Glendora Grand, INC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to:A. Clarify a discrepancy between the physician's order for Resident 270's Olanzapine (treat mental disorders) and the prescription label prior to medication administration.B. Identify Resident 98 and Resident 270 prior to the administration of medication. C. Remove discontinued and inactive controlled medication ([CM]- medications which have a potential for abuse and may also lead to physical or psychological dependence) orders for Residents 47, 261, and 6. These failures increased the risk of medication errors for Residents 6, 47, 98, 261 and 270.Findings:A. During a review of Resident 270's admission record (AR, a document containing diagnostic and demographic information), the AR indicated Resident 270 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including paranoid schizophrenia (a chronic mental health disorder characterized by persistent delusions, false beliefs and hallucinations, hearing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record reviews, the facility failed to:A. Ensure Resident 5's inhalation medication DuoNeb (Ipratropium bromide and albuterol sulfate inhalation solution is a combination medication used to treat breathing problems associated with lung diseases like chronic obstructive pulmonary disease [COPD]) was stored appropriately in accordance with the manufacturer's specifications to maintain the medication's therapeutic effectiveness when needed.B. Remove non-controlled medications from the medication cart for a discharged resident, Resident 5C. Dispose of non-controlled medications in the presence of a witness in accordance with facility's policy titled, Disposal of Medications, Syringes and Needles - Disposal of Medications.These failures increased the risk of Resident 5 receiving an expired DuoNeb inhaler treatment that may result in the medication being less potent, ineffective, or contaminated which could lead to inadequate relief of respiratory symptoms, shortness of breath,…

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 properly cover six of 10 large trash bins with lids as indicated in the facility's Policy and Procedure (P&P) on garbage disposal.This deficient practice had the potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects) and pests (any living thing that has a negative effect on humans) that could potentially enter the facility, affect the resident care areas, and expose the residents and staff to diseases.Findings:During a facility tour and observation on 8/5/2025 at 8:44 AM, two large trash bins full of trash bags in the Lodge Building, three large trash bins in the Manor Building and one large trash bin in the Center Building area outside in the parking lot had open lids.During an interview with Kitchen Manager (KM) on 8/5/2025 at 8:49 AM, KM stated the trash bin lids should be kept closed at all times because it was unsanitary and to prevent cross contamination (transfer from one substance or object to another, with harmful effect).…

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. Licensed Vocational Nurse (LVN) 1 performed hand hygiene (hand washing using soap and water, and cleaning hands with waterless or alcohol-based hand sanitizers) for one of five sampled resident (Resident 59) during medication administration observation. B. Resident 304's [NAME] valve (used to maintain a closed system, minimizing healthcare worker exposure to bodily fluids and reducing the risk of accidental contamination) used with a gastric or enteral feeding tube (GT or ENT, medical devices used to deliver nutrition, fluids, and medications directly into the stomach) was not observed crusty, dirty, or worn, and missing a coverage cap. These failures placed Resident 59 and Resident 304 at risk for the spread of infection between residents and staff and had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another). Findings: A. During 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 provide Resident 197 food choices that accommodated Resident 179's food preferences.This deficient practice has the potential to alter Resident 179's nutritional status and decrease meal intake that can potentially lead to weight loss and malnutrition (not having enough to eat or not eating enough).Findings:During a review of Resident 197's admission Record (AR), the AR indicated Resident 197 was admitted to the facility on [DATE] with diagnoses that included but not limited to major depressive disorder (a serious mental health condition characterized by persistent feelings of sadness, loss of interest, and a reduced ability to function in daily life), type 2 diabetes (a chronic condition where the body either doesn't produce enough insulin or can't properly use the insulin it does produce, leading to high blood sugar levels), bipolar disorder (a mental health condition that causes extreme mood swings).During a review of Resident 197'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 interview and record review, the facility failed to ensure its policies and procedures (P&P) were implemented for one of one sampled resident (Resident 11) by:1. Failing to obtain Resident 11's physician signature on the Acknowledgment of Receipt for Advance Directive (AD - a legal document indicating resident preference on end-of-life treatment decisions)/Medical Treatment Decisions (ARAD).2. Failing to maintain a full copy of the resident's POLST (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) in Resident 11's medical record with a physician signature.This failure resulted in incomplete medical treatment forms for a resident who was to receive comfort-focused treatment and had the potential to result in a violation of the residents' and/or the representatives' right to be fully informed of the option to formulate or provide their advance directives with the discussion of diagnoses and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide privacy for one of one sampled resident (Resident 5) when Registered Nurse 2 (RN 2) did not close the privacy curtain while checking Resident 5's foley catheter's (thin, sterile tube inserted into the bladder to drain urine into a bag outside the body) securement device. This deficient practice violated Resident 5's right to privacy and resulted in unnecessary exposure of Resident 5's lower extremities. This deficient practice had the potential to affect Resident 5's psychosocial (mental and emotional) well-being, self-esteem, and self-worth. Findings: During a review of Resident 5's admission Record (AR), the AR indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included chronic kidney disease (CKD, a progressive condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood) and benign prostatic hyperplasia (enlargement 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.

Based on interview and record review, the facility failed to screen one of four randomly selected employees (Registered Nurse 1 [RN 1]) with the Office of Inspector General (OIG - investigates alleged violations of criminal and civil laws) data base for convictions of fraud and abuse prior to hire. This deficient practice had the potential for applicants with a history of abuse to be hired, which could lead to possible harm and abuse of the residents. Findings:During a concurrent interview and record review of RN 1's employee file on 8/8/2025 at 9:33 am with the Director of Staff and Development (DSD), the DSD stated RN 1 was hired on 7/5/2025. The DSD stated that the facility did the background check after the employee got hired. The DSD stated, We hire applicants first and do the background check after. The previous DSD told me to hire the applicant and do the background check after hire. During a concurrent interview and record review of the facility's undated Policy and Procedure (P&P) titled Abuse, Neglect and Exploitation on 8/8/2025 at 10:43 am with the facility's Director 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 interview and record review, the facility failed to complete the Minimum Data Set (MDS, a resident assessment tool) comprehensive assessment within federal time frames per Center of Medicare and Medicaid Services (CMS, a federal agency that manages healthcare programs like Medicare and Medicaid) requirement for two of two sampled residents (Residents 137 and 172).These failures had the potential to affect Residents 137 and 172's care by not providing CMS specific resident information and assessment timely. Findings:a. During a review of Resident 137's admission Record (AR), the AR indicated Resident 137 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness characterized by disturbances in thought) and suicidal ideations (refers to thoughts, ideas, or contemplations about ending one's own life).During a review of Resident 137's Situation, Background, Appearance,…

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 one sampled resident (Resident 6) was kept clean on 8/5/2025.This failure had the potential to result in social decline, skin breakdown, and body odor to Resident 6.Findings:During a review of Resident 6's admission Record (AR), the AR indicated Resident 6 was admitted to the facility on [DATE] with diagnoses that included type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), schizophrenia (a mental illness that is characterized by disturbances in thought), and adult failure to thrive (a decline caused by chronic [persistent or long-lasting] diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity).During a review of Resident 6's History & Physical (H&P), dated 4/2/2025, the H&P indicated Resident 6 had the capacity to understand and make decisions.During a review of Resident 6's Minimum Data Set…

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 smoking policy and procedure (P&P) was implemented for one of two sampled residents (Resident 213) when Resident 213 was found with two cigarettes in Resident 213's possession. This failure had the potential to put the facility at risk of a fire hazard. Findings: During a review of Resident 213's admission Record (AR), the AR indicated Resident 213 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), schizophrenia (a mental illness characterized by disturbances in thought), and traumatic brain injury (TBI-a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head).During a review of Resident 213's History & Physical (H&P) dated 10/21/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.During a review of Resident 213's Minimum Data Set…

