Laurel Convalescent Hospital

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure dietary staff prepared and served the large portion sizes, as specified in the resident's physician order, for one of one sampled resident (Resident 66) when Resident 66's breakfast tray was sent from the kitchen without the required large portions.This failure had the potential for Resident 66 to receive a meal inconsistent with the prescribed dietary order.Findings: During a review of Resident 66's Face Sheet (contains medical and demographic information), the Face Sheet, indicated Resident 66 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis (weakness and paralysis), hypertension (high blood pressure), and malignant neoplasm of unspecified site of left breast (breast cancer).During a review of Resident 66's physician's orders, an order dated March 15, 2025, indicated Resident 66 was to receive, .Large portions TID [three times a day].During a review of Resident 66's Care Plan…

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's equipment was maintained in safe operating condition for 1 of 2 residents (Resident 86) when Resident 86 bed malfunctioned such that the foot section would not elevate, the head and foot controls were reversed, and normal bed positioning could not be performed as intended. This failure had the potential to affect Resident 86 safety, comfort, and positioning needs, and create risk for confusion, distress, and delayed staff response during care.Findings:During a review of Resident 86's clinical record, the Record of Admission (contains demographic and medical information), the Record of Admission indicated, Resident 86 was admitted to the facility on [DATE] with diagnoses which included, Spinal Stenosis Lumbar Region(A narrowing of the tunnel in the lower back that houses nerves, causing pressure on nerves), Fibromyalgia ( A chronic disorder characterized by widespread pain, fatigue, and tenderness throughout the body),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent one of three sampled residents (Resident 1), who was diabetic, obese, and immobile and at risk for skin breakdown develop pressure injuries (pressure on body prominence causes breakdown to tissue) as follows: a. Left heel, left great toe and 1st metatarsal developed a deep tissue injury (DTI). And right medial foot fluid blister. b. Acquired an open wound to left elbow and sacral (tailbone) c. No family notification of left elbow and sacral open wound and wound treatment. This failure had the potential to result in a clinically compromised resident, (Resident 1) to be placed at risk for unnecessary pain, infection and death due to wounds not being identified and treated to prevent progressing. Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included: myocardial infarction type 2 (heart attack), diabetes type 2 (body…

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

Based on observation, interview, and facility policy review, the facility failed to ensure the kitchen refrigerator temperature was maintained at 40 degrees Fahrenheit (F) or lower. This deficient practice had the potential to affect all residents who received food from the kitchen. Findings included: An undated facility policy titled, Refrigerator/Freezer Storage revealed, 3. If temperatures are not within appropriate range, dietary staff will notify the dietary supervisor and / or Maintenance Supervisor and Administrator: Refrigerator Temperature 40 degrees F or lower. During an observation of the kitchen on 11/11/2024 at 8:35 AM, 8:43 AM, and 10:06 AM, the refrigerator temperature was noted as 45 degrees F. During a concurrent observation and interview on 11/11/2024 at 1:45 PM, the Dietary Supervisor (DS) checked the thermometer inside the refrigerator and stated the temperature was 45 degrees F. The DS stated a temperature reading of 45 degrees F could impact the food. The DS stated the temperature of the refrigerator should not be above 41 degrees F. During an observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure the residents' fingernails were clean and trimmed for 2 (Resident #2 and Resident #136) of 3 sampled residents reviewed for activities of daily living (ADLs). Findings included: A facility policy titled, Activities of Daily Living (ADLs), Supporting, revised 03/2023, revealed, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. The policy specified, 2. Appropriate care and services will be provided for resident's who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a hygiene (bathing, dressing, grooming, and oral care.) 1. An admission Record revealed the facility admitted Resident #2 on 11/20/2007. According to the admission Record, the resident had a medical history that included…

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

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's catheter was secured using a securement device for 1 (Resident #52) of 2 sampled residents reviewed for urinary catheters. Findings included: A facility policy titled, Catheter Care, Urinary, revised 08/2022, indicated 4. Ensure that the catheters remains secured with a securement device to reduce friction and movement at the insertion site. An admission Record indicated the facility admitted Resident #52 on 07/22/2022. According to the admission Record, the resident had a medical history that included diagnoses of chronic kidney disease, benign prostate hypertrophy with lower urinary symptoms, obstructive and reflex uropathy, and urinary tract infection. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/04/2024, revealed Resident #52 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS revealed Resident #52 had an indwelling catheter. Resident #52's Order…

