Mayflower Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were provided with a communication device in a language that the resident understood for one of one sampled resident (Resident 30). This failure had the potential to affect Resident 30's communication with the staff and had the potential to result in a delay in the provision of care, treatment, and services to the residents. Findings: During a review of Resident 30's admission Record (AR), the AR indicated Resident 30 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and anxiety (characterized by excessive, persistent worry and fear that can interfere with daily life). During a review of Resident 30's Care Plan (CP), dated 3/22/2023, the CP indicated…

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 provide supervision to a resident who used a plate guard (a dining aid that can help people with limited control, grip, or dexterity eat with one hand and reduce the risk of spills) during meals for one of one sampled resident (Resident 39). This failure had the potential to result in Resident 39's decline in nutritional status and inability to maintain independence during mealtimes. Findings: During a review of Resident 39's admission Record (AR), the AR indicated Resident 39 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included muscle weakness (lack of muscle strength), osteoarthritis (OA, a progressive disorder of the joints, caused by a gradual loss of cartilage) and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 39's Care Plan (CP), dated 8/19/2022, the CP indicated Resident 39 had an alteration in 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Certified Nurse Assistants 1 and 2 (CNA 1 and CNA 2) donned (put on) the required personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) while providing care to one of one sampled resident (Resident 10) who was on Enhanced Barrier Precaution (EBP, an approach for the use of PPE to reduce transmission of multidrug-resistant organisms [MDRO] between residents in skilled nursing facilities). This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection for the residents and the staff that could result in a widespread infection in the facility. Findings: During a review of Resident 10's admission Record (AR), the AR indicated Resident 10 was admitted to the facility on [DATE], with diagnoses that included encounter for attention to gastrostomy (creation of an artificial external opening…

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 the wheelchair pad alarm was functional to alert the staff for one of one sampled resident (Resident 51) as indicated in the facility's policy titled Alarm Monitor and plan of care. This failure had the potential to result in Resident 51 not receiving care or receiving delayed services to meet the residents' needs and had the potential to result in a fall or injury. Findings: During a review of Resident 51's admission Record (AR), the AR indicated Resident 51 was originally admitted to the facility on [DATE], and readmitted to the facility on [DATE] with diagnoses that included unspecified dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and Alzheimer's disease (irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks). During a review of Resident 51's…

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 12 of 28 residents (12 residents) in the dining room were encouraged to engage in activities of their choice and/or encouraged to participate in the activity program. This failure had the potential to negatively impact the residents' physical, mental, and psychosocial well-being. Findings: During an observation in the dining room on 12/18/24 at 11:03 am, the Activity Director (AD) was exercising with the residents. The AD was standing in the middle of the dining room and was facing the table located next to the right wall of the dining room. There were 15 residents who faced the AD while doing exercises. The 12 residents sitting behind the AD were just sitting and looking around, and some residents were sleeping in their wheelchair. No one encouraged the 12 residents behind the AD to participate in the exercise program and/or encouraged them to engage in any activity of their choice. One resident was getting a haircut in the right corner of the dining room next to the entrance to the dining room.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident environment remained as free of accident hazards as is possible as indicated in the facility's policies and procedures (P&P) titled, Policy & Procedure: Accident/Incident Prevention, and Policy: Call Lights, by failing to: 1. Ensure call light was within reach for two of 11 sampled residents (Residents 1 and 2) in the resident's room. 2. Ensure call light pull cords were within reach for 10 of 11 sampled residents (Residents 1, 2, 4, 5, 6, 7, 8, 9, 10, and 11) when using the bathroom. 3. Ensure call lights were functioning for three of 11 sampled residents (Residents 2, 6, and 7) when using the bathroom. These deficient practices increased the potential for an accident and/or a delay in care due to the inability to call for help because the call lights did not flash above the room door and/or the pull cords were too short to reach from the toilet. Cross Reference F919 Findings: 1. During a review of Resident 1's admission…

