Leisure Glen Post Acute Care Center

Based on interview, observation and record review, the facility failed to set the Alternating Pressure Mattress (APM, mattress that provides pressure redistribution by filling and un-filling air cells within the mattress so that contact points with the body are reduced) according to the resident's weight as indicated in the manufacturer's recommendation and physicians orders for one of [three] residents (Resident 94). This deficient practice had the increased potential for Resident 94 to develop new pressure ulcer or injury (skin injury due to prolonged unrelieved pressure or skin friction) and/or delay the resident's wound to heal. Findings: During a review of Resident 94's admission Record (AR), the AR indicated the facility admitted Resident 1 on 2/22/2008 with diagnoses that included fracture of unspecified part of neck of right femur [the section of the thigh bone (femur) that connects the femoral head (the ball of the hip joint) to the femoral shaft (the main part of the thigh bone)], muscle wasting and atrophy (loss of muscle mass and strength), type 2 diabetes mellitus (DM2…

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 two of two licensed nurses (Minimum Data Set Nurse [MDSN] 1 and 2) were trained and with sufficient competency to conduct and coordinate the development and completion the residents MDS assessment by failing to: Ensure MDSN 1 and MDSN 2 conducted an accurate MDS assessment of Resident 69 and 102's elopement risk. Ensure MDSN 2 had an updated competency skills to conduct annual evaluation used for MDS assessment. This deficient practice placed residents at risk for not receiving appropriate services, treatments, and unsafe level and type of care necessary for the resident population. Cross Referenced to F641 Findings: 1. A review of Resident 69's admission Record indicated Resident 69 was initially admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy (change in how the brain works due to an underlying condition), unspecified dementia (general term for loss of memory, language, problem-solving and other…

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 post the nurse staffing information of the number of Registered Nurses (RN), License Vocational Nurse (LVN)/ License Practical Nurse (LPN) and Certified Nursing Assistant (CNA)/Nursing Assistant (NA) per shift in a prominent location in accordance with the facility's policy and procedure titled Posting Direct Care Daily Staffing Numbers. This deficient practice had the potential to not inform and cause misleading information to the residents and the visitors of the nursing care provided to the residents. Findings: During an observation on 6/24/2025 at 8:30 AM, one page of the Census and Direct Care Service Hours per Patient Day (DHPPD), dated 6/24/2025, was posted on the wall by the facility entrance near Nursing Station 2. There was no other nursing staff information posted. During an observation on 6/25/2025 at 2:40 PM, only the DHPPD, dated 6/25/2025 was posted on the wall by each nursing stations. there was no information posted indicating how many RN ' s, LVN ' s and CNA ' s were on shift for 6/25/25. During 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.

Based on interview, and record review, the facility failed to complete a performance review by completing the Annual Core Clinical Competencies (ACCC, an assessment and training on the Certified Nurse Assistant(s) (CNA) the ability to perform clinical nursing care). In addition, the facility did not have a system in place to keep track of the CNA's performance evaluation to ensure three of five CNAs (CNA 1, CNA 2 and CNA 3) were evaluated for their competencies annually and provided training based on the outcome of the review for each of the CNAs. This failure had a potential to result in the facility's resident's population based on the Facility Assessment (an assessment to make decisions about direct care staff needs, as well capabilities to provide services to the residents) not to receive quality care services from CNAs with insufficient skills and competencies. Findings: A review of the facility's undated Tracking log, indicated there was no tracking for the facility's CNA's ACCC that indicated which CNA required the training. During an interview on 6/13/2024 at 2:08 PM 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 store food in accordance with professional standards of food service safety for residents in the facility by failing to label, date and store food in the refrigerator and freezer. Facility failed to ensure [NAME] 1 change visible soiled gloves prior to plating the residents' food. This deficient practice had the potential to place residents at risk for developing food borne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: During a concurrent observation and interview on 06/10/2024 at 8:50 AM, with Dietary Service Supervisor, observed multiple open items in the walk- in refrigerator without a use by date. Those items were: Chicken broth - open date 5/3/2024 - no use by date. Lemon Juice - open date 5/3/2024 - no use by date. Sweet sour sauce - open date 4/6/2024 - no use by date. Yogurt - open date 6/9/2024 - no use by date. Feta cheese- open date 6/9/2024 - no…