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 their Policy when the nursing staff failed to provide care for 2 of 3 sampled Residents (Resident 1 and 2). This failure had the potential to place two clinically compromised Residents (Resident 1 and 2) psychosocial health and safety at risk. When facility staff failed to provide Resident ' s 1 and 2 with requested care and services. Findings: During an interview on October 2, 2024, at 4:37 PM, with Resident 1, Resident 1 in bed, is alert and oriented. Resident 1 stated it will take hours for the nursing staff to change her diaper no matter what time of day she activates the call light. During review of Resident 1 ' s admission Record (General demographics) on October 2, 2024, indicates admitted to facility on September 18, 2024, with diagnosis (DX) include Enterocolitis (inflammation of both the small intestine and the colon) muscle weakness, abnormalities of gait (the way a person walks) and mobility, hypertension (high blood pressure), Gastro-esophageal reflux (heartburn). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to prevent for one of three sampled residents Resident 1, two pressure injuries from reopening and an physician order placed a Computed tomography (CT) to right foot, instead of left foot. This failure placed a clinically compromised Residents (Resident 1) health and safety at risk and could have delayed treatment. Findings: During review of Residents 1 ' s admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: contracture right knee (stiffness), vascular dementia (brain damage by multiple strokes, causing memory loss), flaccid neuropathic bladder (bladder doesn ' t contract, lead to urine retention). During a review concurrent interview and record review of Resident 1 ' s Medical Record with the Assistant Director of Nursing (ADON), reviewed are as follows: 1. SKIN PROGRESS REPORT: July 12, 2024, Coccyx Stage 4, measuring 3.5cmx4.6cmx0.1cm . Reopened sacrococcyx wound.…

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.

ased on interview and record review, the facility failed to protect against physical and verbal abuse for one of three sampled residents (Resident 1) when Resident 1 fell out of bed and a Certified Nursing Assistant (CNA 1) pulled Resident 1 by one arm back onto the bed and Resident 1 ' s hip rubbed against the footrest. The CNA 1 stated to Resident 1 Stop that! you ' re being annoying! This failure caused Resident 1 to suffer physical and verbal abuse. Findings: An unannounced visit was made to the facility on May 21, 2024, at 9:48 AM, to investigate a facility reported incident regarding an allegation of physical and verbal abuse. A review of Resident 1 ' s face sheet (a document that gives a summary of resident ' s information), undated, indicated an initial admission date of April 9, 2019. Resident 1 had diagnoses that included partial paralysis of the left side of the body following a stroke and dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of a Registered Nurse Supervisor ' s (RNS) witness statement, undated, indicated, RN…

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 follow their policy when staff did not notify the physician and alternative physician promptly for a change of condition for one of four sampled residents (Resident 1). This failure had the potential to result in a delay of treatment for redness, swelling and tender to touch of the left foot of Resident 1. Findings: During a review of Resident 1 ' s admission Record (general demographics) on May 22, 2024, the document indicated Resident 1 was last admitted to the facility on [DATE], with diagnosis that included type 2 diabetes mellitus (a condition of that occurs when the sugar in the blood is too high), osteoporosis ( a condition that causes bones to become weak and more likely to break), hypertension, rheumatoid arthritis (a condition of joint swelling and pain), contracture of muscle left lower leg (a condition that occurs when the muscles, tendons, joints and tissues tighten or shorten). During a review on May 22, 2024, at 10:00 am, of Resident 1 '…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of four clinically compromised residents (Resident 1) was provided transportation for his dialysis treatment appointment. This failure had the potential to result in a delay of treatment that could adversely affect and further compromise Resident 1 ' s health. Findings: During a review of Resident 1 ' s admission RECORD (general demographics) on May 23, 2024, the document indicated Resident 1 was originally admitted to the facility on [DATE], with diagnoses that include diabetes mellitus (a condition that affects the way the body process blood sugar), end stage renal dialysis (a condition that cause the kidney to cease working), hypertension (a condition with blood pressure that is higher than normal), congestive heart failure (a condition that occurs when the heart muscle does not pump blood as well as it should) and hyperparathyroidism (a condition where the thyroid does not create and release enough thyroid hormone into the bloodstream). 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 when the Licensed Vocational Nurse (LVN 1) failed to assess, notify the physician and the responsible party of a change of condition for one of three sampled residents (Resident 1) according to facility policy. This failure placed a clinically compromised Resident (Resident 1) health and safety at risk by causing a delay in treatment, and transfer to acute hospital for evaluation. Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: encephalopathy (brain disease causing declining concentration, memory loss, personality changes, sepsis (infection in bloodstream), type 2 diabetes mellitus ( body does not make enough insulin or does not use insulin well), urinary tract infection (urine infection), hypertension (high blood pressure), hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side…