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 provide a functioning and accessible call light system as indicated in the facility's policy and procedure titled, Policy: Call Lights, by failing to: 1. Ensure call light was within reach for two of 11 sampled residents (Residents 1 and 2) in the resident's room. 2. Ensure call light pull cords were within reach for ten of 11 sampled residents (Residents 1, 2, 4, 5, 6, 7, 8, 9, 10, and 11) when using the bathroom. 3. Ensure call lights were functioning for three of 11 sampled residents (Residents 2, 6, and 7) when using the bathroom. These deficient practices had the potential to delay the provision of care for Residents 1, 2, 4, 5, 6, 7, 8, 9, 10, and 11 and negatively affect the residents' well-being when the residents were unable to call staff for assistance. Cross Reference F689 Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated, the facility initially admitted Resident 1 to the facility on [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 implement its policy on Advance Directive (AD, a written preferences regarding treatment options, a process of communication between individuals and their healthcare agents to understand and plan for future healthcare decisions when individuals were no longer able to make their own healthcare decisions) for five of five sampled residents (Residents 14, 26, 36, 44, 48). These failures had the potential for the facility staff to provide medical care and services against the resident's will. Findings: a. During a review of Resident 14's admission Record (AR), the AR indicated Resident 14 was admitted to the facility on [DATE] with diagnoses that included anemia (decrease in the total amount of red blood cells in the blood) and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review of Resident 14's Minimum Data Set (MDS- a standardized assessment and care…

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 implement an individualized person-centered care plan (CP) to meet the residents' specific needs for two of two sampled residents (Residents 10 and 48 ) by failing to: a. Develop an individualized and person- centered care plan for Resident 48 who had a diagnosis of psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) and major depressive disorder (persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities). b. Develop an individualized and person- centered care plan for Resident 10 who was on oxygen therapy (supplemental oxygen, a treatment that provides people with breathing problems. These deficient practices had the potential for Residents 10 and 48 to not receive necessary care and/or services. Findings: a. During a review of Resident 48's admission Record (AR), the AR indicated Resident 48 was admitted to 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 the resident's care plans (CP) were revised according to the resident's needs for two of two sampled residents (Residents 10 and 36). These failures had the potential risks for Resident's 10 and 36 not to receive interventions specific to the residents' needs. Findings: a. During a review of Resident 36's admission Record (AR), the AR indicated Resident 36 was readmitted to the facility on [DATE] with diagnoses that included dementia (impaired ability to remember, think and make decisions) and seizures (a sudden, uncontrolled burst of electrical activity in the brain that may cause changes in behavior, movements, feelings, and levels of consciousness). During a review of Resident 36's CP revised on 2/14/2024, the CP indicated Resident 36 was at risk for falls and had history of falls. The CP interventions included for staff to place a pad alarm in bed (device that contain sensors that trigger an alarm to detect a change in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation, interview, and record review the facility failed to ensure the resident was provided with communication device with the language that the resident understood in accordance to facility's policy titled Accommodation of Needs Related to Communication and the residents plan of care for two of two sampled residents (Residents 19 and 52). These deficient practices had the potential for Residents 19 and 52 to not be able to express their needs and receive necessary care and services. Findings: a. During a review of Resident 19's admission Record (AR), the AR indicated Resident 19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus (elevated levels of glucose/sugar in the blood and urine), dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and hypertension (high blood pressure). During a review of Resident 19's untitled care plan initiated 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 notify the resident's physician of a resident's refusal to follow the physician's order for fasting blood sugar (FBS, measures blood glucose after fasting) test on 6/5/24, 6/14/24, 6/17/24, 6/18/24, 6/19/24, 6/21/24, 6/22/24, 6/24/24, 6/25/24, 6/26/24, 6/27/24, 6/28/24 and 6/30/24 for one of one sampled resident (Resident 1). This failure had the potential for Resident 1 not to receive necessary treatment and services that would result to adverse consequences for Resident 1. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus ( elevated blood sugar level) and muscle weakness. During a review of Resident 1's Order Summary Report (OSR) dated 12/13/2023, the OSR indicated Resident 1 had an order for FBS daily before breakfast and to notify the physician if the blood sugar level was above 300 milligrams (mg)/ deciliter (dl)…

