Mountain Manor Senior Residence

A review of Resident 147's admission Record, indicated Resident 147 was admitted to the facility in 2025 with diagnoses including right leg cellulitis and right ankle and foot osteomyelitis (a bone infection characterized by inflammation of the bone tissue). A review of Resident 147's OSR, dated 4/23/25, indicated Resident 147 had an open wound dressing on the right arm, left wrist, and left front arm, a surgical site to right foot, and wound care to bilateral feet. During a concurrent observation and interview on 4/22/25 at 8:23 a.m. with CNA 6, CNA 6 confirmed and stated there were no EBPs signage or PPEs placed by Resident 147's room. During a concurrent observation and interview on 4/23/25 at 8:39 a.m. with LN 6, LN 6 confirmed there was no EBP signage or PPE cart available in front of Resident 147's room. During an interview on 4/24/25 at 9:42 a.m. with the IP, IP stated Resident 147 had a wound dressing and should have EBPs in place.Based on observation, interview, and record review, the facility failed to implement infection control practices for a census of 45 residents,…

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 a comfortable noise level for four residents (Resident 299, Resident 38, Resident 1, and Resident 300) of a census of 45. This failure decreased the facility's potential to maintain the residents' comfort level and sleep. Findings: A review of an admission record indicated Resident 299 was admitted to the facility in April 2025 with a diagnosis of insomnia (trouble falling asleep or staying asleep). A review of Resident 299's Order Summary Report, dated 4/12/25, indicated Resident 299 had the capacity to make healthcare decisions. During an interview on 4/23/25 at 8:40 a.m. with Resident 299, Resident 299 stated staff in the evening shift (3 p.m. - 11:30 p.m.) left the room door open at bedtime and had to be reminded to close it because of the hallway's noise. Resident 299 added the certified nursing assistants constantly yelled for each other from each hallway end while performing resident care. Resident 299 tried to sleep by 9 p.m. but could not fall asleep until 10 p.m. or 11 p.m. due to yelling…

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 provide a bed hold notification upon transfer to hospital to one of 17 sampled residents (Resident 36), when Resident 36 was transferred to hospital without a bed hold notification on 3/4/25, 3/11/25, and 4/15/25. This failure decreased the facility's potential to protect Resident 36's right in bed hold and return to facility. Findings: A review of Resident 36's admission Record, indicated Resident 36 was admitted to the facility in 2025 with a diagnosis of congestive heart failure (a condition where the heart's pumping action is weakened, making it difficult to meet the body's needs). A review of Resident 36's Census List, dated 4/23/25, indicated Resident 36 was discharged on 3/4/25, 3/11/25, and 4/15/25. A review of Resident 36's SBAR (Situation, Background, Assessment, and Recommendation) Communication Form and Progress Note, dated 3/4/25 and 4/15/25, indicated Resident 36 was sent out to the hospital on 3/4/25 and 4/15/25. During a concurrent interview and record review on 4/23/25 at 2:40 p.m. with Medical Record…

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 develop a comprehensive person-centered care plan for one of 17 sampled residents (Resident 397), when the care plan did not address Resident 397's insomnia (trouble falling asleep or staying asleep) and trazodone (a medication to treat insomnia). This failure decreased Resident 397's potential to receive appropriate care, services, and treatment. Findings: A review of Resident 397's medical record indicated he was admitted to the facility on [DATE] with multiple diagnoses including dementia (a progressive state of decline in mental abilities), depression, anxiety, and personal history of other mental and behavioral disorders. A review of Resident 397's medical record indicated a physician's order for trazodone 50 milligrams (mg; a unit of measure), give 25 mg at bedtime for insomnia, ordered on 4/13/25. During a concurrent interview and record review on 4/23/25 at 10:09 a.m. with Licensed Nurse 1 (LN 1), Resident 397's care plans were reviewed. LN 1…