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 continually document blood sugar results in the medical record for one of three sampled residents (Resident 1). This failure placed a clinically compromised Resident (Resident 1's) health and safety at risk when the facility was not able to track blood sugar patterns and results. Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: encephalopathy (brain disease causing declining concentration, memory loss, personality changes, sepsis (infection in bloodstream), type 2 diabetes mellitus ( body does not make enough insulin or does not use insulin well), urinary tract infection (urine infection), hypertension (high blood pressure), hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side (paralysis to one side, partial weakness , conditions affection blood flow to the brain), osteoarthritis…

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 1) received intravenous antibiotic medications as prescribed by the physician. This failure had placed a clinically compromised Resident (Resident 1) health and safety at risk by causing a delay in treatment when IV antibiotic medication were not given as ordered by a physician. Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: encephalopathy (brain disease causing declining concentration, memory loss, personality changes, sepsis (infection in bloodstream), type 2 diabetes mellitus ( body does not make enough insulin or does not use insulin well), urinary tract infection (urine infection), hypertension (high blood pressure), hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side (paralysis to one side, partial weakness , conditions…

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 staff reported an allegation of abuse to outside agencies in the timeframe specified by the facility's policy and procedures (P&P) and as required by federal regulations. This failure resulted in an allegation of abuse to not be reported timely which had the potential to place Resident 1 at risk for ongoing abuse or mistreatment due to a delay in the reporting and investigation of the alleged incident. Findings: A review of Resident 1's admission Record (contains medical and demographic information), indicated Resident 1 was initially admitted to the facility on [DATE], with diagnoses which included heart failure, major depressive disorder, schizophrenia (a serious mental disorder in which people interpret reality abnormally), and monoplegia of upper limb affecting left dominant side (paralysis of the left arm). During an interview on February 27, 2024, at 2:55 PM, with Social Worker 1 (SW 1), SW 1 stated the facility reported an allegation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent a serious injury for one of three sampled residents' (Resident 1) who sustained a right distal humeral fracture (a break in lower end of the humerus bone) while Certified Nursing Assistant CNA1 was performing care, for one of three sampled residents (Resident 1). This failure contributed to a clinically compromised Resident 1 having to be transferred to general acute hospital for emergency treatment of fracture. Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: cerebral infarction (damage to tissues in brain due to loss of oxygen), hypertension (high blood pressure), age related osteoporosis without current pathological fracture (bones become brittle and fragile from loss of tissue). During a concurrent interview and record review of Resident 1's Medical Record with the Director of Staff Development…

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 a change in condition of one of four sampled residents (Resident 1) was reported to the attending physician and the representative in accordance with the facility's policy and procedure. This failure had potential to result in a delay of diagnosis and early treatment for symptoms of low blood sugar. Findings: During a review of Resident 1's admission Record (general demographics), on March 5, 2024, the document indicated Resident 1 was admitted to the facility on [DATE], with diagnosis that included type 2 diabetes mellitus (a disease that occurs when the blood sugar is too high), dysphagia (a condition with difficulty swallowing), respiratory failure (a condition that makes it difficult to breathe on your own) hypertension (high blood pressure) and hyperlipidemia (high concentration of fats in blood). During a review of Resident 1's Order Summary Report (physician's orders), on March 5, 2024, the orders included, Insulin Regular NOTIFY MD…

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 implement safeguards to prevent accident hazards, for one of three sampled residents (Resident 1) when Resident 1 was struck by an object falling from the roof during facility approved roof maintenance. This failure caused Resident 1 to suffer an injury to her left shoulder after being struck by the object falling from the roof. Findings: An unannounced visit was made to the facility on August 29, 2023, at 9:50 AM, to investigate a facility reported incident in regard to a resident accident and injury. A review of Resident 1 ' s face sheet (a document that gives a summary of resident information), undated, indicated an admission date of July 13, 2023, with diagnoses that included: end stage renal disease (a medical condition where the kidneys cease functioning on a permanent basis). During an observation and interview with the Maintenance Director (M/D), Administrator (Admin) and Director of Nursing (DON) on August 29, 2023, at 10:20 AM, the M/D stated he was performing maintenance on the roof on August 18,…