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 : a. Ensure one of one walk-in freezer used for food storage was kept clean and sanitary. b. Ensure one fly and two gnats were not found in the kitchen area. These deficient practices had the potential for cross contamination that could lead to foodborne illnesses (illness caused by consuming contaminated food or beverages). Findings: a. During an observation on 7/2/24 at 9:30 am, the walk-in freezer had a mat on the floor. The mat had round holes and the holes were filled with brown, black and dry substance. During an interview on 7/2/24 at 9:31 am, the Dietary Services Supervisor (DSS) stated staff needed to clean the walk-in freezer once a week on weekends. The DSS stated the area under the mat needed to be cleaned. b. During an observation on 7/2/24 at 9:32 am, the dry storage area was located inside the kitchen with the door open. There was one fly inside the storage area. During an observation on 7/2/24 at 9:45 am, there was an open closet space located inside the kitchen where the mops and mop buckets…

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 the resident's call light was within reach for one of one sampled resident (Resident 38). This deficient practice had the potential for Residents 38 not to receive or received delayed care to meet the resident's needs. Findings: During a review of Resident 38's admission Records (AR), the AR indicated Resident 38 was admitted to the facility on [DATE] with diagnoses that included dementia ( long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and Alzheimer's disease (irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks). During a review of Resident 38's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/26/2024, the MDS indicated, Resident 38 had severely impaired cognition (ability to understand) and required moderate assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide notification to the Long-term care Ombudsman (agency who advocates for residents) of a facility-initiated discharge for one of one sampled resident (Resident 29). This failure had the potential risk to result in inappropriate discharge of Resident 29 without the protection from the Ombudsman. Findings: During a review of Resident 29's admission Record (AR), the AR indicated Resident 29 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included heart failure (heart muscle can't pump enough blood to meet the body's needs) and dysphagia (difficult swallowing). During a review of Resident 29's Change of Condition (COC) Form dated 4/22/2024 timed at 9 pm, the COC form indicated Resident 29 was transferred to General Acute Care Hospital 1 (GACH 1) due to chest pain on 4/22/2024 During a review of Resident 29's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 6/20/2024, the MDS indicated…

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 the care plan (CP) intervention to provide night light was implemented for one of two sampled residents (Resident 36) who had a history of falls. This failure had the potential risk for Resident 36 to experience repeated falls. Findings: During a review of Resident 36's admission Record (AR), the AR indicated Resident 36 was readmitted to the facility on [DATE], with diagnoses that included dementia (impaired ability to remember, think and make decisions) and seizures (a sudden, uncontrolled burst of electrical activity in the brain that may cause changes in behavior, movements, feelings, and levels of consciousness). During a review of Resident 36's Change of Condition (COC) form completed on 2/13/2024, the COC form indicated Resident 36 had a fall on 2/12/2024 around 10:10 pm, in Resident 36's room, resulting to a bump in Resident 36's forehead, skin tear on left forearm and discoloration on the right knee. Resident 36 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to administer oxygen therapy (treatment that provides supplemental oxygen) in accordance with the physician's order for one of one sampled resident (Resident 10). This deficient practice placed Resident 10 at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which could lead to serious complications. Findings: During a review of Resident 10's admission Record (AR), the AR indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included heart failure (condition in which the heart doesn't pump enough blood) and hypertension (high blood pressure). During a review of Resident 10's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 4/5/2024, the MDS indicated Resident 10 had severely impaired cognition (ability to understand) and totally dependent (helper did all of the effort, resident did none of the effort to complete…

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 proper waste disposal in one of two trash (garbage) bins. This deficient practice had the potential to harbor pests and placed the facility at risk for diseases and infection. Findings: During a concurrent observation and interview on 7/2/2024 at 9:47 am, there were two trash bins in the facility. Trash Bin 1 was left open because trash from the inside was filled up the brim. Trash Bin 2 had enough space for trash. In an interview, the Dietary Services Supervisor (DSS) stated the facility staff needed to ensure not to overfill trash bins so that the trash bin lid would be closed. The DSS stated when the trash bin was open, it would attract pests, insects, flies, and rodents (rats). During an interview on 7/3/2024 at 4:34 pm, the facility Administrator stated the facility would need to use a third trash bin to prevent overfilling of garbage and ensure proper waste disposal. The Administrator stated an open trash bin would attract pests. During a review of the facility's Policy and Procedure (P&P) titled…