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

Based on interview and record review, the facility failed to revise the care plan for one of 17 sampled residents (Resident 397), when Resident 397 sustained a bruise (an injury or mark where the skin has not been broken but is darker in color, often as a result of being hit by something) to the right cheek. This failure decreased the facility's potential to provide Resident 397 with a person-centered care plan that meets the changed care needs. Findings: A review of Resident 397's admission Record, indicated Resident 397 was admitted to the facility in April 2025 with a diagnosis of vascular dementia (problems with reasoning, planning, judgement, memory and other thought processes caused by brain damage from impaired blood flow to your brain). A review of Resident 397's SBAR (situation, background, assessment, recommendation) Communication Form and Progress Note, dated 4/17/25, indicated Resident 397 had a change of condition that resulted in bruising to face. A review of Resident 397's physician's order, dated 4/18/25, indicated an order to monitor Resident 397's discoloration 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 provide care and services in accordance with acceptable professional standards of quality for one of 17 sampled residents (Resident 196), when Licensed Nurse 2 (LN 2) did not clarify a physician's order with multiple dosages prior to administering medication. This failure had the potential to result in Resident 196 not receiving the correct dosage of medication and worsening of their clinical condition. Findings: During a medication pass observation on 4/21/25 at approximately 9 a.m., LN 2 was observed preparing six medications for Resident 196 including calcium carbonate (a medication to treat heartburn) 500 milligrams (mg, a unit of measurement), one tablet. A review of Resident 196's medical record indicated a physician's order for calcium carbonate 1250 (500 Ca) mg (calcium carbonate), give one tablet by mouth two times a day for heartburn, ordered 4/10/25. During an interview on 4/21/25 at 1:23 p.m. with LN 2, LN 2 stated he prepared and administered one tablet calcium carbonate for a total of 500 mg,…

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 follow the plan of care for one of 17 sampled residents (Resident 247), when Resident 247's communication board was not available for use during provision of care. This failure decreased the facility's potential to meet Resident 247's ability to communicate her needs. Findings: A review of an admission record indicated Resident 247 was admitted to the facility in April 2025 with a diagnosis of chronic respiratory failure. A review of Resident 247's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 4/5/25, indicated Resident 247 had adequate ability to see and hear with a Brief Interview of Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 14 out of 15 with no memory problems. A review of Resident 247's communication care plan, dated 4/7/25, indicated Resident 247 had communication barrier due to language used. The care plan further indicated Resident 247 communicated only in Russian…

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 respiratory care services according to professional standards of quality for one of 17 sampled residents (Resident 24), when Resident 24's administered oxygen was not consistent with the physician's order. This failure decreased the facility's potential to follow the physician's order when providing respiratory services. Findings: A review of Resident 24's admission Record, indicated Resident 24 was admitted to the facility in December 2024 with a diagnosis of anxiety disorder. A review of Resident 24's Order Summary Report, dated 2/27/25, indicated an order for oxygen use two liters per minute (l/min, unit of measurement) via nasal cannula as needed for shortness of breath. During a concurrent observation and interview on 4/21/25 at 12:45 p.m. with Resident 24, Resident 24 was sitting up in bed with her oxygen set at one l/min. Resident 24 stated she was still short of breath even with her oxygen on. During a concurrent interview and record review on 4/21/25 at 12:50 p.m. with Licensed Nurse 3 (LN…

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 Quality Assessment and Assurance (QAA) committee was composed of the required committee members for a census of 45 residents. This failure decreased the facility's potential to identify, monitor, implement and enhance the quality of care for residents. Findings: During a concurrent interview and record review on 4/23/25 at 10:42 a.m. with the Administrator (ADM), the facility's quarterly Quality Assurance and Performance Improvement (QAPI) meeting, dated April 2024 was reviewed. ADM confirmed the Medical Director (MD) did not attend the quarterly QAPI team meeting held in April 2024. A review of the facility's document titled, QA [Quality Assessment] Sign-In Sheet, dated 4/9/24, indicated the MD name and signature were missing as part of the QAA committee for the quarterly QAPI meeting on 4/9/24. A review of the facility's undated document titled, QA Committee Information, indicated the MD was one of the required QAA Committee members. A review of the facility's undated policy titled, 2024/2025 Quality Assurance…

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 follow the Antibiotic Stewardship Program for one of 17 sampled residents (Resident 247), when Resident 247 was prescribed an antibiotic without adequate clinical and laboratory findings for its use. This failure increased Resident 247's potential for an unnecessary administration of an antibiotic without appropriate indication. Findings: A review of an admission record indicated Resident 247 was admitted to the facility in April 2025. A review of Resident 247's hospital admission order, dated 4/3/25, indicated Resident 247 was admitted to the facility with no urinary tract infection (UTI) diagnosis. A review of Resident 247's Order Summary Report, dated 4/7/25, indicated an order for levofloxacin (an antibiotic used to treat bacterial infections) 250 milligrams (mg, unit of measurement) one tablet daily for 14 days for chronic UTI, then half tablet daily to be given until 5/21/25 for UTI prophylaxis. A review of Resident 247's Medication Administration Record, indicated Resident 247 was administered levofloxacin 250 mg…