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 care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of his individuality for one (1) of one sampled resident (Resident 32) by ensuring the facility staff was observed standing over the resident while assisting during a meal. This deficient practice had the potential to affect Resident 32's self-esteem and self-worth. Findings: A review of Resident 32's admission Record indicated the resident was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood) and type II type 2 diabetes mellitus (a medication condition characterized by the body's inability to regulate blood sugar level). A review of the History and Physical Examination (H&P) dated 05/14/2024, indicated Resident 32 does not have the capacity to understand and make decisions. A review 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 ensure call light was within reach for one of eight sampled residents (Resident 11). This deficient practice has the potential to delay necessary assistance, not meeting the needs of the resident promptly. Ensuring that the call light is always within reach is crucial for the safety and well- being of resident. The delay in in meeting the resident's needs for assistance can lead to frustration, falls and accidents. Finding: A review of Resident 11's admission Record indicated the resident was originally admitted to the facility on [DATE], with diagnoses that included repeated falls and abnormalities of gait (walking pattern) and mobility. A review of Resident 11's Care Plan, dated 2/6/2023, indicated the resident was high risk for falls. Resident 11's care plan further indicated to strongly reinforce the use of call light for assistance. A review of Resident 11's Minimum set data (MDS - a comprehensive assessment and care screening tool)…

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 eight sampled residents (Resident 46), was informed of where to find the facility's monthly and alternative, breakfast, lunch, and dinner menu. This deficient practice denied the resident the right to choose and participate in food choices, leading to feelings of helplessness and loss of autonomy, which can have negative impacts on their overall wellbeing. Findings: A review of the admission Record indicated Resident 46 was admitted to facility on 05/08/2024, with the diagnoses of right femur fracture (hip fracture or break), abnormality of gait (walking abnormality) and mobility. A review of the History and Physical dated 05/17/2024, indicated Resident 46 had the capacity to understand and make decisions. A review of Resident 46's care plan dated 05/09/2024, indicated Resident 46 had nutritional risk for weight changes and risk for variable intake of nutrition due to poor appetite. The care plan interventions indicated for dietary service to assess likes and dislikes, food preferences, and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a copy of an Advance Health Care Directives form (AHCD - written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) readily available for review in the medical record of one (1) of 3 sampled residents (Resident 162). This deficient practice had the potential to cause conflict in carrying out the resident's wishes regarding health care. Findings: A review of the admission record indicated Resident 162 was admitted on [DATE], with diagnoses that included hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood) and major depression (a common and serious medical illness that negatively affects how the person feels, the way they think and how they act). A review of the History and Physical Examination (H&P) dated 5/30/24, indicated Resident 162 has fluctuating capacity to understand and make…

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 formulate a care plan for one out of 22 total sample residents (Resident 35) who did not understand the formal language in the facility and did not have a care plan to address the resident's communication needs. This deficient practice had the potential to lead to miscommunication between staff and the resident and the delay in the delivery of care for Resident 35. Findings: A review of Resident 35's admission record indicated Resident 35 was originally admitted to the facility on [DATE], readmitted on [DATE], with diagnoses that included encephalopathy (damage or disease that affects the brain), diabetes mellitus (a chronic disease that result in high blood sugar levels in the blood), and muscle weakness. A review of Resident 35's History and Physical (H&P), dated 5/15/2024, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 35's Minimum Data Set (MDS, a comprehensive standardized…