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 follow its Policy and Procedures (P&P) titled Hand Washing and Enhanced Barrier Precaution (EBP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, bacteria that are resistant to one or more classes of antibiotics] ) for one of one sampled resident (Resident 44) when Licensed Vocational Nurse 1 (LVN 1) did not wear gloves before touching Resident 44's indwelling Foley catheter (FC - thin, sterile tube inserted into the bladder to drain urine into a bag outside the body) and did not perform hand hygiene before touching Resident 44's Gastrostomy Tube (GT, surgical insertion of a tube, creating an artificial external opening into the stomach for nutritional support) feeding. These failures had the potential for infection for Resident 44 and other residents in the facility. Findings: During a review of Resident 44's admission Record (AR), the AR indicated Resident 44 was admitted to 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 follow its policy and procedure (PP) titled, Homelike Environment, for 19 of 22 sampled residents (Residents 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 17, 18, 19, 20, 21, and 22) by failing to: Ensure Residents 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 17, 18, 19, 20, 21, and 22 were provided bedside tables (adjustable table on wheel that can fit over a resident's bed used for eating, personal items and a table for treatment by nursing staff) to use according to each resident's needs. This deficient practice could result in a decline in Residents 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 17, 18, 19, 20, 21 and 22's well-being due to failure to promote a homelike environment. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 to the facility initially on 1/20/2021, and readmitted Resident 2 on 12/28/2023, with diagnoses that included dementia (impaired ability to think, remember or make decisions that interfered with doing everyday…

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 accommodate the needs and preferences of one of 22 sampled residents (Resident 1) by failing to ensure Resident 1's bedside tray was within reach and not broken for Resident 1 to use. This deficient practice had the potential to result in a decline in Resident 1's psychosocial well-being due to possible loss of homelike environment and maintaining independence to the extent possible. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility initially admitted Resident 1 to the facility on [DATE], and readmitted Resident 1 on 1/2/2024, with diagnoses that included generalized muscle weakness (weakness of muscles caused by lack of exercise, ageing, injury, or disease), glaucoma (group of eye diseases that could affect vision and cause blindness by damaging the optic nerve), and unqualified visual loss, both eyes (decrease in vision and/or visual field that spanned from mild blurriness to complete…

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 resident's notice of transfer was sent to the State Long-Term Care (LTC) Ombudsman (public advocate) for three of 15 sampled residents (Resident 5, Resident 37, and Resident 46) by: 1. Failing to send a copy of the transfer/discharge to the Office of the State LTC Ombudsman before or as close as possible to the actual time of a facility-initiated transfer or discharge. 2. Failing to ensure the medical record contained evidence that the notice of transfer was sent to the Ombudsman. These deficient practices had the potential for Residents 5, 37, and 46 to be at risk of an inappropriate transfer due to lack of Ombudsman representation. Findings: a. A review of Resident 5's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE] with diagnoses including bronchitis (inflammation of the airways that carry air to the lungs) and atrial fibrillation (irregular heartbeat). A review of Resident 5'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide padded side rails as ordered for two of four sampled residents (Resident 12 and Resident 20). These deficient practices had the potential to result in accidents and injury to the residents. Findings: a. A review of the facility's admission Record indicated Resident 12 was readmitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (alteration in consciousness caused by brain dysfunction) and epileptic seizure (tremors, shaking movements, twitching or jerking movements for body parts or whole body that cannot be controlled). A review of Resident 12's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 9/19/2021, indicated the resident had clear speech, sometimes understood others and sometimes made self understood. The MDS indicated Resident 12 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one person physical assist for…

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

Based on observation, interview, and record review, the facility failed to ensure, a. Staffing information was posted in a prominent place readily accessible to residents and visitors b. Staffing information was accurate and current, and c. Staffing information was complete and did not have missing information for 12/11/2021, 12/13/2021, 12/14/2021, and 12/15/2021 as required. This deficient practice had the potential to result in misinformation to the residents and the public of the facility's nursing staffing data. Findings: During an observation of the facility with Director of Staff Development (DSD) on 12/16/2021 at 10:34 a.m. , the Census and Direct Care Service Hours Per Patient Day (DHPPD) staffing information was posted in Nursing Station 1. In a concurrent interview, DSD stated DHPPD should be posted in front, by the lobby and easily accessible to residents, family, and visitors. DSD stated the staffing information was only posted inside Nurse Station 1. A review of the Census and Direct Care Service Hours Per Patient Day (DHPPD) with DSD on 12/16/2021 at 11:49 a.m., she…