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 prevent elopement for one of 3 sampled residents (Resident 1 ) when he left the facility unaccompanied by staff. This failure resulted in Resident 1 sustaining a fall, complained of neck and left knee pain and, verbalized he hit his head. Findings: Resident 1 was admitted to the facility in October 2024 with diagnoses which included cognitive impairment, dementia, difficulty in walking, and history of falling. Resident 1's admission MDS (Minimum Data Set-an assessment tool), dated 10/29/24 documented Resident 1 as having clear speech, sometimes able to understand others, sometimes able to make self-understood and his Brief Interview for Mental Status (BIMS) summary score as a 3 out of 15 (indicated severe impairment). The MDS described Resident 1 as not having delirium or behavioral symptoms but as having wandering behavior. Review of Resident 1's Wandering Risk Assessment, dated 10/16/24 indicated Resident 1 as moderate risk for wandering. Review of a Progress Note dated 10/22/2024 at 5:05 p.m. indicated, Resident had an…

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 one of three sampled resident's (Resident 3's) rights were exercised when the resident was moved to another room without advance notice. This failure resulted in a violation of Resident 3's rights and left the resident confused. Findings: Review of Resident 3's medical record, admission RECORD, indicated the resident was admitted to the facility in the spring of 2024 with diagnoses that included heart problems. The admission Record indicated Resident 3 was his own responsible party (RP). In an interview on 8/6/24 at 11:15 a.m., Resident 3 was in his wheelchair near the door of a room in the hallway. Resident 3 stated he was being moved to the room at that time and stated he did not know why he was moving. Resident 3 stated someone came in his room that morning and said, You're moving, while clapping his hands. Resident 3 said he did not receive any notification regarding the room change, did not know where his new room was, or who the new roommate would be and still had not met the roommate. Resident 3…

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 food was prepared, stored, served, or distributed in accordance with professional standards of food serve safety when: 1. The ice machine was not clean with black and pink substances at the bottom of the ice evaporator unit (a part where water freezes to produce ice and push out from the unit) and pink slimy substances on the water curtain (a plastic cover rests over the ice evaporator where the ice dispenses); 2. There were 11 out 15 tomatoes with black and white indented spots found in dry storage; 3. There were several metal pans found stacked wet and contained food debris when stored at the clean and ready-to-use storage areas; 4. Employee's personal belonging found in the dry food storage area; and, 5. Juice dispenser was not clean with significant dust on the vent where juice dispended. Findings: 1.During an inspection of ice machine in the kitchen on 6/4/2024, at 8:39 a.m., the Outside Vendor Technician (OVT) removed the top access panel to reveal the machinery part of the ice machine. There…

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 pharmacy services were maintained for a census of 38 when two opened Emergency drug kits found in the medication room had not been replaced by the pharmacy according to the facility policy. This failure had the potential for residents not receiving necessary medications on time or drug diversion. Findings: During an inspection of medication room [ROOM NUMBER] on 6/3/24 at 11:28 a.m., two e-kits (emergency kit, a box containing emergency medications) were observed to be previously opened and used, but still not replaced by the pharmacy. E-kit #53 was an e-kit containing controlled medications (drugs with higher risk of addiction and high potency) was accessed on 5/29/24 at 9 p.m. E-kit # 49 was an e-kit containing oral medications was first accessed on 5/30/24 followed by 6/1/24, and 6/2/24. During an interview on 6/3/24 at 11:36 a.m. with Licensed Nurse 1, LN 1 confirmed that both e-kits had been used, but still not replaced 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 ensure the medication error rate did not exceed 5% for two of 10 sampled residents (Resident 241 and Resident 540) when: 1. For Resident 241, a licensed nurse administered famotidine, a medication used to treat heartburn and stomach acid reflux, not in accordance with Physician Orders. 2. For Resident 540, metoprolol succinate, a medication used to treat high blood pressure, was not available for the resident. As a result, 2 errors were identified out of 37 opportunities for error during the observation of medication administration; the facility medication error was 5.41%. Findings: 1. During an observation of medication administration on 6/3/24 at 7:52 a.m., Licensed Nurse (LN) 1 was observed to prepare and administer Resident 241's morning medications which included famotidine 10 mg (milligrams, unit of measure). LN 1 verified and administered a total of 10 pills. Reconciliation of the observation of medication administration with Resident 241's current Physician Orders indicated an order for famotidine 20…

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 medications were stored correctly, when: 1. Six metered-dose inhalers were found with unlabeled open dates in Medication Cart A; 2. Two expired insulin vials were found in the medication refrigerator; 3. Prescription medication blister packs were found lodged in the rear gap of Medication Cart A; 4. Two expired glucometer control solutions were found in Medication Cart A; and, 5. Loose pills were found in Medication Cart A. These failures had the potential for omitting medications, medication misuse, and administering or using ineffective expired pharmaceutical products. Findings: 1. During a combined observation and interview [DATE] at 10:17 a.m. with Licensed Nurse (LN) 1, the open dates were not written on six (6) metered dose inhalers or accompanying boxes in Medication Cart A, as follows: a) Umeclidinium (an inhaled medication to relax the airways) 62.5 mcg (microgram, unit of measure) and vilanterol (an inhaled medication to…

