Handmaker Home For The Aging

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review and facility policy, the facility failed to ensure that a thorough investigation was conducted for resident #21. Findings include: Resident #21 was admitted [DATE] with diagnoses of mild cognative impairment and major depressive disorder. An annual Minimum Data Set, dated [DATE] included that this resident was cognitively intact and required extensive assistance with bed mobility, transfers, dressing and personal hygiene. A review of the SA complaint tracking system received October 23, 2023 by Long Term Care Licensing included that a family member is misappropriating the resident's finances and is not paying for bills nor equipment repairs. However, a five day report was not received for this incident. A request was made for the five day report on January 24, 2025 at 9:40 A.M. An interview was conducted with the Assistant Administrator (staff #35) on January 24, 2025 shortly after this request. This staff stated that they did not have a 5 day report for this…

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 clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that abuse policies were implemented for two resident to resident abuse incidents, one involving resident (#222) and(#169); and the other involving residents (#223) and (#49). This deficient practice could result in further instances of resident to resident abuse. -Regarding Residents #222 and #169 -Resident #222 was initially admitted to the facility on [DATE] with diagnoses that included unspecified dementia, bipolar disorder, major depressive disorder, paroxysmal atrial fibrillation, and chronic obstructive pulmonary disease. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that resident #222 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognitive impairment. The assessment also revealed that the resident was exhibiting behavioral symptoms including physical, verbal, and behaviors not directed towards others on one to three days, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interviews, and review of facility policy, the facility failed to ensure that an incident involving abuse between resident (#222) and resident (#169) was reported accurately and in a timely manner, and, that an investigation of an allegation of abuse is reported within five (5) working days for two residents (#223 & #49). The deficient practice could result in further incidents of resident to resident abuse and allegations of abuse not being reported to the SA timely and accurately. Regarding Resident #222 and Resident #169: -Resident #222 was initially admitted to the facility on [DATE] with diagnoses that included unspecified dementia, bipolar disorder, major depressive disorder, paroxysmal atrial fibrillation, and chronic obstructive pulmonary disease. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that resident #222 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognitive impairment. -Resident #169…

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, staff interviews, and policy review, the facility failed to properly discard expired medication in the medication room. this deficient practice could result in expired medication to be administered to residents against professional standards. During a medication admission observation conducted on [DATE] at 7:10a.m. with Registered Nurse (RN/Staff #64), a controlled substance (Lyrica) had an unseal capsule taped behind the medication blister pack. The RN stated that it is not part of the facility best practice to have taped medication behind the medication blister pack during this observation. A follow up interview was conducted on [DATE] at 10:48 a.m with the Registered Nurse (RN/Staff #64) who stated that the risk of having medication taped back onto the blister pack can contaminate the medication. The RN also stated that it is not part of the facility process to have medication taped back onto the medication blister pack. During an Observation on [DATE] at 12:31PM with Registered 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, staff interviews, and policy review, the facility failed to ensure that food was stored under sanitary conditions that maintained freshness in the kitchen and nourishment refrigerators. The deficient practice could result in potential foodborne illness. Findings include: On October 21, 2024 at 10:47 a.m. the initial tour of the kitchen was conducted with the Food Services Director (FSD/Staff#109) and the Food Services Assistant Manager (FSAM/Staff#181). During the tour of the large walk-in refrigerator and secondary walk-in fridge, the following food items were observed to be beyond their use by dates: -Six Gold's Horseradish sauces with a factory expiration label of September 28 2024. -One block of swiss cheese labeled 10-8-2024 to 10-14-2024. During the initial tour of the large walk-in and secondary refrigerators on October 21, 2024, the following items were opened and not dated or labeled according to when they were opened or expected to be discarded: -One salsa container -One apple juice package -One sour cream container Observation of the four…