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 develope care plans (CPs) for two (2) of three (3) sampled residents (Resident 4 and Resident 6) in accordance with care and services to be provided to the residents according to the physician ' s order. Resident 4 ' s and Resident 6 ' s Diabetes Mellitus (DM, a disorder characterized by difficulty in blood glucose [sugar] control and poor wound healing) care plans (CPs) included a goal to maintain blood sugar levels between 70 milligrams per deciliter (mg/dl, a unit of measure) and 150 mg/dl. Resident 4 and Resident 6 did not have a physician ' s order for routine bedside blood sugar monitoring. These failure had the potential for Resident 4 and Resident 6 to receive inappropriate DM care and services. Findings: 1. During a review of Resident 4 ' s admission Record (AR), the AR indicated the facility admitted Resident 4 on 4/21/2025 and readmitted Resident 4 on 5/16/2025 with diagnoses that included DM. During a review of Resident 4 ' s Minimum Data…

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 five sampled residents (Resident 1) was provided with the necessary behavioral health care and services to address Resident 1's history of suicidal ideation (SI- a range of thoughts, fantasies, or contemplations about ending one's own life) by failing to: 1. Ensure the Social Services Director (SSD) and/or admitting licensed nurse accurately assessed and documented Resident 1's episode of suicidal ideation while Resident 1 was in the General Acute Care Hospital (GACH) 1 on 4/20/2025. 2. Develop a care plan for Resident 1's history of suicidal ideations. 3. Monitor Resident 1 for suicidal ideations. These deficient practices had the potential to worsen Resident 1's mental condition and increase Resident 1's risk for suicide and self-harm. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses 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 interview and record review, the facility failed to implement one of two sampled residents (Resident 1)'s care plan, in accordance to the facility's policy and procedure titled, Comprehensive Care Plans by failing to perform daily body checks for Resident 1. This failure resulted in Resident 1 sustaining an infected wound (a wound where bacteria or other microorganisms have entered and are multiplying, causing an infection) to Resident 1's left wrist. Cross reference: F684 and F726 Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility initially admitted Resident 1 on 4/30/2015 with diagnoses including mild intellectual disabilities (limitations on intelligence, learning and everyday abilities) and abnormalities of gait (walk) and mobility. During a review of Resident 1 ' s CP titled, Care Plan Report, dated 12/11/2024, the CP indicated Resident 1 had a risk for development of pressure ulcers secondary to multiple health conditions, limited mobility, effects of medication, impaired cognition. The CP ' s goal indicated, will minimize…

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

Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 and Registered Nurse (RN) 1 assessed/checked one of two sampled residents (Resident 1) when foul (bad) smell was noticed on 3/20/2025 and 3/21/2025 from Resident 1. This failure resulted in unnoticed and untreated infected wound to Resident 1 ' s left wrist. Cross reference F684 and F656 Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility initially admitted Resident 1 on 4/30/2015 with diagnoses including mild intellectual disabilities (limitations on intelligence, learning and everyday abilities) and abnormalities of gait (walk) and mobility. During a review of Resident 1's Minimum Data Set (MDS -a resident assessment tool), dated 1/26/25, the MDS indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify one of eight sampled residents' (Resident 4's) physician(s) and responsible party according to the facility's policies and procedures (P&P) titled, Notification of Changes, and Change in a Resident's Condition or Status by failing to ensure: 1. Licensed Nurses (all licensed nurses that assigned to care for Resident 4) notified Resident 4's physician(s) and Resident 4's family and/or responsible party (RP) when Resident 4 repeatedly refused to be treated by the podiatrist (medical doctor who specializes in the treatment of disorders of the foot, ankle, and the lower leg), for the year of 2024. 2. Licensed Nurses notified Resident 4's physician regarding the condition of Resident 4's toenails. These failures resulted in Resident 4 to be transferred and admitted to the General Acute Care Hospital (GACH) 1, on 2/13/25, for intravenous (IV, given directly into the blood stream through the vein) antibiotic (medications used to treat infections) 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 implement the care plan for one of eight sampled residents (Resident 4) when licensed nurses did not notify Resident 4's physician regarding Resident 4's repeated refusals to be treated by the podiatrist as indicated in Resident 4's care plan (CP) titled, Care Plan Report. This failure had the potential for Resident 4 to not receive the necessary care and treatment for Resident 4's foot and result in discomfort, injury, and/or infections. Cross Reference F687, F580, and F684 Findings: During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was originally admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and dementia (a progressive state of decline in mental abilities). During a review of Resident 4's History and Physical (H&P, physician's clinical evaluation and examination 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 interview and record review, the facility failed to provide necessary care and services to one of eight sampled residents (Resident 4) and failed to implement its policies and procedures (P&P) titled, Change in a Resident's Condition or Status, and Comprehensive Care Plans, when: 1. Resident 4's repeated refusal to be treated by the podiatrist (medical doctor who specializes in the treatment of disorders of the foot, ankle, and the lower leg) was not communicated to Resident 4's physician(s) and to Resident 4's family and/or responsible party (RP). 2. Resident 4's care plan regarding refusal of care and treatment was not implemented. 3. Licensed Nurses did not inform Resident 4's physician regarding the condition of Resident 4's toenails during weekly nursing assessment (a comprehensive evaluation of a resident's health status conducted by a nurse on a weekly basis) of Resident 4. These failures resulted in Resident 4 to be transferred and admitted to the General Acute Care Hospital (GACH) 1, 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, and record review, the facility failed to provide supervision to prevent elopement (when an individual leaves the healthcare facility unsupervised and/or undetected) for one of three sampled residents (Resident 1) assessed as at risk for elopement as indicated in the facility's policy and procedure titled, Elopements and Wandering Residents, by failing to ensure Resident 1 was readmitted to the facility's secured unit (any area in the facility designed and operated to ensure that all its entrances and exits are locked to prevent residents from leaving the facility without permission and/or supervision). As a result, on 2/19/25 at 8:45 pm, facility staff (general) were unable to locate Resident 1 and filed a missing person report with the local police department on 2/19/25 at 10:10 pm. As of 2/26/25 at 5:37 pm, Resident 1 had not been found. This failure had the potential to put Resident 1 at risk for serious injury, harm, and/or death due to not receiving psychotropic medication…

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 lights were within reach for two of two sampled residents (Residents 81 and 25). These deficient practices had the potential to result in Residents 81 and 25 to not receive the necessary care or receive delayed services to meet the residents' needs that could result in a fall and accident. Findings: a. During a review of Resident 81's admission Records (AR), the AR indicated Resident 81 was initially admitted to the facility on [DATE] and Resident 81 was readmitted to the facility on [DATE] with diagnoses that included osteoarthritis (occurs when flexible tissue at the ends of bones wears down), muscle weakness (decreased strength in the muscles) and dementia (loss of cognitive functioning-thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). During a review of Resident 81's Care Plan (CP), dated 4/18/2024, the CP indicated, Resident 81 needed assistance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY b. During a review of Resident 80's AR, the AR indicated the facility initially admitted the resident on 4/4/2015 and readmitted the resident on 6/6/2024, with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and dysphagia (difficulty swallowing.) During a review of Resident 80's MDS dated [DATE], the MDS indicated the resident had severely impaired cognition. The MDS indicated Resident 80 was dependent with all activities of daily living. During an observation on 8/1/2024 at 12:30 pm, Certified Nursing Assistant 5 (CNA 5) was assisting Resident 80 with lunch. Resident 80 coughed twice. Resident 80 was positioned slightly above 45 degrees and the neck was hyperextended (leaning backwards). During an interview on 8/1/2024 at 12:35 pm, Registered Nurse 3 (RN 3) stated Resident 80's neck should not be hyperextended while eating. RN 3 assisted CNA 5 to reposition Resident 80 and adjusted the bed slightly…

