Trinity Village Medical Center

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. The findings are: 1. The 1/13/25 Resident meal of the month lunch menu documented the residents who received regular diets, mechanical soft diets, and residents who received chopped diets were to receive 2 slices of pizza. Residents who required pureed diets were to receive 2 #8 scoops (1 cup of pureed pizza and residents on mechanical soft diets were to receive ground pizza. 2. On 1/13/25 at 11:42 AM, during the lunch meal preparation, Dietary [NAME] (DC) #10 placed 6 slices of pepperoni pizza on a pan liner on top of the counter and sliced them into squares. DC #10 then transferred the squares pieces into a pan and stated she did it for the residents who received chopped meat. DC #10 placed the pan in the oven to be served to the residents who received chopped diets, instead of total of 12 slices of chopped pepperoni pizza since the menu indicated 2 slices of…

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

Based on observation, interview, record review, and facility policy review, the facility failed to ensure food items in the refrigerator, freezer and storage room were covered, and sealed; leftovers meat products were used in a manner to maintain food quality; dented cans were promptly removed from stock; 1 of 2 ice machines was maintained in clean and sanitary condition; dietary staff washed their hands before handling food or clean equipment; ceiling tiles, air vents, dish washer wall , kitchen door frames were free of, debris, dirt, rust, stains, baseboards were secured, and hot food items were maintained at temperature of 135 degrees or above for 1 of 1 meal observed. The Findings are: 1. On 1/13/25 at 8:41 AM, the following observations were made in the kitchen areas. a. A bag of coffee filters with loose coffee in it to be brewed was on the counter by the coffee machine. b. An opened bag of pizza was on the counter by the steam table. The bag was not sealed. c. An opened box of apple pie was on top of the plate warmer. The box was not covered. 2. On 1/13/25 at 8:43 AM, 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, record review and facility policy review the facility failed to ensure enhanced barrier precautions (EBP) were being followed to prevent the spread of possible infection for one (Resident #28) of four sampled residents who were on EBP. The findings are: Resident # 28 had diagnoses of gastrostomy, cerebral infarction, bipolar disorder, diabetes mellitus type 2, and Alzheimer's disease. The review of Physician Orders for January 2025 did not indicate an order for enhanced barrier precautions. On 01/13/2025 at 9:12 AM, EBP signage was observed on Resident #28's door and a stocked personal protective equipment (PPE) cart was on Resident 28's side of the room. On 01/13/25 at 09:13 AM, Certified Nursing Assistant (CNA) #3 was observed at Resident #28's bedside, preforming incontinent care, without PPE on. When asked, CNA #3 stated she had changed the resident without donning PPE. On 01/13/2025 at 1:22 PM, Hospice CNA #4 was observed bathing Resident #28 without PPE on. When questioned, CNA #4, responded it was her first time working with the resident 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 observations, interviews, record review, and facility policy review the facility failed to ensure the care planned positioning device was in place to prevent further contracture for 1 of 1 sampled (Resident #27) resident reviewed for positioning. The findings include: A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/17/2024 revealed Resident #27 had a Brief Interview of Mental Status (BIMS) score of 15 that indicated cognitively intact. A review of a plan of care for Resident #27 (revision date 01/04/2023) revealed Resident #27 had an Activities of Daily Living (ADL) self-care performance deficit related to cerebrovascular accident (CVA) with left non-dominant side. An intervention in place noted place carrot in left hand. On 01/13/25 at 10:51 AM, this surveyor observed contracture to Resident #27's hand with no positioning device in place and noted a hand roll on the nightstand. Resident #27 stated the facility used to place a carrot in each hand, but the resident did not know what happened to them. On 01/14/25 at 09:07 AM,…

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 ensure gradual psychotropic (anti-anxiety) dose reductions (GDR) were attempted in the absence of a physician's documented evaluation of the specific risks versus benefits of continuing the as needed (PRN) medication past 14 days and a documented explanation as to why a dose reduction attempt would be contraindicated, in order to ascertain the smallest effective dose and minimize the potential for adverse drug effects for 1 (Resident #27) of 5 sampled residents reviewed for unnecessary medications. The findings include: A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/17/2024 revealed Resident #27 has a Brief Interview of Mental Status (BIMS) score of 15 which indicated cognitively intact. A review of the plan of care for Resident #27 (revision date 04/05/2024) revealed Resident #27 used anti-anxiety medications. A review of the Note to Attending Physician/Prescriber printed date 08/25/2024 noted Resident #27 had an order for [benzodiazepine medication…