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 clinical record review, staff interviews, and the facilities policy, the facility failed to ensure one resident (resident #2) was informed of the risks and benefits of and had consented to the usage of a psychotropic medication. This deficient practice could result in further violations of resident rights. Findings include: Resident #2 was admitted to the facility on [DATE] with the diagnosis that included Schizoaffective Disorder, Bipolar Type Major Depressive Disorder, Recurrent, Unspecified; Unspecified Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, Unspecified Psychosis, and Bipolar Disorder. A Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a BIMS (Brief Interview for Mental Status) score of 14, which indicated the resident had no cognitive impairment. A physician's order dated April 17, 2024, revealed an order for Sertraline 200mg (milligrams) by mouth one time a day for depression. Review of the Medication Administration Record (MAR) for April 2024 through…

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 clinical record review, resident and staff interviews, and policy review, the facility failed to ensure two residents (#222) was free from abuse by another resident (#169). This deficient practice could result in further incidents of resident to resident abuse. -Resident #222 was initially admitted to the facility on [DATE] with diagnoses that included unspecified dementia, bipolar disorder, major depressive disorder, paroxysmal atrial fibrillation, and chronic obstructive pulmonary disease. A care plan revised on October 22, 2021 revealed a focus related to a history of behavior problems with an intervention to place her in a secured memory care unit and administer medications as ordered. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that resident #222 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognitive impairment. The assessment also revealed that the resident was exhibiting behavioral symptoms including physical, verbal, and behaviors…

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 clinical record review and staff interviews, the facility failed to ensure one Resident (#2) with a diagnosis of a serious mental illness was referred to the appropriate state-designated mental health or intellectual disability authority for review. The deficient practice could result in necessary specialized services not being provided in accordance with professional standards. Findings include: Resident #2 was admitted to the facility on [DATE] with the diagnosis that included Schizoaffective Disorder, Major Depressive Disorder, Dementia, Psychotic Disturbance, Mood Disturbance, anxiety, psychosis, Bipolar Disorder with Psychotic Features. A Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a BIMS (Brief Interview for Mental Status) score of 14, which indicated the resident had no cognitive impairement A physician's order dated April 1, 2024, revealed an order for Seroquel 100mg (milligrams) by mouth one time at bedtime for bipolar disorder. A physician's order dated April 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policies and procedures, the facility failed to ensure that a comprehensive person-centered care plan with interventions was developed for one resident (#225). This deficient practice could result in further care plan's not being updated timely in accordance with professional standards. Resident #225 was initially admitted to the facility on [DATE]. She was later re-admitted to the facility on [DATE] with diagnoses including COPD, acute and chronic respiratory failure with hypoxia, and history of falling. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS also revealed that the resident was taking an anticoagulant medication. Review of the comprehensive care plan, initiated August 20, 2024, revealed no focus regarding anticoagulant usage or interventions regarding anticoagulant usage. Review of physician orders revealed an order dated August 22, 2024 for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and resident interviews, and observation of current facility practice, the facility failed to ensure nutritional status was assessed and managed in accordance with facility policy for one resident (#60). The deficient practice could result in a decline in nutritional status being missed and untreated for other residents. Resident #60 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, muscle weakness (generalized), and essential hypertension. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had no cognitive impairments. The MDS also revealed the resident had no issues with swallowing or chewing food, and no weight loss or weight gain had been noted. Review of the care plan, initiated July 3, 2024, revealed a focus that the resident had nutritional risk related to abdominal aortic aneurysm, depression, HTN, and adult malnutrition score 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and facility documentation, the facility failed to ensure one resident (# 32) received dialysis care consistent with professional standards. This deficient practice could result in residents not being provided with necessary treatment in accordance with professional standards. Findings include: Resident #32 was admitted on [DATE] with diagnoses including stage 4 chronic kidney disease, dependence on renal dialysis, respiratory failure, and type 1 diabetes. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. Active diagnoses included renal insufficiency or end-stage renal disease (ESRD), and dependence on renal dialysis. A Care plan dated February 13, 2024, revealed that the resident needs dialysis for renal failure and interventions included: to monitor/document/report for any signs/symptoms of infection to the access site. Review of physician orders…