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

Based on observation, interview, and record review, the facility failed to ensure the therapeutic diet menu was followed for the census of 38 during the lunch service on 6/4/2024 when: 1. Four residents (Resident 1, 5, 25, and 491) with (CCHO consistent carbohydrate) diet (a diet used in the treatment for diabetes) received one serving of fruit mix crumble cake instead of half serving for dessert; 2. One resident (Resident 2) with small portion diet, received one serving of fruit mix crumble cake instead of half serving for dessert; and, 3. One resident (Resident 5) with mechanical soft texture (a texture-modified diet that restricts foods that are difficult to chew or swallow) diet, received chopped salad with croutons instead of without croutons. These failures had the potential to result in compromising the medical and nutrition status of those five residents. Findings: 1.During an observation on lunch service on 6/4/2024 beginning at 11:45 a.m., it was noted Resident 1, 5, 25, and 491 were on CCHO diet indicated on the meal tickets (a ticket including resident's diet, date,…

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 complete the Minimum Data Set (MDS, an assessment tool used to guide care) admission Assessment within 14 calendar days after admission for two in a census of 38 (Resident 9 and Resident 21). This failure had the potential to delay care planning and the delivery of care that would have been identified in the admission assessment. Findings: 1. Resident 9 was admitted to the facility on [DATE], with diagnoses including dementia and cognitive communication deficit. Review of Resident 9's MDS Assessment, dated 12/15/23, indicated the comprehensive admission Assessment was completed on 1/10/24, 28 calendar days after admission. 2. Resident 21 was admitted to the facilty on 1/4/24 with diagnoses including altered mental status. Review of Resident 12's MDS Assessment, dated 1/6/24, indicated the comprehensive admission assessment was completed on 1/29/24, 26 calendar days after admission. During a concurrent interview and record review of the MDS assessments…

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 develop a comprehensive person-centered care plan for one of 15 sampled residents (Resident 491), when the care plan did not address Resident 491's dialysis (a procedure to remove waste products from the blood when the kidneys stop working properly) care and interventions. This failure decreased the facility's potential to address the residents' individualized and specific needs. Findings: A review of an admission record indicated Resident 491 was admitted to the facility in May 2024 with diagnoses including dependence on renal (kidney) dialysis and end stage renal disease. During a concurrent observation and interview on 6/4/24 at 8:38 a.m. with Resident 491 in her room, Resident 491 had a tube connected to her left abdominal area. Resident 491 stated she had peritoneal dialysis (a treatment for kidney failure that uses the lining of abdomen to filter the blood) tube, went yesterday to dialysis, and was scheduled for dialysis on Monday, Wednesday, and Friday. A review of Resident 491's Minimum Data Set (MDS;…

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 services which meet professional standards of quality of care for one of 15 sampled residents (Resident 290) when Resident 290 was allowed to wear a left leg/knee immobilizer without a physician's order. This failure resulted in Resident 290's use of a leg/knee immobilizer without a required physician's order. Findings: A review of Resident 290's admission Record indicated she was admitted 6/24 with diagnoses including left tibial plateau fracture (fracture in the upper part of the shinbone) after a ground level fall. During an intial tour observation on 6/3/24 at 10:30 a.m., Resident 290 was observed lying in bed wearing a left leg/knee immobilizer. During a concurrent observation and interview on 6/4/24 at 2:32 p.m. with the Physical Therapist (PT) while doing therapy with Resident 290, the PT stated a leg/knee immobilizer should be worn at all times as ordered from the hospital to prevent the knee from bending or flexing. During a concurrent interview and record review of the Order Summary Report…

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 maintain nail care for one of 15 sampled residents (Resident 25) when, Resident 25's fingernails on both hands were long and packed with a brownish-black substance. This failure decreased the facility's potential to maintain residents' nail care and prevent infection. Findings: A review of an admission record indicated Resident 25 was admitted to the facility in May 2024 with diagnoses including dementia (impaired ability to remember, think, or make decisions). During a concurrent observation and interview on 6/3/24 at 12:20 p.m. with Certified Nurse Assistant (CNA) 4 in the Resident 25's room, Resident 25 was observed with long fingernails packed with a brownish-black substance on both hands. The CNA 4 agreed fingernails on both hands were long and dirty. The CNA 4 stated to inform the Licensed Nurse and the Activities Aide (AA) to take care of Resident 25's fingernails. During an interview on 6/5/24 at 2:20 p.m. with AA, the AA stated she can trim resident's nails as per CNA's request, but she was not aware…