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 did not have a policy regarding use and storage of foods brought in for residents by family and other visitors, that indicated how they would ensure safe and sanitary storage, handling, and consumption. This had the potential to lead to unsafe food handling and foodborne illness in a medically compromised population of 83 residents. Findings: During interview with a Certified Nursing Assistant (CNA 7) on November 16, 2021 at 09:17 AM, she stated we do not allow food to be brought in from home or outside because of Covid -19, if there was a food borne infection it would be our fault. During an interview with the Registered Nurse Supervisor (RN 1), on November 16, 2021 at 9:17 AM, he stated that they do not have refrigerators for residents to use to store food. During interview with the Dietary Services Supervisor (DSS) on November 16, 2021 at 09:56 AM, she stated they cannot store food in the kitchen from outside. They do not have a refrigerator to store resident food, if family brings in something from home, they need…

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 perform preventative maintenance on five out of fifteen oxygen concentrators (an electrically powered medical device that uses environmental air and delivers it to a patient in the form of supplemental oxygen), when preventative maintenance was not completed by the expiration date listed on the machine. This failure had a potential to cause avoidable hazards and accidents to residents due to electrical failure, electric shock, and lack of oxygen due to inadequate levels of oxygen being produced by the machine. Findings: During an observation on November 15, 2021, at 7:08 AM, in room [ROOM NUMBER]-A, an oxygen concentrator was present and had a label noting that preventative maintenance was due on March 5, 2021. During an observation on November 15, 2021, at 9:38 AM, in room [ROOM NUMBER]-B, an oxygen concentrator was present and had a label noting that preventative maintenance was due on March 5, 2021. During an observation on November…

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 direct care service hours for the entire patient day when there was a shortage of certified nursing assistant (CNA) hours noted on: October 24, 2021, November 5,6,13,and 14 2021 (Dates reviewed October 15, 2021 to November 14, 2021). This failure had the potential of putting the health and safety of clinically compromised residents residing in the facility at risk. Findings: During an interview with Resident 29 on November 15, 2021 at 10:59 AM, he stated, he believed there was a shortness of staff, sometimes he has to wait up to half an hour or more when he needs assistance. During an interview with Resident 40 on November 15, 2021 at 11:23 AM, he stated, staffing was poor at times, sometimes one CNA was running around trying to do everything. Resident 40 stated he knew they were short of staff at nighttime the most. During an interview with CNA 2 on November 15, 2021 at 2:02 PM she stated sometimes we were really short of CNA's, sometimes only three CNA's or less on the night shift. During an interview with…

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

Based on observation, interview, and record review, the facility failed to provide two out of 18 sampled residents (Residents 71 and 63) the choice to eat their meals in the dining room when there were not enough staff to accommodate them. This failure had a potential to cause psychological harm due to loss of interaction with other residents and the provision of rights that are conducive to a homelike environment. Findings: During an observation and concurrent interview on November 15, 2021, at 12:45 PM, with Resident 71, it was noted that she was eating her lunch within her room. She stated, that the dining room was closed but she didn't know why. She expressed that she very much preferred to eat in the dining room. During an observation and concurrent interview on November 15, 2021, at 12:53 PM, with a Resident 63, who was observed to be eating lunch in her room. She stated, I don't like eating in my room, but the dining room is closed today because they don't have enough staff to watch us. During an interview on November 15, 2021, at 12:55 PM, with a certified nursing assistant…

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 hold the medication as per physician's orders for one of four residents (Resident 25) when the dialysis center recommendation was not followed. This failure has the potential to place Resident 25 at risk of developing complications such as bone fractures, bone pain and muscle weakness. Findings: During a review of Resident 25's admission Record (clinical record with demographic information), the admission Record indicated, Resident 25 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease (a condition where kidneys cannot longer function on their own) and dependence of renal dialysis (a medical procedure of removing waste and excess fluid from the body). During an observation on November 15, 2021, at 9:03 AM, Resident 25 was sitting on his wheelchair, outside his room, waiting for transportation to the dialysis center. During a review of Resident 25's Dialysis Communication Record (DCR) (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a system for the disposition of all controlled drugs was maintained in a universe of 83 residents, when two containers, used for the destruction of expired or discontinued controlled drugs, were not secured in a double locked location and contained non-destroyed drugs. This failure had the potential to cause drug diversion (the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use) and accidental exposure. Findings: During a medication storage and disposition observation and interview with the Director of Nursing (DON) on [DATE] at 11:58 AM, the DON stated when controlled drugs were expired or discontinued, I place them here. The DON indicated a metal, two drawer, filing cabinet. The filing cabinet had two locks. The DON opened the filing cabinet, the filing cabinet contained multiple containers of controlled drugs. The DON stated she was the only…