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 provide a communication tool for one of 22 total sample residents (Resident 35) who did not understand the formal language, was not provided a communication board (a communication device, usually a whiteboard and a marker, used to facilitate communication between resident and staff). This deficient practice had the potential to lead to miscommunication between staff and the resident and the delay in the delivery of care for Resident 35. Findings: A review of Resident 35's admission record indicated Resident 35 was originally admitted to the facility on [DATE], readmitted on [DATE], with diagnoses that included encephalopathy (damage or disease that affects the brain), diabetes mellitus (a chronic disease that result in high blood sugar levels in the blood), and muscle weakness. A review of Resident 35's History and Physical (H&P), dated 5/15/2024, indicated the resident does not have the capacity to understand and make decisions. A review 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 ensure one of three sampled residents (Resident 106), received care and services for urine and bowel incontinence (no control) care promptly and after each incontinent episode as indicated in the resident's care plan and the facility's policy and procedure. Resident 106 waited one hour before she was assisted to be cleaned and brief to be changed due to incontinent. This deficient practice could result in discomfort and pain due to skin breakdown that could lead to skin infection. Findings: A review of Resident 106's admission Record indicated Resident 106 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included muscle wasting and atrophy (decrease in size of muscle tissue), generalized muscle weakness, diabetes mellitus (a condition that happens when the blood sugar is too high), osteoporosis (a condition with a decrease in the amount and thickness of bone tissue, which causes the bones 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the facility provided respiratory care as indicated in the facility's policy and procedure and plan of care for one out of 22 residents (Resident 24) with a physician order to receive continuous oxygen therapy was observed with an empty oxygen tank that required a refill. This deficient practice had the potential to cause Resident 24 to suffer complications associated to inadequate oxygen intake such as shortness of breath. Findings: A review of Resident 24's admission record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses that included asthma (inflammation and muscle tightening around the airways, which makes it harder to breathe), chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), and respiratory failure (a serious condition that makes it difficult to breathe). A review of Resident 24's history and physical (H&P), dated…

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 implement the facility's policy and procedure for standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) for one of one resident (Resident 31) by ensuring the Permcath (a flexible tube inserted into the skin and into the blood vessels and used for hemodialysis [is a type of treatment that helps your body remove extra fluid and waste products from the blood when the kidneys]) dressing was not peeling off. This deficient practice placed the resident at risk for infection and accidental dislodgement (removal) of the Permacath. Findings: A review of an admission Records indicated resident 31 was originally admitted to the facility on [DATE] and admitted on [DATE] with diagnoses including dependence on renal (kidneys) dialysis and type II type 2 diabetes mellitus (a medication condition characterized by the body's inability to regulate blood…

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, interviews and record review, the facility failed to report an allegation of abuse to the Department and other officials immediately, but not later than two hours for one of one sampled resident (Resident 1) in accordance with the mandated Federal and State regulatory guidelines. This deficient practice had the potential for the facility to under report allegations of abuse, which could lead to failure to investigate alleged abuse in a timely manner. Findings: A review of Resident 1 ' s admission Record indicated an admission date on 4/3/2024 with diagnoses including hemiplegia (paralysis on one side of body) and hemiparesis (muscle weakness on one side of body) following cerebral infarction (stroke) affecting left non-dominant side. A review of Resident 1 ' s History and Physical Examination dated 4/9/2024, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS, an assessment and screen tool) dated 4/7/2024 indicated Resident 1 had moderately impaired cognition and needed some help 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 fortified diet (diet enhanced to increase caloric content) as ordered by the physician for 19 out of 102 residents requiring fortified diet. This deficient practice had the potential to result in decrease caloric intake and lead to undesirable weight loss. Findings: During an observation of the tray line service for lunch on 2/2/2024 at 12:15 PM, residents who were on fortified diet received the same food as those residents who did not have an order for fortified diets. Dietary Aide (DA1) did not communicate the fortified diet orders written on the meal tickets during the observation of the facility's tray line for lunch service. A concurrent review of the tray or meal tickets on the meal cart indicated the orders for each resident's fortified diet. During the observation, DA 1 did not read out loud the fortified diet and the cook (Cook1) did not add any additional food items to the resident's meal trays with orders for fortified diet. During an interview with [NAME] 1 on 2/2/2024 at 12:40 PM, [NAME] 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 observation, interview, and record review, the facility failed to maintain a safe, sanitary environment to help prevent the spread and transmission of infections for two of three sampled Resident (Resident 2 and 3) in accordance with the facility ' s policy and procedure titled Hand Hygiene revised 10/2022, Covid-19, Prevention and Control revised 9/29/2023 and infection Prevention Quality Control Plan revised 10/10/2021, by failing to: 1.Ensure the Licensed Vocational Nurse (LVN) 1 performed hand hygiene (cleaning/washing hands to prevent the spread of germs) before entering Resident 3 ' s room to administer Resident 3 ' s medication. 2.Ensure Certified Nurse Assistant (CNA) 2 perform hand hygiene before entering Resident 2s room to render personal care. This deficient practice had the potential to spread infection such as COVID- 19 virus to Resident 2 and Resident 3 and negatively affect their quality of life. Findings: During an observation on 1/18/2024 at 8:15 AM in the facility ' s front entrance,…