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, personnel record review, facility assessment review, and facility policies, the facility failed to ensure 2 out of 6 sampled nursing staff (staff #6 and #82) possessed the competencies and skills needed to care for residents' needs. The deficient practice could result in delayed care and inadequate care for residents. Findings include: Review of the Facility Assessment with an updated date of August 2024, stated that the staff competencies needed to care for residents would hand hygiene, infection control procedures, bloodborne pathogens and exposure, resident rights and elder justice, communicating respectfully weight the residents, prohibition of photo/audio recordings, social media, emergency preparedness, workplace violence, dietary needs and kosher restrictions, dementia & Alzheimer's crisis intervention, sexual harassment, harassment and discrimination, privacy & HIPAA compliance, emergency procedures and fire safety, bullying-abuse, staff sensitivity towards residents, fire safety, medication administration, medication error prevention, understanding and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, closed record review and facility policy, the facility failed to ensure a sampled resident (#219) received behavioral health services when resident reported concerns and grievances to staff for one of one sampled resident. This deficient practice can result in lasting emotional disturbance for the resident. Findings include, Resident #219 Resident was admitted to the facility on [DATE], with the diagnoses that included rheumatoid arthritis, spinal stenosis, status post gallbladder removal, and muscle weakness. The admission Minimum Data Set (MDS)assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. A Social Service note dated November 20, 2020 revealed She is very pleasant and cooperative towards others. She does not have a psychiatric related diagnosis. She is her own person and makes her own decisions. A progress note from a provider dated November 24, 2020 revealed resident statement of Oh, it's nice to meet you!…

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 clinical record review, facility documentation, staff interview, policy review, the facility failed to ensure to include procedures that medication were recorded accurate to professional standard of care. During an observation on October 14, 2024 at 7:25AM on Unit Golding medication cart the Narcotic Count Sheet sheet revealed that there were days where Out-Going Nurse signature was missing with an In-coming nurse signature missing. The record was not recorded properly in the the following days for: September 5, 2024 at 10:00 PM - 06:00 AM September 6, 2024 at 10:00 PM - 6:00 AM October 22, 2024 at 10:00 PM - 6:00 AM October 24, 2024 at 2:00 PM - 10:00 PM October 24.2024 at 10:00 PM - 6:00 AM An interview was conducted on October 14, 2024 at 7:25AM with Licensed Practical Nurse (LPN/Staff # 76). The LPN stated that when administering narcotics one nurse will sign as out-going Nurse and the other nurse will sign as In-coming Nurse. (LPN/ Staff #76) stated that medications were not recorded properly for the above listed days. The LPN concluded that medication not recorded…

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 clinical record review, interviews, and review of policies and procedures, the facility failed to reduce or discontinue anticoagulant therapy for Resident #325 in the presence of adverse consequences. This deficient practice can result in harm related to unnecessary medications. Findings include: -Resident #325 was admitted to the facility October 16, 2024, with the diagnoses of atrial fibrillation with thrombophilia (low platelet count), a history of colon cancer, and muscle weakness. According to the admission Minimum Data Set (MDS), dated [DATE] resident scored 15 on the Brief Interview Mental Status (BIMS) suggested resident was cognitively intact. A physician's order was written on October 16, 2024 to report to provider if signs and symptoms of bleeding, hemorrhage, or bruising occurred. A progress note dated October 19, 2024 stated dark stools were noted in toilet that day at 21:00. However, the morning and evening doses of Apixaban were given on the following day October 20, 2024, despite 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, clinical record review, staff interview, and policy review, the facility failed to ensure the medication error rate did not exceed 5%. The medication error rate was 6.9%. The deficient practice could result in additional medication errors. Finding include: -Resident #32 was admitted on [DATE] with diagnoses including stage 4 chronic kidney disease, respiratory failure, and type 1 diabetes. The Minimum Data Set assessment dated [DATE] revealed a Briefs Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. A care plan initiated on September 09, 2024 revealed a focus for Diabetes Mellitus Type 1 with interventions for diabetes medication as ordered by doctors, and to monitor and document for side effects and effectiveness. A Physician's orders dated August 31, 2024 for Insulin Lispro Injection solution given based on the sliding scale. 60-199= 0 Units, Noftity MD if FSBS is less than 60, 200-249= 2 Units , 250 - 299= 4 Units, 300- 249= 6 Units, 350-400= 8 Units,…