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 pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 1 of 1 meal observed. The findings are. 1. On 1/13/25 at 11:22 AM, DC #7 used a 4-ounce spoon to put 9 servings of boiled, seasoned squash into a blender and poured the juice from the squash over it, covering the squash. As DC #7 began to puree the squash the consistency of the pureed squash was too runny. DC #7 added a cup of thickener and pureed it some more. At 11:23 AM, DC #7 poured the pureed squash into a pan, and placed it in a pan of hot water on the stove. The consistency was still runny. The pureed squash remained thin when it was served to the residents who required pureed diets. At 1:15 PM, DC #7 was interviewed and was asked if she could describe the consistency of the pureed squash served to the residents on pureed diets, and DC #7 stated she thought it was a little thin, and she should have added more thickener. 2. On 1/13/25 at 11:51…

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 dirty trash cans were stored away from the food storage racks; kitchen sink was free of leaks; the walk-in freezer floor was free of ice buildup; the ice machine and ice scoop were maintained in clean and sanitary conditions to prevent potential growth of harmful bacteria that could be transferred to the residents food; opened food items in the refrigerator, freezer and storage room were covered, sealed, and dated; and expired foods were promptly removed from stock to maintain freshness and prevent potential cross contamination; dietary staff practiced good hand hygiene to prevent potential cross contamination of food and clean dishes; and hot food item was maintained at the required temperature on the steam table and serving line to prevent potential foodborne illness. These failed practices had the potential to affect 75 residents who received meals from the kitchen (Total Census: 78), as documented on a list provided by the Dietary Manager on 07/17/2024 at 3:11 PM. The findings are: 1. On 07/15/2024 at 9:38 AM, in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a refund was received by the resident or responsible party within 30 days from the date of discharge for 2 (Residents #230 and #231) sampled residents within 30 days from the date of discharge. The findings are: On [DATE] at 2:21 PM, during an interview with Business Office (BO) #12, the Surveyor requested the last 2 quarter bank statements for Resident #230 and Resident #231. The statements were provided showing Resident #230 had a balance of $1,510.87, and Resident #231 had a balance of $407.00, with no charges coming out of the accounts. On [DATE] at 03:20 PM, per record review Resident #231's medical record revealed the resident passed away in the facility on [DATE], and Resident #230 passed away in the facility on [DATE]. The Administrative Assistant was asked to provide documentation and proof that the facility had attempted to contact the family regarding the remaining funds. On [DATE] at 10:15 AM, the Surveyor met with BO…

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 failed to ensure the G Hall shower room and the beauty shop were locked to prevent residents from being harmed from the ingestion of the chemicals present. The findings are: 1. On 07/15/2024 at 11:45 AM, while walking down the G Hall the surveyor observed the shower room door, near the common area, was slightly open. The surveyor observed open, uncapped gallon jugs of shampoo and personal cleanser. On 07/16/2024 at 2:03 PM, Certified Nursing Assistant (CNA) #14 accompanied the surveyor to the G Hall shower room and read from the personal cleanser, Keep out of reach of children. If swallowed, get medical help or contact a Poison Control Center Immediately from the open gallon jug of personal Cleanser. CNA #14 confirmed residents are showered on G Hall, and it sits outside the E, F, and G Hall common area and a resident could come into the unlocked shower room and drink from the shampoo or personal cleaner jugs that do not have caps. 2. On 07/15/2024 at 11:52 AM, the surveyor walked into the unlocked beauty shop 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 observation, record review and interview, the facility failed to ensure oxygen was administered at the physician ordered rate to prevent respiratory complications for 2 (Residents #25 and #60) of 2 sampled residents who received oxygen. The findings are: 1. Review of the Medical Diagnosis noted Resident #60 had diagnoses of chronic obstructive pulmonary disease (COPD), heart failure, and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/11/2024 suggested a Brief Interview for Mental Status (BIMs) score of 12 (8-12 suggests moderate cognitive impairment). Section O0110, C1 shows the resident is on oxygen. Review of Resident #60's Order Summary Report noted an order for oxygen at 3 liters via nasal cannula related to shortness of breath. Review of Resident #60's Care Plan with a revision of 10/12/2023, revealed Resident #60 was to receive oxygen per doctor orders. On 07/15/2024 at 11:37 AM, during a concurrent observation and interview, Resident #60 was sitting in a wheelchair receiving 2 liters of oxygen.…