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 necessary care to prevent Urinary Tract Infection ([UTI] an infection in any part of the urinary system [kidneys, bladders, ureters and urethral]) for two of two four residents (Residents 214 and 236) who had Foley catheter (a thin, sterile tube inserted into the bladder to drain urine), by failing to ensure: a. Licensed staff monitored Residents 214's urine output and notified the physician promptly for signs and symptoms of UTI. b. Licensed staff and/or Certified Nursing Assistant (CNA) positioned Resident 236's urine bag above the floor to prevent contamination of the urine. These deficient practices placed Residents 214 and 236 at risk for infection due to delayed treatment and contaminated urine when the urine bag was on the floor. Findings: a. During a review of Resident 214's Face Sheet (FS), the FS indicated the facility admitted Resident 214 on 6/10/24, with diagnoses that included diabetes mellitus (a 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 follow its policies and procedures (P&P) titled, Oxygen Administration, and Oropharyngeal Suction, for two of two sampled residents (Resident 67 and 653) by failing to: 1. Remove and/or replace the suction canister after use for Resident 67 when the suction canister contained moderate amount of thick, yellow sputum (secretion, a mixture of saliva and mucus produced by the lungs). 2. Date (label with a date) Resident 653's humidifier (used to increase the level of moisture for supplemental oxygen) when Resident 653 had an oxygen machine at the bedside. These findings had the potential to result in the use of expired respiratory items for Resident 653 and result in inaccurate monitoring of sputum/secretion for Resident 67. Findings: 1. During a review of Resident 67's admission Record (AR), the AR indicated, the facility admitted Resident 67 to the facility on [DATE], and readmitted Resident 67 on [DATE], with diagnoses that included but…

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 three of five sampled residents (Residents 22,198 and 210) on psychotropic drugs (any drugs that affects brain activities associated with mood, emotions, and behavior) were free from unnecessary medication. a. For Resident 198, licensed staff failed to attempt a gradual dosage reduction ([GDR] a stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) for Resident 198's Risperdal (antipsychotic drug) 1 milligram ([mg] unit of measurement) and Lexapro (antidepressant drug) 10 mg since ordered on 6/8/21. b. For Resident 210, licensed staff failed to attempt a GDR for Resident 210's Lexapro 10 mg since ordered on 3/27/23. c. For Resident 22, licensed staff failed to monitor Resident 22's target behavior symptom and side effects every shift for the use of Ativan 1 mg (antianxiety drug). These deficient practices placed Residents 22, 198…

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 kitchen staff were routinely trained and evaluated for competency skills when: a. Two of two staff (Dietary Aide 1 [DA 1] and the Dietary Account Manager [DAM]) failed to follow the manufacturer's guidelines for chlorine paper (a type of test strip) testing when checking the chlorine (a chemical used to disinfect dishes) sanitizer concentration. b. Staff failed to follow manufacturer's guidelines of smartpower sink and surface cleaner sanitizer (a solution used to sanitize kitchen surfaces) in two of two kitchens (Kitchen 1 and 2) by not checking temperature for testing solution. These failures had a potential to result to cross-contamination (a transfer of bacteria from one object to another), unsanitized dishware and bacterial growth on food that could lead to food borne illness (an illness caused by contaminated food and beverages) in 297 of 308 medically compromised residents who received food and ice from the kitchen. Findings: a. During a concurrent observation and an interview with DA 1 on…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in two of two facility kitchen (Kitchen 1 and Kitchen 2) when: a. Freezer A bottom shelves had food debris, dust and gasket had dirt buildup.Freezer B vents had dust buildup. b. Reach-in refrigerator's vent had dust and dirt buildup in Kitchen 1. c. Stainless steel racks for kitchen utensil storage had rust. Stainless steel storage racks in the dry storage area had rust. Storage rack in Kitchen 2 had rust. d. Two (2) dented cans were stored with non-dented cans in Kitchen 1. One (1) dented can was stored with non-dented cans in Kitchen 2. e. The lids for the bulk container for oatmeal, thickener and flour had dirt buildup. f. Reach-in refrigerator in Kitchen 2 had ice buildup and dirt debris. g. Dry storage wooden racks in Kitchen 2 had farina cereal debris. h. [NAME] storage shelves in Kitchen 2 were not six (6) inches (in., unit of measurement) above the ground. i. Staff was wearing dangling and beaded bracelet while checking food for…

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

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when: 1. Four of four gray trash bins located outside of Kitchen 1 area and one of two black trash bin was not completely covered and closed located outside of Kitchen 3. 2. The facility did not maintain the trash area free from trash, soiled gloves, and other dirt debris in two of three kitchen (Kitchen 1 and Kitchen 3) dumpster areas. This deficient practice had a potential to attract birds, flies, insects, and pest and the potential to result in the spread of infections to residents residing at the facility. Findings: 1. During a concurrent observation of the dumpster (a large metal trash container designed to be emptied into a truck) area located outside of Kitchen 1 building and interview with the Dietary Area Manager (DAM) on 7/30/2024 at 10:30 am, four of four gray trash bins were overflowing with trash and were not completely closed. The DAM stated the trash bins should be completely covered and this was not good because the trashes were exposed. The DAM stated this…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide Speech Therapy (ST, profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) evaluations in accordance with physician's orders for three of nine sampled residents (Residents 147, 198, and 280) who had swallowing, communication, and cognitive (ability to think, understand, learn, and remember) concerns. This deficient practice prevented Residents 147, 198, and 280 from receiving ST services to potentially improve swallowing, cognitive, and communication abilities and maintain or achieve the highest practicable level of function. Findings: a. During a review of Resident 147's Face Sheet, the Face Sheet indicated the facility initially admitted Resident 147 on 1/9/2018 and re-admitted the resident on 6/21/2024 with diagnoses including encephalopathy (any damage or disease that affects the brain), cirrhosis (condition in which the liver is scarred and permanently…

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 its Resident-Facility Arbitration Agreement (AA, a Binding Arbitration Agreement requires the person who signed it resolve any dispute by binding arbitration, rather than in court) included selection of a venue convenient to both facility and residents and resident's responsible party for three of three sampled residents (Residents 250, 294 and 402). These deficient practices placed Residents 250, 294 and 402 at risk for unjust arbitration and delayed arbitration hearing in an event of an arbitration dispute. Findings: a. During a review of Resident 250's Face Sheet (FS), the FS indicated Resident 250 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows), psychosis (a mental disorder characterized by a disconnection from reality), and dysphagia (difficulty swallowing foods or liquids). 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 for one of three sampled residents (Resident 80) on hospice care (medical service designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life), the facility failed to ensure: a. Documentation of services provided by the Hospice Health Aide (HHA) to Resident 80 during HHA visits. b. Accurate documentation of hospice Licensed Vocational Nurse visits. c. Hospice Licensed Nurse visits were implemented in accordance with the hospice physician's order. Findings: During a review of Resident 80's Face Sheet, the face sheet indicated the facility initially admitted the resident on 4/4/15 and readmitted the resident on 6/6/24, with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and dysphagia (difficulty swallowing.) During a review of Resident 80's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 6/21/24, the MDS indicated the resident had severe…