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, staff interview, and review of policy and procedures the facility failed to ensure that one of one sampled residents (#32) was free from significant medication errors. The deficient practice could result in residents receiving unnecessary medication. Findings include: -Resident #32 was admitted on [DATE] with diagnoses including stage 4 chronic kidney disease, respiratory failure, and type 1 diabetes. A quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. A care plan initiated on September 09, 2024 revealed a focus for Diabetes Mellitus Type 1 with interventions that included to administer diabetes medication as ordered, and to monitor and document for side effects and effectiveness. A Physician's order dated August 31, 2024 for Insulin Lispro Injection solution as per sliding scale. -If 60-199= 0 Units, Notify MD if FSBS is less than 60, -200-249= 2 Units -250 - 299= 4…

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 clinical record review, facility documentation, staff interview, policy review, the facility failed to ensure that glucometer controls were consistently completed. During an observation on October 23, 2024 at 12:41 p.m. with Registered Nurse (RN/staff #82) on Unit Rich with medication Cart 2 the Quality Control Record sheet had revealed that glucometer controls were not consistently completed. An interview was conducted on October 23, 2024 at 1:00 p.m. with the Assistant Director of Nursing (ADON/Staff #94). The ADON stated that glucometer quality controls were not consistently completed. An Interview was conducted on October 23, 2024 at 1:02 p.m. with the a Register Nurse (RN/Staff#112) The RN stated that the glucometer controls were not consistently completed on the following days in September 2024: 14,15,19,21,22, 26,27,28 and 29. The RN also stated glucometer controls were not consistently completed on the following days in August 2024: 1, 2, 11,25 and 31. The RN also stated glucometer controls were not completed on the following days in October 2024: 4,5,6,9,10,11,12,…

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 clinical record review, observations, interviews, and review of policy, the facility failed to appropriately implement their enhanced barrier precaution (EBP) program on two residents (#38 and #64). This deficient practice can result in harmful transmission of pathogens to other residents. Findings include, Regarding Resident #38 Resident # 38 was admitted to the facility on [DATE] with diagnoses of paroxysmal atrial fibrillation, Type 2 Diabetes, and open wound infection of the right artificial knee. The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which suggested the resident has intact cognitive ability. The MDS also reveals the resident is receiving care for a surgical wound and is currently receiving Intravenous (IV) medications. The order summary report revealed the resident's peripherally inserted central catheters (PICC) interventions began on September 21, 2024 The order summary report revealed wound care began on the right knee…

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, clinical record reviews, resident and staff interviews, and facility documentation, policy and procedures, the facility failed to ensure 3 residents (#5, 24, 40) were free from preventable falls. The deficient practice put the residents at increased risks for serious injury and harm. Findings include: -Regarding Resident #5: Resident #5 was admitted [DATE] with diagnoses of metabolic encephalopathy, Parkinson's, Dementia, and anxiety disorder. A MORSE fall scale (Fall Assessment tool) was conducted on 7/25, 7/31, 8/7, 8/13, 8/16 and 9/3/2024. All assessments include the resident was high risk for falling. A care plan focus dated 7/26/24 included that the resident is at high risk for falls related to confusion, deconditioning, history of falls and was unaware of safety needs. Interventions include following facility fall protocol, encouraging non skid socks while ambulating or in wheelchair, and placing the call light in reach and prompt response to requests for assistance. A progress note…

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 clinical record review, staff interviews, and policy reviews, the facility failed to ensure one resident (#60) was allowed to return to the facility following hospitalization. This deficient practice could result in unsafe discharges for future residents. Findings include: Resident #60 was admitted to the facility on [DATE] with diagnoses that included dementia, bipolar disorder, chronic obstructive pulmonary disease, spinal stenosis, and atrial fibrillation. Review of the quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed a BIMS (brief interview for mental status) score of 8, which indicated the resident had significant cognitive impairment. The discharge MDS assessment dated [DATE] revealed that the resident had been discharged with return anticipated. A nursing progress note dated June 8, 2024 revealed the resident was being sent out emergently via 911 because of altered mental status and labored breathing. An interview was conducted with hospital case manager (HCM/staff #15) on June…