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 Minimum Data Set (MDS, a standardized assessment and care-screening tool) was accurate for two of four sampled residents (Residents 58 and 43). 1. Resident 58's MDS, dated [DATE], did not accurately reflect the resident's active diagnoses for anxiety (intense, excessive, and persistent worry and fear about everyday situations). 2. Resident 43's MDS Section I (Active Diagnosis) did not indicate schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior) as one of the diagnosis. These deficient practices had the potential for the residents to not receive appropriate treatment and/or services. Findings: 1. A review of Resident 58's Face Sheet (a record of admission) indicated the resident admitted to the facility on [DATE] with a diagnoses of chronic obstructive pulmonary disorder (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs), dementia…

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 develop a comprehensive, resident-centered care plan for four of 20 sampled residents (Residents 58, 20, 31, and 17). 1. Resident 58's care plan did not have a measurable goal to address the resident's diagnosis of anxiety. 2. Resident 20's care plan did not indicate a measurable goal for tracking behaviors of psychosis (a mental disorder characterized by a disconnection from reality) for the use of quetiapine (a medication used to treat bipolar disorder, schizophrenia, and depression). 3. The facility did not develop an individualized plan of care for Resident 31's use of Eliquis (a medication used to prevent blood clots). 4. The facility failed to develop an care plan for Resident 17's for risk for falls upon readmission on [DATE]. These deficient practices had the potential for the residents to not have person-centered interventions addressing the residents' specific needs, potentially resulting in a decline in emotional, physical,…

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 professional standards of nursing care were followed. 1. During a treatment observation for Resident 14's pressure injury (injuries to the skin and underlying tissue, primarily caused by prolonged pressure), a Licensed Vocational Nurse 2 (LVN 2) left treatment medication (Calcium Alginate, a highly absorbent, biodegradable dressing derived from seaweed and Medi-Honey, a treatment used on wounds for non-draining to moderately draining wounds) and treatment supplies unsupervised. 2. LVN 1 did not give Resident 30's 2 Cal (nutritional drink supplement) during medication pass as ordered. LVN 1 signed and documented in Resident 30's eMAR (electronic Medication Administration Record) that it was given when the resident refused the 2 Cal nutritional drink. LVN 1 did not document that it was refused. This deficient practice had the potential for accidental application, consumption, and/or contamination of the treatment medications for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident's environment was free of accidental hazards for three of three sampled residents (Residents 31, 63, and 17), who were assessed at risk for falls. Residents 31, 63, and 17 were not observed in bed in the lowest position. This deficient practice had the potential to result in injury and harm to the residents in the event of a fall. Findings: 1. A review of Resident 31's Face Sheet (a record of admission) indicated the resident admitted to the facility on [DATE], with diagnoses that included heart failure (a condition when your heart doesn't pump enough blood for your body's needs), chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), and generalized muscle weakness. A review of Resident 31's Fall Risk Assessment Tool, dated 9/14/2021, indicated Resident 31 was at risk for falls. A review of Resident 31's care plan titled, At risk for falls due 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 store, discard, and/or label medications in accordance with the facility's policy and procedure. The following were observed during inspection of the medications carts: 1. Medication cart in Unit 300 had expired Budesonide Inhalation Suspension (a medication used to prevent difficulty of breathing, chest tightness, wheezing and coughing; used to treat breathing problems) for Resident 69. 2. Medication cart in Unit 300 had Anoro Ellipta (a medication used to treat breathing problems) for Resident 53 that was opened and not labeled with when it was opened to ensure how long it was good to use. 3. Medication cart in Unit 200 had Ipratropium-Albuterol (a medication used to treat breathing problems) inhaler for Resident 11 that was opened and not labeled with when it was opened to ensure how long it was good for. These deficient practices had the potential for the residents to be at risk for ineffective medications and/or suffer from side effects of using expired medications. Findings: During an inspection of 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 perform hand hygiene before and after assisting two of two sampled residents (Residents 9 and 24). During an observation, a Certified Nursing Assistant 1 (CNA 1) was helping Resident 9 and went into Resident 24's room to assist Resident 24 without performing hand hygiene. This deficient practice had the potential to increase the spread of infection and illnesses to other residents, staff, and the community. Findings: During an observation while in Resident 24's room, on 11/18/2021 at 7:49 AM, Resident 24 was observed eating breakfast while seated in bed. CNA 1 was observed in an adjacent (next door) room, seated in front of Resident 9, preparing Resident 9's breakfast tray. CNA 1 was then observed standing up and walking into Resident 24's room, and picked up Resident 24's spoon and began feeding Resident 24 a spoonful of oatmeal. CNA 1 did not perform hand hygiene prior to entering Resident 24's room or prior to touching Resident 24'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that one of two sampled residents (Resident 70) was treated with dignity and respect when staff assisted Resident 70 with his meal. A Certified Nursing Assistant 3 (CNA 3) was feeding Resident 70 not at eye level. This deficient practice had the potential for the resident to feel rushed and impersonal with the staff. Findings: During an observation, on 11/17/21 at 8:08 AM, CNA 3 was observed feeding Resident 70 while standing at the resident's bedside. During a concurrent observation and interview with CNA 4 on 11/17/21 at 8:10 AM, CNA 4 went inside the room and handed a chair to CNA 3, who was feeding Resident 40 while standing. CNA 4 stated staff should feed the residents at eye level or sitting down so residents do not feel rushed. A review of Resident 70's Face Sheet (a record of admission) indicated Resident 70 admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (serious condition that…