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 one of 15 sampled residents (Resident 2) received care in accordance with professional standards when Resident 2's physician order to float heels when in bed was not implemented. This failure decreased the facility's potential to prevent skin breakdown. Findings: A review of Resident 2's admission Record indicated she was admitted on 8/23 with diagnoses including muscle weakness and age-related physical debility. In a concurrent observation and interview during the inital tour on 6/3/24 at 9:15 a.m., Resident 2 stated she had a good sleep and was ready to get up, was still in bed in her nightgown and feet observed to have edema (swelling). Review of Resident 2's Order Summary Report (OSR), dated 8/30/23, indicated an order to ensure heels are floated when in bed every shift for skin breakdown prevention. In a concurrent observation, interview, and record review on 6/4/24 at 7:50 a.m. with Licensed Nurse 4 (LN 4), Resident 2 was observed lying in bed, LN 4 confirmed Resident 2's feet/heels were not…

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 one of 15 sampled residents (Resident 15) had access to vision services when Resident 15 was not assisted in obtaining prescription eyeglasses. This failure resulted in Resident 15 not having eyeglasses to maintain good vision. Findings: A review of an admission Record for Resident 15 indicated she was admitted in 7/23 with diagnoses including cataracts (cloudy area in the lens of the eye) and syncope (fainting). In a concurrent observation and interview on 6/3/24 at 9:45 a.m. with Resident 15, observed Resident 15 was lying in bed, squinting while watching television. A magnifying glass was on top of her table; Resident 15 stated she used it for reading. Resident 15 further mentioned the facility was supposed to provide a pair of new eyeglasses to her and she's been waiting for it for a long time. A review of Resident 15's Minimum Data Set (MDS, an assessment tool used to guide care), dated 4/19/24, indicated Resident 15 needed corrective lenses to maintain vision. In an interview on 6/5/24 at 10:10…

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 two of 15 sampled residents (Resident 2 and Resident 3) were free from unnecessary medication when: 1. Resident 2's anti-anxiety medication (a medication used to help reduce symptoms of worry, fear, and panic) was prescribed without a stop date; and, 2. Resident 3's use of an antibiotic medication (medicines that treat bacterial infections in humans) was continued without adequate indication. These failures increased the risk of Resident 2 and Resident 3 to receive unnecessary medications. Findings: 1. A review of Resident 2's admission Record indicated Resident 2 was admitted in 8/2023 with diagnoses including anxiety disorder. A review of an Order Summary Report (OSR) of Resident 2, dated 5/2/2024, indicated an order for hydroxyzine hydrochloride (an anti-anxiety medication) 25 milligrams (mg, unit of measurement) every 8 hours as needed (PRN) for anxiety with restlessness, there was no stop date written. A review of Resident 2's Medication Regimen Review (MRR) for 5/2024 the Pharmacy Consultant (PC) recommended…

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 follow infection control practices for one of 15 sampled residents (Resident 32) when the Certified Nursing Assistant 3 (CNA 3) did not apply a face shield (a device to protect the eyes and face) while assisting Resident 32 with meal in the Coronavirus-19 Disease (COVID-19, an infectious disease caused respiratory illness) unit. This failure had the potential to spread infection in the facility. Findings: Review of Resident 32's admission Record, indicated Resident 32 was admitted to the facility in 2024 with diagnoses including COVID-19. During an observation on 6/3/24 at 12:25 p.m. in Resident 32's room with CNA 3, the CNA 3 entered Resident 32's room, a COVID-19 positive room. The CNA 3 put on N-95 mask (a respiratory protective mask to provide efficient filtration of airborne), gown, and gloves. The CNA 3 assisted Resident 32 with meal and did not use any face shield or goggles. There was a visible sign by the wall of the room with instructions to don (put on) face shield and N-95, hand hygiene before…