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: a. Dispose soiled gauze in a safe and sanitary method in one of one resident's room (Resident 191's room). b. Ensure one of one Restorative Nursing Aide (RNA 1) removed an isolation gown (protective apparel used to protect the wearer from the transfer of microorganisms and body fluids) and gloves and performed hand hygiene after exiting Resident 147's room and entering the hallway during an Restorative Nursing Aide (RNA, nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) session with Resident 147 who was on Contact Isolation Precautions (procedures to reduce risk of spread of infections through direct or indirect contact). c. Follow the facility's policy on COVID-19 (highly contagious respiratory disease caused by the SARS-CoV-2 virus that is spread through droplets when an infected person coughs, sneezes, or talks) and Public Health Nurse (PHN) COVID-19 guidance for…

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

Based on observation, interview, and record review, the facility failed to keep three of three laundry dryers in a safe, operating, and sanitary condition for residents. This failure had the potential to result in spread of infection and pose as potential fire hazard. Findings: During a concurrent observation and interview on 8/1/2024 at 10:13 am with the Environmental Service Manager (EVSM), in the facility's laundry room, there were total of three dryers in the laundry room. All three dryer's drum (the actual container to put wet laundry for drying) had multiple random thick patches of brown/black material on the dryers' drum inner wall. The EVSM stated the dryers' drums were dirty with these patches, and the EVSM did not know how these patches formed. The EVSM stated the facility needed to keep the dryers' drum clean to prevent cross contamination and infection when drying residents' clothes. The EVSM stated the patches could pose as potential fire hazard when the patches covered the drum holes decreasing heat and moisture ventilation. The EVSM stated the EVSM needed to report…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were provided a homelike environment for one of one sampled resident's room (Resident 209) by failing to ensure the room did not have peeling paint on the walls and stain on the floor. This failure had the potential for unsafe and unclean resident's environment. Findings: During a review of Resident 209's Face Sheet (FS), the FS indicated Resident 209 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included muscle weakness, anxiety disorder (group of mental disorders characterized by feelings of anxiety [an unpleasant state of inner turmoil] and fear) and insomnia (inability to sleep). During a review of Resident 209's History and Physical Examination (H&P) dated 2/13/2024, the H&P indicated Resident 209 does not have the capacity to understand and make decisions. During a review of Resident 209's Minimum Data Set (MDS-a standardized assessment and care planning tool) dated 5/13/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop an individualized/person- centered care plan for one of one sampled resident (Resident 22), who was on Ativan, (medication used to treat anxiety [group of mental disorders characterized by feelings of anxiety [an unpleasant state of inner turmoil] and fear]) in accordance to the facility's policy titled Comprehensive Care Plans. This deficient practice had the potential to result in Resident 22 not receiving appropriate care treatment and/or services. Findings: During a review of Resident 22's admission Record (AR), the AR indicated Resident 22 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included anxiety and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review of Resident 22's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 6/5/2024, the MDS indicated, Resident 22…

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

Based on interview and record review, the facility failed to revise one of one sampled resident (Resident 228) care plan (CP) when Resident 228's scratch (skin injury from something sharp or rough) on the right hip changed in color on 7/24/2024. This failure had the potential to delay the provision of care and treatment for Resident 228' injury and cause Resident 228's skin injury to worsen. Cross reference F686 Findings: During a review of Resident 228's admission Record (AR), the AR indicated, the facility originally admitted Resident 228 to the facility on 2/23/2024, and readmitted Resident 228 on 5/30/2024, with diagnoses that included but are not limited to type two diabetes mellitus (T2DM, occurs when there is too much sugar in the blood), end stage renal disease (occurs when kidneys are unable to filter blood properly), and dependence on renal dialysis (procedure to remove waste products and excess fluid from the blood when kidneys are not working). During a review of Resident 228's Minimum Data Set (MDS, a standardized comprehensive assessment of each resident's functional…

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 safe administration of medications during a medication administration observation for one of three sampled residents (Resident 124) by failing to ensure Licensed Vocational Nurse (LVN) 6 did not administer medications that were dropped on the floor to Resident 124. This failure had the potential to result in infection for Resident 124 from consuming contaminated medications. Findings: During a medication administration observation on 7/31/2024 at 8:53 am, in Resident 124's room LVN 6 prepared 13 medications and put the medications in a medication cup for Resident 124. LVN 6 accidentally dropped three pills on the floor before giving the medication cup to Resident 124. LVN 6 looked on the floor, found the three pills, picked up the three pills, and put the three pills back into the medication cup with the rest of Resident 124's medications. LVN 6 then gave the medication cup to Resident 124. Resident 124 received the medication cup from LVN 6 and was about to put the medications from the medication cup…

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 one sampled resident (Resident 42) received foot care in a timely manner. Resident 42's had unclean, yellow, and long toenails for both feet. This failure placed Resident 42 at risk for complications such as infection or injuries of the feet. Findings: During a review of Resident 42's Face Sheet (FS), the FS indicated, Resident 42 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Chronic Kidney Disease (CKD- a condition characterized by a gradual loss of kidney function over time), dementia (progressive brain disorder that slowly destroys memory and thinking skills), and schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves). During a review of Resident 42's History and Physical Examination (H&P) dated 6/21/2023, the H&P indicated Resident 42 had fluctuating capacity to understand and make decisions. During a review of Resident 42's…

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

Based on observation and interview, the facility failed to post nursing staff data (the total number and actual hours worked by Registered Nurses, Licensed Vocational Nurses, and Certified Nurse Aides) on a daily basis at a place that was easy accessible for public review as required for one of six nursing stations (Station 1), at the beginning of each shift, which made the data unavailable to residents and visitors. This failure had the potential to give residents/visitors inaccurate staffing information and potentially affect the quality of care provided to the residents. Findings: During a facility tour and concurrent interview on 7/30/2024 at 11:59 am, with Director of Staff Development (DSD), there was no nursing staff data posted in Station 1, including its hallway. The DSD stated, the DSD did not post the nursing staff data in Station 1 and residents and visitors for Station 1 may review the facility's staffing information upon request only. The DSD stated residents and family members for Station 1 would not be able to see the posting in other nursing stations because it was…

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

During an observation, interview, and record review, the facility failed to provide necessary interventions for one of one sampled resident (Resident 80) who had dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). Resident 80 was calling out repeatedly from 8:30 am to 11:36 am on 8/1/24 without any help from staff. This deficient practice had the potential to not meet Resident 80's need such as pain, discomfort, hunger, thirst, or frustration. Findings: During a review of Resident 80's Face Sheet, the face sheet indicated the facility initially admitted the resident on 4/4/15 and readmitted the resident on 6/6/24, with diagnoses that included dementia and dysphagia (difficulty swallowing.) During a review of Resident 80's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 6/21/24, the MDS indicated the resident had severe cognitive ( ability to understand) impairment. The MDS indicated Resident 80 was dependent with all activities of daily living. During an observation…

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 for one of three sampled residents (Resident 250) who signed the Resident-Facility Arbitration Agreement (AA, a Binding Arbitration Agreement requires the person who signed it resolve any dispute by binding arbitration, rather than in court) on 1/1/2024 had the capacity to understand and make decisions. This failure had the potential risk to result in Resident 250 to not be able to make an informed decision and/or his rights to be denied. Findings: During a review of Resident 250's Face Sheet (FS), the FS indicated Resident 250 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows), psychosis (a mental disorder characterized by a disconnection from reality), and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 250's History and Physical (H&P) dated 5/20/2024, the H&P…