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 failed to ensure staff were trained on how to monitor residents on a high-risk medication (anticoagulants), Apixaban (Eliquis), for 1 (Resident #37) of 1 sampled resident. The findings are: Review of an admission Record indicated the facility admitted Resident #37 on 01/06/2024. Review of the admission Record indicated Resident #37 had a diagnosis of unspecified atrial fibrillation. Review of the Physician's Orders revealed Resident #37 had an order for Sertraline HCl, an antidepressant which may cause you to bruise or bleed easily, with a start date of 02/24/2024, and Apixaban (Eliquis), an anticoagulant, related to atrial fibrillation, with a start date of 01/06/2024. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/29/2024 revealed Resident #37 had severe cognitive impairment per a Brief Interview of Mental Status (BIMS). The resident was taking an antidepressant and anticoagulant medication. Review of Resident #37's Care Plan (initiated date 01/09/2024) revealed 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 observation, record review, and interview, the facility failed to show a monthly Medication Regimen Review was completed on a monthly basis as required for 4 (Residents #3, #24, #25, and #41) sampled residents. The findings are: 1. Review of Medical Diagnosis for Resident #41 noted the resident had diagnoses of respiratory failure, type II diabetes mellitus, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/06/2024 suggested a Brief Interview for Mental Status (BIMs) score of 7 (0-7 suggests severe cognitive impairment). On 07/16/2024 at 2:54 PM, per review of the pharmacy consult notes, the following dates did not have Medication Regimen Review recommendations: 08/22/2023, 09/11/2023, 11/14/2023, 01/17/2024, 02/06/2024, and 04/15/2024. Per record review of the Director of Nursing's (DON) Medication Regimen Review binder on 07/17/2024 at 2:41 PM, there were no discrepancies for 05/01/2024, 06/02/2024 On 07/17/2024 at 3:51 PM, during an interview the Surveyor asked the Director of Nursing (DON) 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 observation, record review, and interview, the facility failed to ensure medications were stored behind a locked door; medications were not left at the bedside for 2 (Resident #13 and Resident #56) of 2 residents reviewed for medication storage at the bedside; and narcotic medications were stored in a permanently affixed compartment to prevent the potential of misappropriation of resident property. The findings include: 1. On 07/15/2024 at 9:40 AM, the Surveyor observed an oxygen concentrator holding open a door to the Employee Training/Staff Development room. On entering the Surveyor observed betadine and Dyna-hex on the counter across the room, to the right of the sink, the unlocked upper cabinets contained multiple bottles of betadine, and 2 bottles of Dakins solution. There were 2 unlocked medication (med) carts resting against the right side of the room. The first unlocked med cart had the following medications in the drawers: a. 2 - tubes of wound and burn gel b. Hibiclens (used to clean the skin to prevent infection) c. 0.25% Sodium Hypochlorite Solution d. Dakins…

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 failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. The failed practices had the potential to affect 11 residents who received pureed diets, and 6 residents who received mechanical soft diets from 1 of 1 kitchen according to a list provided by the Dietary Manager on 07/17/2024 at 3:11 PM. The findings are: 1. The 07/17/2024, the noon meal menu documented the residents who received pureed diets and mechanical soft diets were to receive 2 ounces (1/4 cup) of gravy, a #8 scoop (1/2 cup) of pureed cabbage and a #8 scoop (1/2 cup) of pureed apple cobbler. 2. On 07/17/2024 at 11:42 AM, Dietary [NAME] (DC) #19 placed 10 servings of cornbread into a blender, added 3 cartons of whole milk and pureed. At 11:44 AM, DC #19 poured the pureed cornbread into a pan and placed it in a pan of hot water on the stove to serve 11 residents on pureed diets. 3. On 07/17/2024 at 11:56 AM, Dietary [NAME] (DC) #19 used a #8 scoop to place…

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 pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 1 of 1 meal observed. The failed practice had the potential to affect 11 residents who received pureed diet, as documented on the list provided by the Dietary Supervisor on 07/17/2024. The findings are: 1. On 07/17/2024 at 11:30 AM, Dietary [NAME] (DC) #19 placed 13 servings of polish sausage into a blender, added chicken broth and pureed. At 11:31 AM, DC #19 poured the pureed polish sausage into a pan and placed it in a pan of hot water on the stove. The consistency of the pureed polish sausage was lumpy and was not smooth. There were pieces of meat still visible in the mixture. 2. On 07/17/2024 at 11:42 AM, Dietary [NAME] (DC) #19 placed 10 servings of cornbread into a blender, added 3 cartons of whole milk and pureed. At 11:44 AM, DC #19 poured the pureed cornbread into a pan and placed it in a pan of hot water on the stove. The consistency 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.