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 complete the annual performance reviews for eight of eight sampled certified nursing assistants (CNAs; CNA 1, CNA 2, CNA 3, CNA 4, CNA 5, CNA 6, CNA 7, and CNA 8). This failure increased the residents' potential to receive poor quality of care from CNAs. Findings: A review of the New Hire Report, dated 5/10/23, indicated, CNA 1's date of hire (DOH) was 11/13/20, CNA 2's DOH was 9/8/20, CNA 3's DOH was 9/5/18, CNA 4's DOH was 10/29/19, CNA 5's DOH was 8/16/21, CNA 6's DOH was 8/1/14, CNA 7's DOH was 7/6/19, and CNA 8's DOH was 3/15/17. During a concurrent interview and record review, on 5/10/23, at 1:44 p.m., with Director of Staff Development (DSD), the personnel records for CNA 1, CNA 2, CNA 3, CNA 4, CNA 5, and CNA 6 were reviewed. The personnel records indicated, no performance evaluations (PEs) were completed in 2022 for CNA 1, CNA 2, CNA 3, CNA 4, CNA 5, and CNA 6. DSD stated, the PEs for all the CNAs in the facility were not done for the last two years. DSD further stated, the PEs were supposed to be done annually to…

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

Based on observation, interview, and record review, the facility failed to ensure professional standards were followed when: 1. Insulin (a hormone that works by lowering levels of glucose-sugar in the blood) was injected into the muscle instead of into fatty tissue for Resident 149; and, 2. The pharmacy auxiliary sticker label (a label added on to a dispensed medication package by a pharmacist that displays additional warnings, information, or instructions) was not followed by nursing staff during medication administration for Resident 14. These failures had the potential for residents to have dangerous blood glucose levels and more painful injections, and medications to not be absorbed properly due to their properties being altered from not being administered correctly. Findings: 1. During a medication pass observation on 5/8/23, at 8:07 a.m., alongside Licensed Nurse 3 (LN 3), LN 3 was observed preparing insulin glargine (a long-acting insulin to treat diabetes) for Resident 149. LN 3 prepared the injection then went to the resident's room to administer it. Resident 149 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, interview, and record review, the facility failed to ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction), availability of emergency drugs, and develop and implement procedures to ensure safe handling of hazardous drugs (medications capable of causing serious effects) when: 1. Random controlled medication use audits for 1 out of 3 residents (Resident 44) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) to indicate they were given to the resident; 2. Two out of 3 medication cart controlled drug sign-in/sign-out sheets (a sheet used to reconcile inventory of controlled medications in the medication cart by the outgoing and incoming nurse during a shift change) were missing signatures of the outgoing and incoming nursing shift; 3. Controlled medication was not securely stored in the Medication Storage Room; 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure irregularities were identified during the medication regimen reviews for three of 12 sampled residents (Resident 3, Resident 5 and Resident 9) when: 1. Resident 3 had an order for a PRN (as needed) psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) with no end date; 2. Resident 5 had an order for two PRN psychotropic medications with no end date and no indication for haloperidol lactate (a medication used to treat schizophrenia [a serious mental disorder in which people interpret reality abnormally]); and 3. Resident 9's indication for clonazepam (a medication used to treat seizures, panic disorders and anxiety) was incorrect. These failures had the potential for undetected medication irregularities or residents to receive unnecessary medications. Findings: 1. A review of Resident 3's admission record indicated she was admitted on [DATE] with diagnoses including cerebral infarction…

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 ensure four of 12 sampled residents (Resident 3, Resident 5, Resident 9 and Resident 14) did not receive psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) unnecessarily when: 1. Resident 3 had an order for a PRN (as needed) psychotropic medication with no end date; 2. Resident 5 did not have a signed consent or behavior monitoring for psychotropic medication use; 3. Resident 9's indication for clonazepam (a medication used to treat seizures, panic disorders and anxiety) was incorrect and there was no behavior and side effects monitoring; and 4. Resident 14's hydroxyzine (medication used to treat anxiety and allergies) order did not have an indication, there was no behavior monitoring and no signed consent for the medication in the resident's record. These failures placed the residents at risk for unnecessary psychotropic medication use. Findings: 1. A review of Resident 3's admission record…

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: 1. Opened biologicals and multi-dose inhalers were dated with an open and discard date, to ensure they were not used beyond the discard date; and expired and discontinued medications were not available for resident use; 2. Medications were not left unattended on top of medication carts, and carts were kept securely locked when left unattended; and 3. Monitor and record temperatures for the Medication Storage Room Refrigerator used to store medications and vaccine. The deficient practices had the potential for residents to receive medications with unsafe or reduced potency from being used past their discard date or improper storage, and diversion or misuse of medications from not being securely stored in medication carts. Findings: 1. On 5/8/23 at 11:55 a.m., an inspection of the Medication Storage Room alongside Licensed Nurse 3 (LN 3) identified two bottles cranberry 450 milligram (mg, a unit of measurement) tablets expired 3/2023, two bottles vitamin B-12 100 microgram (mcg, a unit of measurement)…