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 have a documented tracking process in place to ensure one of three sampled Certified Nursing Assistants (CNA 4) attended the required in-service trainings for nurse aides. This failure had the potential to result in CNA 4 to not receive the necessary training that could affect resident care and safety. Findings: During a review of the facility's Inservice Education Record (IER), dated 7/10/2024, the IER indicated, the subject for training was abuse prevention, types of abuse, and mandated abuse reporting. The IER indicated, CNA 4 did not attend the training. The IER indicated, the Director of Staff Development (DSD) provided the training. During an interview on 7/30/2024 at 4:04 pm with the DSD, the DSD stated the DSD provided the abuse in-service training on 7/10/2024. The DSD stated all staff needed to attend the regularly scheduled in-service trainings including abuse. The DSD stated the DSD did not know that CNA 4 had not attended the abuse training. The DSD stated the DSD did not have a system in place to check,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete the Situation Background Assessment Recommendation (SBAR- tool used to communicate important often critical information that required immediate attention and action) and notify the physician of a change in condition (change in physical, mental, or functional abilities) in accordance with the facility's Policy and Procedure (P&P) on Change in a Resident's Condition or Status for one of two sampled residents (Resident 1), when Resident 1 had two vomiting episodes on 6/12/24 and 6/13/24. This deficient practice resulted to Resident 1 to continue to have vomiting episodes with no treatment. Findings: During a review of Resident 1's Face Sheet (FS), the FS indicated the facility admitted Resident 1 on 8/27/19 and readmitted on [DATE], with diagnoses that included hepatic failure ( liver starts to shut down because it has been damaged and can't be repaired) and type 2 diabetes mellitus (a disease in which the body's ability to produce or respond 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 evaluate the competency (the capability to apply or use the knowledge, skills, and abilities required to successfully perform tasks in the work setting) of Registered Nurse Supervisor (RNS) 1, Licensed Vocational Nurse 1 (LVN) 1, LVN 6, Certified Nursing Assistant 1 (CNA) 1, CNA 2, and CNA 3 to prevent choking and to recognize when to provide cardiopulmonary resuscitation (CPR, emergency lifesaving procedure, consisting of chest compressions and mouth-to-mouth or mechanical breaths, performed when the heart stops beating or beats ineffectively and/or to restore breathing) when: 1. CNA 1 failed to follow Resident 1's care plan by leaving Resident 1 unsupervised and unmonitored during dinner. This deficient practice had the potential to affect the 17 other residents who were residing in the facility and needed monitoring and supervision during meals to be left with their meal trays unsupervised/unmonitored. 2. RNS 1, LVN 1, CNA 1, CNA 2, and CNA 3 failed…

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 protect one of eight sampled residents (Resident 3) from physical abuse (aggressive or violent behavior with the intention to cause physical harm) as indicated in the facility's policy and procedure (P&P) titled, Abuse, Neglect and Exploitation. As a result, on 4/24/2024 at 9 pm, Resident 4 threw a trash bin at Resident 3 (Resident 4's roommate) while Resident 3 was sleeping in Resident 3's bed. Resident 3 sustained corneal abrasion (scratch or cut on the white portion of the eye) and acute iritis (inflammation of the colored portion of the eye) to Resident 3's right eye. Resident 3 was transferred to General Acute Care Hospital (GACH) 1 on 4/25/2024 at 12:50 am for evaluation and treatment of injuries. Resident 3 received antibiotic (medication used to prevent and treat infections) eye ointment to be applied to both eyes every eight hours. Findings: a. During a review of Resident 3's Face Sheet (FS), the FS indicated, the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the clinical record for three of three sampled residents (Resident 1, Resident 5, and Resident 6) was complete and accurate when: 1. The names of staff who provided Heimlich Maneuver (HM, a first aid procedure for dislodging an obstruction from a person's windpipe in which a sudden strong pressure is applied on the abdomen, between the navel and the rib cage) and cardiopulmonary resuscitation (CPR, emergency lifesaving procedure, consisting of chest compressions and mouth-to-mouth or mechanical breaths, performed when the heart stops beating or beats ineffectively and/or to restore breathing) to Resident 1 on 4/19/2024 were documented on Resident 1's clinical record. 2. The name of staff who initially found Resident 5 unresponsive in the dining room, the time when Resident 5 was initially found unresponsive in the dining room, the time when Licensed Vocational Nurse 6 (LVN) 6 assessed Resident 5 in the dining room and found the resident…

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

Based on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee (responsible for identifying quality deficiencies [deviations in performance resulting in an actual or potential undesirable outcome, or an opportunity for improvement] throughout the facility, for developing and implementing corrective actions, for monitoring to ensure performance goals or targets are achieved, and for revising corrective actions when necessary) implemented the facility's Plan of Correction (POC, a plan developed by the facility and approved by the state survey agency that describes the actions the facility will take to correct deficiencies and specifies the date by which those deficiencies will be corrected) to prevent residents who were identified at risk for choking from choking. This failure had the potential for 16 residents identified at risk for choking to choke. Findings: During a review of the facility's POC signed by the Administrator (ADM) on 5/20/2024, the POC indicated the facility updated the list of residents who were identified 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one of five sampled residents (Resident 1) on 3/13/2024 when Resident 2 hit Resident 1 on the head. This failure resulted to a skin tear on Resident 1's left forehead and subjected Resident 1 to physical abuse by Resident 2 while under the care of the facility. Based on the reasonable person concept (hypothetical [suggested], average person's reaction to the actual circumstances of alleged illegal activities) due to Resident 1's moderately impaired cognition (ability to think and make decisions), an individual subjected to physical abuse would have suffered physical pain and psychological (mental or emotional) effects including feelings of fear, embarrassment, humiliation, and emotional distress. Findings: During a review of Resident 1'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 one out of three sampled residents (Resident 4) who were not able to perform activities of daily living receive the necessary services to maintain good personal hygiene. Resident 4 did not receive his shower as scheduled. This failure had the potential to result in resident with poor hygiene causing dermatitis, bacteria buildup on skin, lost sense of well-being and satisfaction with life. Findings: During a review of Resident 4's Face Sheet indicated Resident 4 was readmitted on [DATE] with diagnoses that included gastro-esophageal reflux disease (GERD, stomach acid repeatedly flows back into the tube connecting your mouth and stomach) and contracture of right and left elbow (a fixed tightening of muscle, tendons, ligaments, or skin. It prevents normal movement of the associated body part). During a review of Resident 4's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 7/25/2023, indicated Resident 4 had…

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 obtain an alternative source of power when doing work on the emergency generator ' s (a device that converts fuel-based power into electric power to power the facility) automatic transfer switch (ATS - electrical switch that switches power from the electrical power grid to emergency generator power). This deficient practice has the potential for the facility to not have alternative electrical power if the facility experiences a power outage while the generator is undergoing maintenance. Findings: During an interview on 8/10/2023, at 2:15 p.m., the Administrator stated that on 8/9/2023 the facility had started to do work on the ATS, and the Inspector on Record (IOR) had informed them that the work needed to be stopped as they did not have an alternate source of emergency power while the ATS is being worked on. The Administrator stated that the ATS was retested by the IOR after the work was stopped. During a concurrent observation and interview on 8/10/2023, at 4:21 p.m., with the Maintenance Supervisor (MS), in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record revied, the facility failed to ensure, for one of two sampled residents (Resident 1), Resident 1's Medical Doctor (Physician 1) was notified of Resident 1's skin problems on 4/13/2023, 4/15/2023, 4/18/2023, 4/26/2023, and 4/27/2023 as indicated in the facility's Policy and Procedure (P&P) titled, Change in a Resident's Condition or Status. This failure had the potential to result in a decline of Resident 1's physical well-being. Findings: During a review of Resident 1's Face Sheet (admission Record, AR) the AR indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The AR indicated Resident 1 had diagnoses that included dementia (progressive impaired ability to think, remember or make decisions that interfere with doing everyday activities), chronic (long standing) peripheral venous insufficiency (occurs when the walls and/or valves in the veins are not working effectively, making it difficult for blood to return to the heart), and…