Based on observation, record review, and interview, the facility failed to ensure the physician's plan of care for chopped meat was followed for 8 residents who had a physician's order for chopped meat diets. The failed practice had the potential to affect 8 residents who had physician orders for chopped meat diets (census of 78), according to a list provided by the Dietary Manager on 07/17/2024. The findings are. 1. On 07/17/2024 at 12:12 PM, when staff were preparing to serve lunch the meal from the steam table during kitchen observation, the kielbasa was not pre-chopped to serve to the eight residents who had physician orders for chopped meat. 2. On 07/17/2024 at 1:45 PM, three residents were served regular polish sausage with skin intact with the size ranging from 1 inch to 1.5 inches. The surveyor showed the Dietary Manager and Dietary [NAME] (DC) #19 the size of the chopped meat/entrée ranging from 1 inch to 1.5 inches served to three residents on regular chopped meat diets in the dining room. During the interview DC #19 confirmed that was the size she was cutting the meat.…

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

Based on interview, and record review, the facility failed to ensure the Binding Arbitration Agreement stated the resident or resident representative were not required to sign the binding arbitration agreement as a condition of admission or as a requirement to continue to receive care at the facility. The findings are: On 07/15/2024, the Director of Nursing (DON) provided a copy of the arbitration agreement the facility provided at admission. The document did not specify whether the resident or resident representative are not required to sign the binding arbitration agreement as a condition of admission to or as a requirement to continue to receive care at the facility. On 07/15/2024 at 10:40 AM, review of the Arbitration Agreement, the required wording of neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at the facility was not located within the document. On 07/15/2024 at 10:53 AM, the Social Worker confirmed families are told they can sign 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, record review and interview, the facility failed to ensure a water management program was put in place to prevent the growth of Legionella and other opportunistic waterborne pathogens in the water system or ways to intervene in the instance of a Legionella outbreak for 1 of 1 facility; failed to ensure enhanced barrier precautions were in place for 1 (Resident #29) of 1 sampled resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube and open wound; failed to ensure proper hand hygiene during meal service to prevent cross contamination for 1 (Resident #15) to prevent cross contamination; failed to ensure upper dentures were stored in a closed container with denture cleaner to prevent infection, and germs for 1 (Resident #71); failed to ensure hand hygiene was performed to prevent infection, and cross contamination for 1 (Resident #277) of 2 sampled residents observed for perineal care (Resident #41 and Resident #277); and failed to ensure clean linens were properly stored as to not become contaminated prior to use by residents. The findings are: 1. 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 observation, interview, and record review, the facility failed to ensure interventions for a hand device was consistently used for 1 (Resident #39) of 1 sampled resident who had a hand contracture. The findings are: A review of Order Summary Report noted Resident #39 had hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. A review of Resident #39's Physician's Orders revealed Resident #39 had an order to have a right palm guard to be worn during the day and taken off at night. May consult therapy if redness/irritation occurs. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/09/2024 revealed Resident #39 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The resident had upper and lower extremities impairment on one side and was not receiving active or passive range of motion nor splint or brace assistance. A review of Resident #39's Care Plan (revision date 06/13/2023) revealed Resident #39 had an Activity of Daily Living (ADL) with…

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

Based on observation, record review, and interview, the facility failed to ensure dental care was provided for 1 (Resident #71) of 1 sampled (Resident #71) to promote good oral hygiene. The findings are: 1. Review of Medical Diagnosis revealed Resident #71 had diagnoses of chronic kidney disease, dementia, and metabolic encephalopathy. 2. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/22/2024 suggested a Brief Interview for Mental Status (BIMs) score of 14 (13-15 suggest cognitively intact). Section GG0130 indicated the resident required set up assistance for oral care. 3. On 07/16/2024 at 8:49 AM, Resident #71 was observed riding a hand bike in the therapy room and smiling at the surveyor. The surveyor observed Resident #71's had an upper tooth on the right and left side of the mouth protruding out, and had noticeable yellowing teeth with a thick, white substance on the bottom teeth. 4. On 07/16/2024 at 3:40 PM, during an interview with Resident #71, the surveyor noted yellowing bottom teeth with a white milky film. 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 all bodily areas were cleansed during incontinent care to promote cleanliness and good personal hygiene to prevent the potential infection for 1 (Resident #277) of 1 sampled resident reviewed for incontinent care. The finding include: Review of Medical Diagnosis noted Resident #277 had hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and dementia Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/03/2024 revealed Resident #277 had short-term and long-term memory problems. The resident was always incontinent of bowel and bladder. Review of Resident #277's Care Plan (revision date 06/26/20234) revealed Resident #277 was high risk for falls related to gait/balance problems, incontinence, and unaware of safety needs. On 07/16/2024 at 1:25 PM, Resident #277 was incontinent of bowel and bladder. The Surveyor observed CNA #4 and #5 did not use proper technique while providing incontinence care and not enough supplies were used…

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.