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 infection control practices were implemented when nursing staff did not perform hand hygiene during direct resident care and glucometers were not sanitized and disinfected in accordance with facility policy and procedure (P&P) and manufacturer's specifications after resident use. These failures had the potential to expose residents to infectious disease and result in the development of infection and transmission of bloodborne diseases (such as HIV [human immunodeficiency virus, a virus that attacks the body's immune system], Hepatitis B, and Hepatitis C). Findings: 1. During an observation on 5/8/23, at 8:03 a.m., with Licensed Nurse 3 (LN 3), LN 3 was observed preparing insulin lispro (a fast-acting insulin used to treat diabetes) for a resident. LN 3 donned a pair of gloves, wiped the top of the insulin vial with an alcohol prep pad and drew up the insulin. LN 3 went the resident's room, knocked on the door with the gloved hand, and proceeded inside. LN 3 injected the insulin lispro into the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of 12 sampled resident's (Resident 17) dignity was maintained when staff was observed standing in front of the resident while assisting him with his meal. This failure had the potential to negatively impact Resident 17's dignity. Findings: A review of Resident 17's admission record indicated he was admitted [DATE] with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as stiffness, and difficulty with balance and coordination) and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Resident 17's MDS (Minimum Data Set, an assessment tool), dated 4/1/23, indicated Resident 17 had moderate memory impairment and required the extensive assistance of one person with eating. In an observation, on 5/8/23 at 10:35 a.m., Resident 17 was sitting in his wheelchair at his bedside tray table. Certified Occupational…

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 ensure one of three sampled residents (Resident 39) was informed of changes in their treatment when a new medication was added without education. This failure had the potential to deprive the resident of the right to make decisions regarding care. Findings: A review of Resident 39's admission Record, indicated Resident 39 was admitted on [DATE] with diagnoses including but not limited to: idiopathic aseptic necrosis of left femur (a loss of blood flow to bone tissue, which causes the bone to die without any cause), morbid (severe) obesity, localized edema (swelling to one part of the body) and muscle weakness. Resident 39 was her own responsible party. A review of Resident 39's Health Status Note, dated 3/29/23, the Health Status Note indicated a nurse notified the Medical Doctor (MD) Resident 39 had worsening lymphedema [tissue swelling caused by an accumulation of protein-rich fluid that's usually drained through the body's lymphatic system] and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Physician Orders for Life-Sustaining Treatment (POLST) for one resident (Resident 22) of 12 sampled residents was valid in the electronic health record (EHR). This failure had the potential for Resident 22's POLST not to be followed in the event of medical emergency. Findings: A review of an admission record indicated, Resident 22 was admitted to the facility on [DATE] with diagnoses including cerebral palsy (group of disorders that affect a person's ability to move and maintain balance and posture), multiple buttock pressure ulcers (skin injuries), chronic kidney disease, gastrostomy (surgical opening in the stomach), intellectual disabilities, hemiplegia (paralysis of one side of the body), and sepsis (a life-threatening medical emergency characterized by the body's extreme response to an infection). A review of Resident 22's POLST, dated [DATE], indicated, attempt resuscitation (CPR) if Resident 22 has no pulse and is not breathing. 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 interview and record review, the facility failed to comprehensively reassess one of 12 sampled residents (Resident 7) when Resident 7's skin tear deteriorated to a pressure injury (injury to the skin and underlying tissue resulting from prolonged pressure on the skin). This failure had the potential to result in Resident 7 having unmet care needs. Findings: A review of Resident 7's admission record indicated he was admitted on [DATE] with diagnoses including quadriplegia (paralysis that affects all of a person's limbs and body from the neck down). A review of Resident 7's MDS (Minimum Data Set, an assessment tool), dated 3/10/23, indicated he had no memory impairment, was totally dependent on staff for bed mobility and had no pressure injuries. A review of Resident 7's clinical record included the following documents: A Skin/Wound Note, dated 4/14/23 and written by Licensed Nurse 2 (LN 2), indicated Resident 7 had a skin tear on his left buttock. A Skin/Wound Note, dated 4/24/23 and written by LN 2,…