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 four sampled residents (Resident 44) had an interdisciplinary team (IDT, a team of professionals responsible for planning and coordinating a resident's care) assessment and physician order for self-administration of medications. During a medication pass observation, Resident 44 self-administered Symbicort (a medication used to treat breathing problems) without an assessment or physician's order indicating the resident was safe to do so. This deficient practice had the potential for the resident to administer medications incorrectly, which could result in over or under medicating and negatively impact the resident's overall health and well-being. Findings: A review of Resident 44's admission Record indicated the resident admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, group of lung diseases that block airflow and make it difficult to breathe), essential hypertension…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to revise the care plans for two of two sampled residents (Residents 63 and 76). Resident 63 and Resident 76, who were receiving Hemodialysis (a treatment to filter wastes and water from your blood, as your kidneys did when they were healthy), had care plans for risk of infection at the dialysis access site that were not updated to include the residents had a Permacath catheter (a long, flexible tube that is inserted into a vein most commonly in the neck vein) as the access site for treatment. This failure had the potential for the residents to not receive the appropriate care and services individualized to their needs. Findings: 1. A review of Resident 63's Face Sheet (a record of admission) indicated the resident readmitted to the facility on [DATE], with a diagnosis that included end stage renal disease (ESRD, a medical condition in which a person's kidneys stop functioning on a permanent basis) needing hemodialysis treatment, cellulitis (a common…

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 three sampled residents (Resident 70), who was at risk for weight loss and/or decline in nutritional status, was monitored. The facility failed to complete the following: 1. Monitor and accurately document Resident 70's meal percentage intake. 2. Monitor and record Resident 70's weights as ordered by the physician. 3. Implement the resident's care plan interventions for the resident's altered nutritional status. These deficient practices had the potential for the resident to have unplanned weight loss that could adversely affect the resident's health and safety. Findings: A review of Resident 70's Face Sheet (a record of admission) indicated the resident admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (serious condition that develops when the lungs can't get enough oxygen into the blood) and aortic aneurysm (balloon-like bulge in an artery [blood vessels that carry blood from heart…