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

Based on observation, interview, and record review, the facility failed to promote dignity and respect for two of two sampled residents (Residents 169 and 357): a. Certified Nursing Assistant 1 (CNA 1) stood over Resident 357 while assisting Resident 357 with eating his lunch. b. Certified Nursing Assistant 7 (CNA 7) stood over Resident 169 while assisting Resident 169 while feeding the resident. These deficient practices had the potential to negatively impact the resident's psychosocial well-being and/or make the resident feel rushed. Findings: a. A review of Resident 357's Face Sheet indicated, Resident 357 was admitted to facility on 5/13/23 with multiple diagnoses including encephalopathy (brain disease that alters brain function or structure), sequelae (complication or condition that results from an illness ) of nontraumatic intracerebral hemorrhage (bleeding inside the brain), and dysphagia (difficulty swallowing foods or liquids). A review of Resident 357's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/21/23, indicated Resident 357 had 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.

Based on observation, interview, and record review, the facility failed to post the Long-Term Care Ombudsman (LTC Ombudsman, representatives who assist residents in long-term care facilities with issues related to day-to day care, health, safety, and personal preferences) information in two of five nursing stations in the facility. This failure had the potential to prevent residents, including three of six residents attending the resident group meeting, from communicating their concerns and obtaining resources from the Long-Term Care Ombudsman. Findings: During a group interview on 6/7/23 at 10:26 AM, three of six alert, verbal, and oriented residents did not know where to find the contact information for the LTC Ombudsman in the facility. During a review of the undated facility map, the facility had three separate buildings. The largest building had three distinct nursing stations, namely Nursing Station 1 (NS 1), NS 2, and NS 3. The facility's secured unit (specific area with security and safety measures to prevent residents from leaving unsupervised) had NS 4 and NS 5 while 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 observation, interview, and record review, the facility failed to ensure the most recent State and Federal inspection results (survey binder) were posted in a manner that was clear and visible for the residents and their families, including six of six residents who attended the resident group meeting. This failure had the potential to prevent the residents' and their families' right to view survey inspection results. Findings: During a resident group meeting on 6/7/23 at 10:26 AM, six of six alert, verbal, and oriented residents stated they did not know where to find the latest State and Federal survey inspection results for the facility. During a review of the undated facility map, the facility had three separate buildings. The largest building had three distinct nursing stations, namely Nursing Station 1 (NS 1), NS 2, and NS 3. The facility's secured unit (specific area with security and safety measures to prevent residents from leaving unsupervised) had NS 4 and NS 5, while a smaller building was NS 6. During an observation on 6/7/23 at 11:03 AM of NS 1, at 11:08 AM 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 develop and/or implement the plan of care for four of four sampled residents (Residents 71, 557, 22 and 111), by failing to: a. For Resident 71, the facility failed to implement the resident's activities care plan. b. For Resident 557, the facility failed to implement the resident's activities care plan. These deficient practices resulted in Residents 71 and 557 not receiving activities as indicated in the care plan, inhibiting the residents' well-being, according to the facility's Policy and Procedures on Activity. c. For Resident 22, the facility failed to develop/ implement an individualized person-centered care plan for Resident 22 who had pitting edema (a type of swelling, often in the lower extremities, that causes enough fluid retention to leave a pit or indentation) on both lower extremities. This deficient practice had the potential to result in inconsistent implementation of care and and services for Resident 22. d. For Resident…

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 communication board and/or other functional communication system to five of nine non-English speaking sampled residents (Residents 71, 249, 259, 271 and 557), in accordance with the facility's Policy and Procedure on Communicating with Persons with limited English Proficiency. This deficient practice placed Residents 71, 249, 259, 271 and 557 at risk for miscommunication and delayed care. Findings: a. During a review of Resident 249's admission Record, the admission record indicated the resident was admitted to the facility on [DATE], with diagnoses that included gastro esophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube connecting the mouth and stomach) and major depressive disorder (persistently depressed mood or loss of interest in activities causing significant impairment in daily life). During a review of Resident 249's Minimum Data Set (MDS, a standardized assessment and care planning…

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 the resident activity preferences in accordance with activity assessment for five of nine sampled residents (Residents 71,182,188, 249 and 557). This deficient practice placed Residents 71,182, 188, 249, and 557 at risk for cognitive decline (a gradual loss of thinking abilities such as learning and remembering) and behavioral problem due to boredom (feeling disinterested in one's surroundings, having nothing to do, or feeling that life is dull). Findings: a. During a review of Resident 249's admission Record, the admission record indicated Resident 249 was admitted to the facility on [DATE], with diagnoses that included gastro esophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube connecting the mouth and stomach) and major depressive disorder (persistently depressed mood or loss of interest in activities causing significant impairment in daily life). During a review of Resident 249's Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the necessary care and services for four of four sampled residents (Residents 22, 122, 658 and 71) by failing to: a. Notify Resident 22's physician regarding the resident's edema (excess fluid in tissues of the body) on both legs. b. Follow Resident 122's physician's order to follow up with a specific hospital regarding the resident's eye treatment. c. Ensure the Registered Dietician (RD) consult for Resident 658's needs was acted upon in a timely manner to meet the resident's dietary needs. These deficient practices placed the residents at risk for delay of necessary medical treatments and care services to improve the resident's quality of life and/or nutritional status d. Ensure Resident 71 received an accurate and comprehensive assessment of Resident 71's body rash by qualified licensed staff. This deficient practice resulted in Resident 71 experiencing itchiness on her body without receiving proper care and treatment for a body rash,…

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 an environment free from accident hazard and adequate assistive device and supervision for two of four sampled residents (Resident 286 and Resident 240) by failing to: a. Implement Resident 286's plan of care to provide low bed and two-person physical assistance during turning and bed mobility (moving to either side in bed and moving from lying in bed to the edge of bed) to prevent further fall incidents. b. Monitor Resident 240 for left over cigarette before leaving the designated smoking area. These deficient practices placed Residents 286 and 240 at risk for accidents. Findings: a. During a review of Resident 286's admission Record, the record indicated the facility readmitted the resident on 2/15/23, with diagnoses that included contracture (a permanent shortening and tightening of the muscle that makes movement difficult) of the right and left knee and generalized muscle weakness. During a review of Resident 286's Minimum Data…

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 use appropriate alternatives prior to the use of bedrails for two of two sampled residents (Resident 286 and Resident 557.) These deficient practices had the potential for Residents 286 and 557 to sustain injuries due to the use of bedrails. Findings: a. During a review of Resident 286's admission Record, the admission Record indicated the facility readmitted Resident 286 on 2/15/2023, with diagnoses that included contractures (permanent shortening and tightening of the muscle that makes movement difficult) of the right and left knee, and generalized muscle weakness. During a review of Resident 286's Minimum Data Set (MDS- an assessment and care planning tool) dated 2/22/2023, the MDS indicated Resident 286 had severe cognitive deficit, the resident was totally dependent with transfers, dressing, eating, toilet use and personal hygiene. The MDS indicated Resident 286 required extensive assistance (resident involved in activity, staff…

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 account for one dose of controlled medication ([CM]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Resident 76 in one of six inspected medication carts (Medication Cart on the East Side of Station 3.) This deficient practice increased the opportunity for CM diversion (the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use,) placed Residents 76 at risk for receiving delayed medication treatment and continuity of care due to lack of availability of the CM, and had the potential to expose Resident 76 to harmful medications, possibly leading to physical and psychosocial harm. Findings: On 6/7/23 at 2:09 PM, during an observation and a concurrent interview with Licensed Vocational Nurse (LVN) 3, in Medication Cart on the East Side of Station 3, there was a discrepancy in the count between the Controlled Drug Record (inventory and accountability record for CM) form and the amount 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.