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 accurately assess two of 12 sampled residents (Resident 10 and Resident 22) when: 1. Resident 10's MDS, dated [DATE], indicated she had recently had pneumonia (infection in the lungs); and 2. MDS did not accurately reflect Resident 22's functional status. These failures decreased the facility's potential to identify residents' care needs. Findings: 1. A review of Resident 10's admission record indicated Resident 10 was admitted [DATE] with diagnoses including congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should). A review of Resident 10's MDS, dated [DATE], indicated Resident 10 had an active diagnosis of pneumonia in the seven days prior to the assessment. In a concurrent record review and interview, on 5/11/23 at 12:56 p.m., Licensed Nurse 2 (LN 2) confirmed she reviewed Resident 10's clinical record and had found no indication of pneumonia during the time period. In an interview, 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 interview and record review the facility failed to ensure a baseline care plan was accurately developed and signed within 48 hours for one of 12 sampled residents (Resident 250). This failure had the potential for Resident 250 to not receive person-centered care. Findings: A review of Resident 250's admission record indicated Resident 250 was admitted to the facility with diagnoses including Parkinson's disease (progressive brain disorder which causes uncontrollable movements and stiffness) and dysphagia (difficulty in swallowing). During a review of Resident 250's clinical record, the baseline care plan (BCP) form was not completed, and was missing the following: A date of admission, a date the BCP was submitted to Resident 250 or their Responsible Party (RP), a name of the recipient of the baseline care plan, and Interdisciplinary Team (IDT) signatures. During an interview on 5/10/23, at 11:15 a.m., with the Medical Records Director (MRD), the MRD confirmed Resident 250's BCP form was incomplete and missing signatures. During a concurrent interview and record review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to develop and complete a comprehensive person-centered care plan for two out 12 sampled residents (Resident 42 and Resident 99). These failures had the potential for Resident 42 and Resident 99 to not receive appropriate care, services, and treatment. Findings: 1. During a review of Resident 42's clinical record, it indicated Resident 42 was admitted to the facility in March 2023 with diagnoses including sepsis (presence of infection in the blood that can lead to death) and chronic kidney disease. During a review of Resident 42's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 3/30/2023, the MDS indicated Resident 42 required extensive assistance with bed mobility, transfers, eating, toileting, personal hygiene and was non-ambulatory. He was at risk for falls, was taking an anticoagulant (blood thinner) medication and an antibiotic (a drug used to treat infections caused by bacteria). Resident 42 had a BIMS (Brief…

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 revise the comprehensive care plan for one resident (Resident 22) of 12 sampled residents, when Resident 22's restorative nursing (RNA) program intervention was not quarterly revised and evaluated for effectiveness. This failure decreased the facility's potential to provide a person-centered care plan that meets the residents' needs. Findings: A review of an admission record indicated, Resident 22 was admitted to the facility on [DATE] with diagnoses including cerebral palsy (group of disorders that affect a person's ability to move and maintain balance and posture), intellectual disabilities, hemiplegia (paralysis of one side of the body), and generalized muscle weakness. A review of Resident 22's RNA program task, indicated, Resident 22 received passive range of motion (PROM) during RNA program on 5/1/23, 5/2/23, 5/3/23, 5/9/23, 5/10/23, and 5/11/23 for bilateral upper extremities (BUE) and bilateral lower extremities (BLE). During an interview 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 menus were followed for a census of 46 when staff prepared pureed rice without referring to the recipe. This failure had the potential to alter the taste and nutritive value of the food. Findings: In a concurrent observation and interview, on 5/10/23 at 11:10 a.m., [NAME] 2 (CK 2) had already placed the ingredients for the rice pilaf puree into a blender. When asked what ingredients she had placed in the blender, CK 2 stated rice pilaf, water and a teaspoon (tspn., a unit of measurement) of chicken base. CK 2 stated she blended the ingredients, tasted the puree and added more water or chicken base if needed. When asked if there was a recipe for the pureed rice pilaf, CK 2 stated she did not have one. During a record review, on 5/10/23 at 11:37 a.m., a facility recipe book contained a recipe for pureed starch (rice, pasta, potatoes). The recipe indicated to use warm milk and a stabilizer, such as instant potatoes, non-fat dry milk or breadcrumbs. In an interview, on 5/11/2 at 12:52 p.m., the Certified…

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 dry bulk goods were stored safely for a census of 46 when a bag of older flour was placed inside a bag of new flour and mislabeled. This failure had the potential to cross-contaminate the flour and lead to foodborne illnesses. Findings: In a concurrent observation and interview, on 5/8/23 at 8:04 a.m., with [NAME] 1 (CK 1), a large bin of flour was labeled as opened on 2/20/23 and had a use by date of 3/20/23. The bin was opened and a bag of flour was found stored inside another bag of flour. CK 1 stated he believed the use by date was wrong and the flour was good for six months. CK 1 further stated when they opened a new bag of flour they put the new flour on the bottom of the bin and whatever was left in the prior bag was placed on top. In an interview, on 5/11/23 at 12:52 p.m., the Certified Dietary Manager (CDM) stated he expected when staff opened flour and placed it in the bin they threw out the previous bag, with whatever flour was remaining, and labeled the bin appropriately. The CDM stated 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.