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

Based on observation, interview, and record review, the facility failed to ensure foods thawed (process of warming food that has been frozen) were labeled and dated in the walk-in refrigerator. This deficient practice had the potential to result in food contamination and/or foodborne illness (illness caused by consuming contaminated food or beverages). Findings: During an observation of the the kitchen on 12/13/2021 at 10:13 a.m. in the presence of the Dietary Supervisor (DS), four packaged bags of chicken legs (about 15 pounds total) in a tray and one packaged bag of pork leg (5 pounds) in a tray were thawed in the bottom shelf of the walk-in refrigerator without a label and without a date. During an interview with DS on 12/13/2021 at 10:15 a.m., she stated the cook should have labeled and dated the food at the start of the thawing process. A review of the facility's Policy and Procedure titled, Thawing Food, revised 2019, indicated all food will be thawed in a safe and sanitary manner, in a refrigerator at 40 degrees Fahrenheit (F) or colder. Allow 2 to 3 days to defrost,…

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 staff treated residents with dignity and respect while assisting with meals for two of 15 sampled residents ( Resident 19 and Resident 52). This deficient practice had the potential to negatively affect the residents' well being. Findings: a. A review of the admission Record (face sheet) indicated Resident 19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including anemia (decrease in the total amount of red blood cells in the blood) and Alzheimer's Disease (irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks). A review of Resident 19's Minimum Data Set (MDS), a resident assessment and care screening tool dated 9/21/2021, indicated the resident's cognitive (ability to understand) skills for daily decision making was severely impaired and the resident required extensive assistance to total dependence with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a care plan for fall was revised after the resident fell and hit the back of his head on 11/4/2021, for one of 15 sampled residents (Resident 57). This deficient practice had the potential to place the resident at risk for future falls. Findings: A review of the facility's admission Record indicated Resident 57 was readmitted on [DATE] with diagnoses including, muscle weakness, abnormalities of gait and mobility (ability to move) and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). A review of Resident 57's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 9/1/2021 indicated the resident had clear speech, sometimes understood others and sometimes made self understood. The MDS indicated, Resident 57 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one person…

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 provide nutritional supplement as ordered by the physician for Urinary Tract Infection (UTI-infection that affects part of the urinary tract) prophylaxis (prevention) for one of 15 sampled residents (Resident 12). This deficient practice resulted for Resident 12 not to receive meal as ordered by the physician and placed the resident at risk for infection. Findings: A review of the facility's admission Record indicated Resident 12 was readmitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (alteration in consciousness caused by brain dysfunction) and epileptic seizure (tremors, shaking movements, twitching or jerking movements for body parts or whole body that cannot be controlled). A review of Resident 12's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 9/19/2021, indicated the resident had clear speech, sometimes understood others and sometimes made self understood. The 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure oxygen tubing was dated and was not on the floor for one of two sampled residents (Resident 50). This deficient practice had the potential to contaminate the oxygen tubing placing the resident at risk for infection. Findings: A review of Resident 50's admission Record (face sheet) indicated the resident was admitted to facility on 8/1/2021 and was re-admitted on [DATE] with diagnoses including encephalopathy (disease that affects the function or structure of the brain) and G-tube (creation of an artificial external opening into the stomach for medication / nutritional support). A review of Resident 50's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 11/4/2021 indicated the resident had severely impaired cognition ( ability to understand). The MDS indicated the resident required total dependence from staff for her activities of daily living with one person assist for bed mobility and transfer. The 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 staff failed to follow their policy and procedure to sign or initial the maintenance log at the time it was checked. The facility staff signed/initialed the laundry water temperature log and lint cleaning schedule log for future days. This deficient practice had the potential for the laundry washer and dryer not maintained in a timely manner causing potential spread of infection and a potential fire hazard. Findings: During a tour of the laundry area on 12/15/2021 at 3:52 pm, the facility's laundry washer water temperature log and lint cleaning schedule-daily log was posted on a board in the facility's laundry room. A review of the facility's maintenance log titled Facility Washer Water Temperature Log/Temperature must be 160 (F)(Fahrenheit) or Above, dated December 2021 indicated on 12/16/2021 at 11 am, washer #2's temperature was documented at 160 and on 12/16/2021 at 4 am, 11 am and 6 pm, washer #3's temperature was documented at 160. A review of the facility's maintenance log titled Lint Cleaning Schedule-Daily…

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.