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, staff interviews, and policy, the facility failed to ensure multiple food items were stored in accordance with professional standards and wet cleaning rags were not left on the top of counters or carts. The deficient practice could result in placing residents at risk for food-borne illnesses. Findings include: A kitchen and food storage observation were conducted September 25, 2023 at 8:26 a.m. with the food services director (staff #90). There were 2 plastic packages of strawberries, 2 packages of blackberries, 4 packages of raspberries and 3 green peppers with multiple grey fuzzy growths on the surface of individual fruits in each of these packages found inside the refrigerator. There were also 3 cucumbers that were misshapen, partially desiccated and extremely soft (mushy) to the touch. During the same observation on September 25, 2023 at 8:26 a.m. a wet cleaning rag was observed on the top of a food cart. In another observation conducted on September 26, 2023 at 10:17 a.m. there was a wet cleaning rag on top of a food preparation counter. A nutritional…

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

Based on resident and staff interviews, facility documentation, policy and procedures, the facility failed to act upon grievances voiced during resident council meetings. The facility census was 73. The deficient practice could result in residents' concerns, views, grievances or recommendations not being considered or acted upon. Findings include: Review of the resident council meeting minutes for the past 6 months revealed inconsistent documentation of facility actions/response or communication to residents related to issues or concerns voiced or brought up during the resident council meetings. A resident council meeting was conducted on September 26, 2023 at 1:30 p.m. with four (#49, #21, #5 and #35) alert and oriented residents. One resident stated that concerns voiced to the facility were heard but not always acted upon; and/or facility missed providing status updates regarding the concerns to the resident council. Two residents said that the facility had not reported back on several issues to include having live or artificial plants in the common areas, independent wheelchair…

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 clinical record review, staff interviews and review of facility policy and procedure, the facility failed to ensure that one resident (#21) was appropriately transferred using a mechanical lift. The deficient practice could result in preventable accidents such as falls. Findings include: Resident #21 was admitted with diagnoses of hemiplegia and hemiparesis following cerebral infarction. A quarterly Minimum Data Set (MDS) assessment dated [DATE], included a Brief interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. The assessment also included that the resident required an extensive 2 person assist for transfers. A care plan included the resident had an Activities of Daily Living (ADL) self-care performance deficit; and that, the resident had hemiplegia affecting the left side related to cerebrovascular accident. Interventions included the resident required 2 staff for all care related to accusations against others and to assist with ADL's and locomotion as…

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 interviews, and facility policy, the facility failed to ensure that one agency staff (#81) had appropriate competency and skill sets necessary to transfer one resident (#21) using a sit to stand lift. The deficient practice could result in resident injury and staff not having the skills to provide the care the resident needs. Findings include: Resident #21 was admitted with diagnoses of hemiplegia and hemiparesis following cerebral infarction. A quarterly Minimum Data Set (MDS) assessment dated [DATE], included a Brief interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. The assessment also included that the resident required an extensive 2 person assist for transfers. A care plan included the resident had an Activities of Daily Living (ADL) self-care performance deficit; and that, the resident had hemiplegia affecting the left side related to cerebrovascular accident. Interventions included the resident required 2 staff for all care related to accusations…

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 clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure pain medication was administered according to physician ordered parameters for one resident (#67). The deficient practice could result in residents receiving unnecessary medication and adverse side effects. Findings include: Resident #67 was admitted [DATE], with diagnoses of chronic pain syndrome, major depressive disorder, and diabetic neuropathy. The physician order dated July 14, 2023, included the following: - Acetaminophen (analgesic). Give 650 milligrams (mg) by mouth every 6 hours as needed for pain 1-3 NTE (not to exceed) 3 gm (grams) in 24 hours; - Oxycodone (opioid) 5 mg. Give two tablets by mouth every 4 hours as needed for severe pain 8-10; and, - Oxycodone 5 mg. Give one tablet by mouth every 4 hours as needed for moderate pain 4-7. The admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicates…

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.