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 a drug regimen review system was maintained for one of 18 sampled residents (Resident 56) when the pharmacist's reported irregularities were not acted upon for four months. This failure had the potential to cause Resident 56 to receive too much antidepressant medication. Findings: A review of Resident 56's face sheet (a document that gives a summary of a resident's information), undated, indicated Resident 56 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). A review of Resident 56's Note To Attending Physician/Prescriber, dated July 20, 2021 indicated the following: Resident has been on Remeron [an antidepressant medication] 7.5 mg [milligrams] qhs [every night] for depression m/b [manifested by] poor appetite since 4/20 [April 2020] and Depakote [an anticonvulsant medication used to treat bipolar disorder] 125 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 secure a metered dose inhaler (a device used to administer medication by breathing it into the lungs) containing Fluticasone, Proprianate and Salmeterol, (medications commonly used for respiratory conditions) when it was observed on a resident's (Resident 7's) bedside table. This failure had a potential to cause harm to other residents who could access the medication without the appropriate knowledge of its use. Findings: During a tour of the facility on November 15, 2021, at 9:08 AM, a metered dose inhaler of Fluticasone, Proprianate, and Salmeterol, was observed to have been left unattended and accessible to other residents on Resident 7's bedside table. During an interview on November 15, 2021, at 9:10 AM, with a Licensed Vocational Nurse (LVN 6), she stated that the inhaler should not have been left at Resident 7's bedside. It should have been locked back into the medication cart as soon as she had taken it. She doesn't have a doctor's order to keep it at her bedside and even if she did it would be locked…

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 menu for the dysphagia mechanical diet (texture-modified diet that restricts foods that are difficult to chew or swallow) when Resident 45 received puree (smooth without any lumps) green beans instead of mash-able chopped green beans. This had the potential to lead to the resident not eating the food because it was a more restrictive texture modification than physician prescribed. Findings: During an observation on November 15, 2021 at 11:54 AM, Dietary Aide 1 (DA1) was plating the food for residents and served Resident 45 who was on a dysphagia mechanical soft diet puree green beans. During an interview with the Dietary Services Supervisor (DSS) on November 15, 2021, at 04:22 PM, she stated, DA 1 should have served the mash-able green beans, as specified on the menu, not puree green beans. A review of the recipe: Southern [NAME] Beans, Dysphagia, dated 2019, make with cut green beans chopped ½ or less. May add bacon fat or margarine, onions chopped ½ or less, and salt and pepper. [NAME] until…

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 did not store, and prepare food in accordance with professional standards for food service safety when: 1. There was no air gap on the food preparation sink (a gap between the water supply outlet and the flood level rim of a plumbing fixture or equipment that prevents contamination that may be caused by backflow) 2. Can opener had residue on the blade 3. Bottom shelf of the refrigerator had debris and food stain 4. Pepperoni was uncovered in the freezer 5. The bulk sugar was contaminated with a bug 6. Floor in the dry storage had food debris and trash This had the potential to lead to food borne illness in an immune-compromised population of 80 residents who received food from the kitchen. Findings: 1. During the kitchen observation on November 15, 2021 at 07:40 AM, there was no air gap on the food preparation sink. During an interview with the Dietary Services Supervisor (DSS) on November 15, 2021, at 08:11 AM, the DSS stated she would let maintenance know, she did not know the sink needed an air gap. During 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility record review, the facility failed to maintain infection control practices when: 1. Three of eighty-three residents (Resident 25, 40 and 64) had urinals in their rooms which were not labeled with room/bed number and/or resident's name. 2. Staff was observed not performing hand hygiene after providing care for one resident (Resident 13) and retrieve clean linen from the closet. These failures had the potential to spread infectious disease to other residents and staff in the facility. Findings: 1a. During a review of Resident 25's admission Record (clinical record with demographic information), the admission Record indicated, Resident 25 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease (a condition where kidneys cannot longer function on their own) and dependence of renal dialysis (a medical procedure of removing waste and excess fluid from the body). During a concurrent observation and interview on November 16, 2021, at…

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.