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 readily accessible language communication boards (a device that displays photos, symbols, or illustrations to help people with limited language skills express themselves) for three of four sampled residents (Residents 23, and 79) who were not fluent in English and had difficulty making needs known due to the language barrier and/or medical diagnoses. 1. Resident 23, who spoke Armenian, did not have a communication board present in the resident room. 2. Resident 79, who spoke Armenian, did not have a communication board in the resident's room. This deficient practice had the potential for a delay in the residents' needs not being met and/or provided. Findings: 1. A review of Resident 23's Face Sheet (a record of admission) indicated the resident admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), dementia (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 accurately account for the use of one controlled substance (medications with a high potential for abuse), Pregabalin (a medication used to treat nerve and muscle pain) for one sampled resident (Resident 79) in one of three medication carts inspected (Unit 300). This deficient practice increased the risk that Resident 79 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization. Findings: During an inspection and record review of the medication cart in Unit 300 with a Licensed Vocational Nurse 5 (LVN 5), on 11/16/21 at 2:36 PM, the facility's Controlled Drug Record (a log signed by the nurse with the date and time each time a controlled substance was given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication) for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to define and monitor specific target behaviors related to the use of psychotropic medications (medications that affect brain activities associated with mental processes and behavior) for one of five sampled residents (Resident 43). Resident 43, who was receiving quetiapine (a medication used to treat schizophrenia) and escitalopram oxalate (a medication used to treat depression), did not have specific behaviors the resident exhibited to monitor the use of these psychotropic medications. This deficient practice increased the risk for the resident to have adverse effects (unwanted or dangerous medication side effects) of psychotropic medications and/or inability to monitor effectiveness of each medication. Findings: A review of Resident 43's Face Sheet (a record of admission) indicated the resident initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included schizophrenia (a brain disorder that affects a person'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Symbicort HFA aerosol inhaler (a medication used to treat breathing problems) medication was administered to one of four sampled residents (Resident 44) in accordance with physician's order. This deficient practice had the potential in complications that could lead to hospitalization and/or death. Findings: A review of Resident 44's Face Sheet (a record of admission) indicated the resident admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, group of lung diseases that block airflow and make it difficult to breathe), essential hypertension (high blood pressure that doesn't have a known secondary cause), and glaucoma (group of eye conditions that can cause blindness). A review of Resident 44's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 9/17/2021, indicated the resident had no impairment in cognitive skills (ability to make daily decisions)…

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 and recipe on preparation of foods during a lunch tray line observation. The following were observed: 1. [NAME] 1 did not follow the recipe to make southern green beans and served plain steamed green bean. 2. [NAME] 1 prepared the pureed southern green beans by using peas instead of pureed southern green beans and did not have a recipe to make pureed diet. This deficient practice had the potential for the nutritional value and/or tastes of the prepared foods to not be met. Findings: A review of the facility's lunch menu for 11/15/2021, indicated the following items would be served: 1. Meatball sandwich with sauce and shredded cheese (1 sandwich), 2. Southern [NAME] Beans ½ cup, 3. Creamy cucumber and celery salad ½ cup, and 4. Pudding with whipped Topping 1/3 cup. During a lunch tray line observation and interview, on 11/15/2021 at 10:40 AM, [NAME] 1 was blending peas and not southern green beans for the puree diet. [NAME] 1 stated the green beans for residents who were on a regular diet were…

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 prepare food in manner that was flavorful and had a variety of food options. Two of 22 sampled residents (Residents 5 and 67), who were on mechanical diets (texture modified diet that restricts foods that are difficult to chew or swallow), complained that the food served lacked flavor and that the facility did not have many choices to choose from. This deficient practice had the potential to affect the resident's satisfaction and decrease meal intake which could result in weight loss. Findings: During a test tray observation, on 11/15/2021 at 12:45 PM, a regular and pureed diet of meatball sandwiches and southern green beans were tested. The southern green beans tasted like plain steamed green beans with no seasonings (salt and pepper) or sauteed onions. The pureed southern green beans tasted like peas and not like green beans. The meatballs from the sandwich was dry and had no flavor. A review of the facility's undated record titled, Recipe: Southern [NAME] Beans, indicated to sauté onions in margarine or…

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

Based on observation and interview, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen. Dish Washer (DW) did not wash hands when removing the clean and sanitized dishes from the dish machine. This failure had the potential for cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) that could lead to foodborne illness (caused by food contaminated with bacteria, viruses, parasites, or toxins) for 85 of 87 residents who eat meals prepared from the facility's kitchen. Findings: During an observation on 11/15/2021 at 8:45 AM in the dish washing area, Dish Washer (DW) was observed rinsing (no soap used) dirty dishes before loading the dirty dishes into the sanitization machine. After the sanitization machine finished sanitizing the dishes, DW rinsed (no soap used) his soiled hands under the faucet that was used to wash dirty dishes. The sink contained soiled dishes. DW then proceeded to remove the clean and sanitized dishes from the dish machine without performing…

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.