Based on observation, interview, and record review, the facility failed to review orders for accurate medication reconciliation (process of identifying most accurate list of all medications) and ensure that resident's drug regimen was free from unnecessary drugs (any drug in excess) for one of five sampled residents (Resident 282). Resident 282's duplicate medication orders remained as active drugs on the Medication Administration Record ([MAR]- a record of medications administered to a resident) since 6/1/23. This deficient practice had the potential to cause Residents 282 to receive suboptimal (less than the highest standard or quality) care, increase the risk of serious adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) and health complications, such as bleeding, likely resulting in hospitalization or death. Findings: Review of Resident 282's MAR for 5/23, indicated, by a handwritten markup, to discontinue apixaban (a medication used to reduce blood clots) 2.5 milligram ([mg] - a unit of measure of mass) tablet orally twice a day on 5/19/23,…

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 its medication error rate was less than five percent (%) due to six errors observed out of 25 total opportunities (error rate of 24%). The medication errors were as follows: a. Resident 264 received a dose of vitamin D3 (a medication used to help the body absorb calcium and build strong bones) that was different than the one ordered by Resident 264's physician. b. Resident 161 received five medications in a form that was not ordered by Resident 161's physician. These failures had the potential to result in Residents 264 and 161 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and had the potential to result in Residents 264's and 161's health and well-being to be negatively impacted. Findings: a. During an observation, on 6/7/23 at 9:13 AM, Licensed Vocational Nurse (LVN) 3 administered one tablet of vitamin D3 1000 international unit (IU, unit of measure of mass) to Resident 264. Resident 264 swallowed the one tablet whole with water.…

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 five licensed vocational nurses (LVNs) did not administer expired insulin (a medication used to treat high blood sugar) to one resident (Residents 208) in one of six inspected medication carts (Medication Cart [NAME] Side Station 3). This failure resulted in Residents 208 to receive a combined total of ten expired insulin doses from [DATE] to [DATE] and had the potential to result in Resident 208 to experience serious health complications, hospitalization, or death due to uncontrolled blood sugar (BS) levels. Findings: During a review of Resident 208's Face Sheet (admission record) indicated Resident 208 was originally admitted to the facility on [DATE] with diagnosis including type 2 diabetes mellitus (a disease characterized by an impairment of the body's ability to control blood sugar levels). During a review of Resident 208's Physician Orders, for [DATE], indicated Resident 208's physician prescribed Novolog (a brand name 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: a. Label one Haldol (medication used to treat disorders that cause difficulty in telling the difference between things or ideas that are real and not real) vial for Resident 100, with an open date and discard the vial after one use, in accordance with the manufacturer's requirements, in one of six inspected medication carts (Medication Cart East Cart Station 1). b. Remove and discard one expired insulin (medication used to regulate blood sugar levels) vial for Resident 208, in accordance with manufacturer's requirements, in one of six inspected medication carts (Medication Cart [NAME] Side Station 3.) c. Label one insulin vial for Residents 208, with an open date and correct dose, in accordance with the manufacturer's requirements and physician orders, in one of six inspected medication carts (Medication Cart [NAME] Side Station 3). These failures resulted in an increased risk for Residents 100 and 208 to have received medications 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.

Based on observation, interviews and record reviews, the facility failed to ensure staff were competent in safe and effective food handling practices when: a. [NAME] 1 did not follow safe thawing (process of frozen substance becoming soft) procedure for thawing chicken under running water. The raw chicken temperature registered at 68 degrees Fahrenheit (normal range <41 Fahrenheit). b. Dietary aide DA1 did not know the acceptable range for dishwasher sanitizer concentration. DA1 documented sanitizer concentration at 200 Parts Per Million (PPM- measurement of the mass of the active ingredient chemical per volume of water), and supervisor was not notified. Findings: a. During an observation on 6/6/23, at 9:37 AM, in the kitchen (lodge), there was chicken thawing in a bowl filled with water with running water continuously filling it. During a concurrent interview on 6/6/23 at 9:40 AM with the [NAME] 1, [NAME] 1 stated, the chicken has been out since before 8:00 AM, it was in the refrigerator, but it was not thawed completely so he removed and placed it under running water to thaw.…

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 safe and sanitary food storage and food preparation practices in the kitchen when: a. Raw breakfast sausage and bacon were stored next to ready-to-eat ham and turkey, and the breakfast sausage and bacon did not have thaw (process of frozen substance becoming soft) dates. b. Expired burritos were stored in the refrigerator. c. Chicken was thawing in the sink under running water that is 73 degrees Fahrenheit (F) and the chicken temperature was over 41 degrees F (actual temperature of 68 degrees F) from 8:00AM until 10:40AM on 6/6/23. d. The food refrigerator for residents with outside foods in Unit Station 3 had freezer ice buildup, stored ice cream with did not have a label, and one ice cream belonged to a resident who had already been discharged . e. The ice machine in Building A, located in the dining room was not cleaned and had some slimy pink and black color residue in the corner and under the baffle. These failures had the potential to result in harmful bacteria growth and cross contamination…

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 therapy services, including Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]), Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function), and Speech Therapy (ST or SLP, profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) to one of eight sampled residents (Resident 357) who had range of motion (ROM, full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns. For Resident 357, who was independent with mobility (ability to move freely) and activities of daily living (ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility) prior to admission to the General Acute Care Hospital (GACH), the facility failed to: a. Provide Resident 357…

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 accuracy of medical records and altered restorative nursing aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) records for one of one sampled resident (Resident 286) who had range of motion (ROM, full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns. For Resident 286, who received RNA services for ROM exercises and was on a feeding program, the facility initialed multiple RNA sessions as completed for 10/2022, 11/2022, and 12/2022 on 6/8/23 (six to eight months later). This deficient practice resulted with inaccurate medical records for the provision of RNA services to Resident 286 and had the potential to result in inaccurate assessments and treatment plans and a decline in Resident 286's physical well-being. Findings: During a review of Resident 286's Face Sheet (admission record) indicated the facility admitted Resident 286 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, and record review, the facility failed establish and maintain an infection control program, by failing to: a. Ensure two urinals in Resident 171's bathroom were labeled. b. Ensure facility staff perform hand hygiene after handling Resident 22's bed sheets/blankets and prior to pushing Resident 142's wheelchair. c. Ensure staff perform hand hygiene after replacing Resident 181's soiled mask d. Ensure to contain five large containers filled with soiled linen in the laundry room. e. Ensure not to use a cloth gait belt with Resident 271 and properly sanitize the cloth gait belt. f. Ensure Resident 263's foley catheter (F/C-flexible tube inserted into the bladder to drain urine) privacy bag and the F/C tubing were not touching the floor These deficient practices had the potential to result in cross contamination and spread of infection in the facility. Findings: a. During a review of Resident 171's admission Record (Face Sheet), the record indicated Resident 171 was admitted to the…

