review of Resident #21's Order Summary Report showed a physician order dated 09/17/23 for a nebulizer treatment when necessary. The following observations were on 10/09/23 : a. Resident #21's oxygen tubing was extended out of a drawer of the bedside table. With the Resident's permission the drawer was opened, and a nebulizer mask was in the drawer. b. Resident #21's nebulizer mask was in the drawer and had what appeared to be oil and particles of debris inside the mask. During interview on 10/10/23 at 9:52 AM, Licensed Practical Nurse (LPN) #2 said the nebulizer mask should be cleaned and stored in a bag to prevent infection. Review on 10/13/23 at 8:48 PM of a facility document titled cleaning the nebulizer showed after cleaning place the nebulizer in a plastic bag at the bedside.

Based on observation an interview the facility failed to ensure that the menu was followed for 2 sampled resident's (Resident #27 and #28) who receive a pureed diet. The findings are: During observation on 10/10/23 at 12:30 PM, Resident #28 was served pureed ham, turnip greens, sweet potatoes, and a bowl of pureed cake. Resident #27 received a tray containing the exact foods at 12:31 PM. Review of facility ' s pureed lunch menu for 10/10/23 showed baked ham, sweet potatoes, greens, cornbread, margarine spread, and plain white cake. During interview on 10/10/23 at 12:38 PM, the Dietary Manager confirmed the cornbread was not served to Resident #27 and #28.