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

Based on observation, interview, and record review, the facility failed to ensure the call light (a device used by a resident to signal need for assistance from staff) was within reach for one of four sampled residents (Resident 357). Resident 357's call light cord was hanging off the bed, out of reach of Resident 357. This deficient practice had the potential for the delay in meeting Resident 357's needs to get assistance. Findings: A review of Resident 357's Face Sheet indicated, Resident 357 was admitted to facility on 5/13/23 with multiple diagnoses including encephalopathy (brain disease that alters brain function or structure), sequelae (complication or condition that results from an illness) of nontraumatic intracerebral hemorrhage (bleeding inside the brain), and dysphagia (difficulty swallowing foods or liquids). A review of Resident 357's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/21/23, indicated the resident had no impairment in cognitive skills (ability to make daily decisions). Resident 357 required extensive assistance (resident…

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 one sampled resident (Resident 22) was assessed for edema (swelling caused by fluid retention). Resident 22 was observed with edema to the left and right lower legs. This deficient practice had the potential for Resident 22 not to receive individualized care to meet the resident's medical needs in a timely manner. Findings: During a review of Resident 22's Face Sheet (an admission record), the face sheet indicated Resident 22 was readmitted to the facility on [DATE] with diagnosis that included hypertensive (elevated blood pressure) heart disease and acute kidney disease (kidneys suddenly can't filter waste from the blood). During a review of Resident 22's admission Body Assessment, ([NAME]) dated 3/1/23, the [NAME] did not indicate Resident 22 had edema on either left or right leg. During a review of Resident 22's Minimum Data Set (MDS, an assessment and care-screening tool) dated 3/8/23, the MDS indicated Resident 22 had clear speech,…

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 accurately assess functional limitation (limited ability to move a joint that interferes with daily functioning) in range of motion [ROM, full movement potential of a joint (where two bones meet)] of both legs for one of 39 sampled residents (Resident 357). This failure had the potential to affect the provision of care to Resident 357 and provided inaccurate information to the Federal database. Findings: During a review of Resident 357's Face Sheet (admission record), the Face Sheet indicated the facility admitted Resident 357 on 5/13/23 with diagnoses including nontraumatic intracerebral hemorrhage (ICH, bleeding in brain tissue), dysphagia (difficulty swallowing) and attention to gastrostomy tube (G-tube, tube placed directly into the stomach for long-term feeding). During a review of Resident 357's History and Physical (H&P), dated 5/13/23, the H&P indicated Resident 357 was admitted to the facility from the General Acute Care Hospital (GACH) for continued skilled nursing care. Resident 357's H&P indicated Resident 357…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the state mental health authority for one of three sampled resident (Resident 150) who required Preadmission Screening and Resident Review (PASRR, a comprehensive assessment evaluation by the appropriate state-designed authority that determines the appropriate setting for individuals and recommends any specialized services and/or rehabilitative services the individual needs) Level II (a screening to determine whether placement or continued stay in a Nursing Facility is appropriate) as indicated in the facility's policy on Resident Assessment - Coordination with PASARR Program. This deficient practice had the potential for Resident 150 to not receive the necessary care and services needed in the appropriate setting. Findings: During a review of Resident 150 Face Sheet (admission data), indicated Resident 150 was re-admitted to the facility on [DATE] with diagnoses that included schizophrenia (mental disorder characterized by abnormal social…

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 dialysis (treatment for kidney failure that removes unwanted toxins, waste products and excess fluids by filtering the blood) emergency kit was available at the bedside for one of three sampled residents (Resident 658). This deficient practice had the potential to result in the risk of prolonged bleeding and prevent emergency care and treatment to the dialysis access (a way to reach the blood for dialysis) site when needed. Findings: During a review of Resident 658's admission Record (Face Sheet), the record indicated the resident was admitted to the facility on [DATE] with diagnoses that included urinary tract infection (an infection in any part of the urinary system), End Stage Renal Disease (condition in which kidneys cease to function), and dependence on renal dialysis. During an observation on 6/6/23 at 12:05 PM at Resident 658's room, there was no emergency dialysis kit found at the bedside for Resident 658. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to monitor and document the side effects (unwanted effects of medication) of psychotropic medications (medications that affects brain actives associated with mental processes and behavior) for two of seven sampled resident (Residents 188 and 238) according to the facility's policy and procedure: a. For Resident 238, who is taking psychotropic medication, nursing staff did not accurately monitor and record Resident 238's hand tremors (involuntary shaking or movement) which a side effect (an effect that is unintended) of psychotropic medications. b. For Resident 188, who is taking psychotropic medication, nursing staff did not accurately monitor and record Resident 188's hours of sleep which is a side effect of psychotropic medications. These deficient practices had the potential for Residents 188 and 238 to experience adverse side effects without adequate assessment and monitoring. Findings: A review of Resident 238's Face Sheet indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a dental recommendation follow up was done, for one of two sampled residents (Resident 116). This failure resulted in Resident 116 to not receive necessary dental services and had the potential to result in an infection and a decline in Resident 116's physical health. Findings: During a review of Resident 116's admission Record (Face Sheet) indicated Resident 116 was readmitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease (buildup of fat and substances in/on artery walls), acute kidney failure (kidneys suddenly can't filter waste from the blood), and major depressive disorder (persistent feeling of sadness and loss of interest). During a review of Resident 116's History and Physical (H&P) dated 2/14/23, the H&P indicated, Resident 116 was alert and able to make needs known. During a review of Resident 116's Minimum Data Set (MDS, a standardized assessment and care planning tool), 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 interviews and record review, the facility failed to ensure a comprehensive oversight (supervision) of the Food and Nutrition Services by the Registered Dietitian (RD-food and nutrition experts who can translate the science of nutrition into practical solutions for healthy living) for two (Residents 111 & 658) of three sampled residents, to ensure consults were followed, new admits were assessed, and annual assessments were completed, as evidenced by: a. Resident 111 was not assessed or followed up by a Registered Dietitian since October 2022 b. Resident 658 was not assessed by the Registered Dietitian since being readmitted to the facility on [DATE] with a tube feeding (creation of an artificial external opening into the stomach for nutritional support) and with no order for weekly weights This oversight failure was evident when there was a lack of timely nutrition assessments and follow up notes. This deficient practice had the potential to cause deterioration in nutrition and hydration status 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 interview and record review, the facility failed to ensure one of three sampled residents (Resident 182), or Resident 182's representatives were informed of the binding arbitration agreement (a private process where disputing parties agree that one or several other individuals can decide about the dispute) rights. Resident 182's agreement was signed by the Interdisciplinary Team (IDT, a group of professionals and direct care staff employed by the facility) and not by Resident 182 or Resident 182's representatives. This failure resulted in Resident 182 and Resident 182's representatives to not be informed about their right to make informed decisions and make important choices regarding aspects of the binding arbitration agreement. Findings: During a review of Resident 183's Face Sheet (FS, admission record) indicated Resident 182 was admitted to the facility on [DATE] with diagnoses that included depression (feelings of sadness and/or a loss of interest in activities once enjoyed) and paranoid…

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 post a No Smoking sign in front of one of one sampled resident room (Resident 73's room), as indicated in the policy and procedure (P&P) titled, Resident Smoking Policy. Resident 73 was observed using oxygen in the room. This failure had the potential to result in a fire in Resident 73's room and result in harm and injury to the residents and the facility staff. Findings: During a review of Resident 73's Face Sheet (admission record), indicated, Resident 73 was readmitted to the facility on [DATE] with diagnoses that included acute respiratory failure (too little oxygen passes from your lungs and to your blood) and hypoxemia (not enough oxygen in the body). During a review of Resident 73's Physicians Orders (PO), dated 5/31/23, the PO indicated for oxygen two-litters to be administered by nasal cannula ([NC] a device consisting of lightweight tubing used to deliver supplemental oxygen) to keep oxygen levels above 88 % (percent). 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.