Parkway Hills Nursing & Rehabilitation

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 10.71% when three medication errors occurred out of 28 opportunities during the medication administration for one of seven randomly observed residents (Resident 26). This failure had the potential for Resident 26 not to get the full therapeutic benefit of his medications or to experience negative health outcomes. Findings:During a medication administration observation on 9/21/25 at 9:03 A.M., Licensed Nurse (LN) 1 was observed preparing and administering eleven medications for Resident 26. LN 1 stated Resident 26 received his medications crushed and mixed with applesauce. LN 1 crushed all of Resident 26's tablets individually and mixed each one with applesauce in separate medicine cups, including the following tablet: methadone (a strong painkiller) oral tablet 5 milligrams (mg, unit of measurement) - give 1 tablet by mouth every 8 hours for pain management, dated 9/14/25.LN 1 opened all of Resident 26's…

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

Based on observation, interview, and record review, the facility failed to ensure a medication was stored under proper temperature controls in one of one Medication Rooms. This failure had the potential to negatively alter the drug's stability, physical properties (such as consistency) and effectiveness, which could result in adverse resident outcomes.Findings:During a concurrent observation and interview on 9/21/25, 10:05 A.M., an inspection of the Medication Room was conducted with Licensed Nurse (LN) 17. A tube of erythromycin (an antibiotic) ophthalmic (for the eye) ointment for Resident 29 was found in the medication refrigerator, which was 37 F (degrees Fahrenheit, a measurement of temperature). The drug manufacturer's labeling on the medication instructed, store between.59 F to 77 F . LN 17 confirmed the manufacturer's labeling and stated, it would have to be stored outside. During an interview with the Director of Nursing (DON) on 9/22/25 at 1:44 P.M., the DON stated medications have to be stored how [the drug manufacturer] says. The DON stated it was important to follow 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 resident food brought into the facility from outside sources was stored appropriately, and procedures were in place for safe reheating of foods.This failure had the potential to result in pest control concerns, as well as foodborne illnesses.Findings:An observation and interview was conducted on 9/21/25 at 9 A.M. with Resident 24. Resident 24 was sitting in a wheelchair next to her bed. The bedside table was covered with large bags of candy, cookies and other opened food items. A blanket was folded at the foot of the bed, and on top of the blanket was a bunch of ripe bananas and a small brown bag from a fast food restaurant. None of the foods were in plastic bags, and none had labels attached with dates or the resident name and room number. Resident 24 stated the food from the kitchen was sometimes cold, so she had friends and family bring her food from outside to keep in her room. Resident 24 stated the facility had not offered her bins or containers to store her food items. An observation 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 interview and record review, the facility failed to maintain accurately documented records when the wrong blood pressure (BP) reading was recorded on the Medication Administration Record (MAR, an official legal document that has a complete and accurate record of all medications administered to a resident to ensure patient safety) of one out of five sampled residents (Resident 9). This failure resulted in inaccurate documentation in Resident 9's medical records.Findings:During a concurrent interview and record review with Licensed Nurse (LN) 16 on 9/24/25 at 10:53 A.M., a review of Resident 9's clinical records was conducted. Resident 9's clinical records indicated she had active orders for medications, including the following: losartan (a medication for high blood pressure) 25 milligrams (mg, unit of measurement for dose) - give one tablet by mouth one time a day for HTN (hypertension, high blood pressure). Hold if SBP (systolic blood pressure, the top number in a blood pressure reading) less than 110, started 10/1/24, and metoprolol (a medication for high blood pressure)…

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

Based on observation, interview and record review, the facility failed to implement proper infection control practices in one of 15 sampled residents (Resident 26). This occurred when Certified Nursing Assistant (CNA) 1 and CNA 2 did not wear proper personal protective equipment (PPE, clothing or equipment, such as gowns, gloves and masks, designed to prevent the spread of infections) while caring for Resident 26, who was on enhanced barrier precautions (EBP, infection control practices designed to prevent the spread of multidrug resistant organisms [MDROs, germs that cannot be killed or inactivated by medications] in nursing homes). This failure had the potential to put residents, staff, and visitors at risk for infections due to cross-contamination.Findings:During a medication administration observation on 9/21/25 at 9:28 A.M., immediately outside Resident 26's room, Licensed Nurse (LN) 1 stated Certified Nursing Assistants (CNAs) were changing Resident 26. LN 1 stated she would give Resident 26 medications after the CNAs were done providing him with care. A sign was observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe and homelike environment for residents residing in the facility when: 1. Hallway floors were taped and with missing floorings, 2. A handrail was observed loose and wobbly. This failure had the potential for residents to trip, fall and sustain injury. Findings: 1. During the initial tour of the facility on 8/20/24 at 8:26 A.M., the hallway floors were observed to have gray duct tape (tape used for general sealing, patching holes, and repairs) to secure the flooring. Multiple duct tapes extended from the flooring in the front nursing station to both hallways of the facility. One hallway had missing flooring in front of room [ROOM NUMBER] which created an uneven surface. a. Resident 30 was admitted to the facility on [DATE] with diagnoses including muscle weakness according to the facility's admission Record. On 8/21/24 at 9:52 A.M. Resident 30 was observed walking into room [ROOM NUMBER] using a cane. During an interview on…

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

Based on interview and record review the facility failed to staff a Registered Nurse (RN) for at least 8 hours a day for 18 days from January 1, 2024 through March 31 of 2024. This failure had the potential for residents and staff to receive inadequate supervision and for residents to not receive an appropriate quality of care. Findings: Review of PBJ Staffing Data Report, CASPER Report 1705 (a report that can helped Skilled Nursing Facilities identify areas for improvement in care and operations) for January 1st through March 31, 2024 indicated ,No RN (Registered Nurse) hours was triggered for 19 days. On 8/23/24 at 9:15 A.M., a concurrent interview with the Staffing Coordinator (SC) and record review of staffing log for January 1st through March 31, 2024 was conducted. SC stated her records indicated the following days did not have an RN scheduled for at 8 least hours: January 1, 6, 7, 8, 20, 28 February 2, 3, 9 10, 11, 24, 25 March 2, 3, 9,10,17 SC stated that staffing numbers for Licensed Nurses (LN) and Certified Nursing Assistants (CNAs) were within limit those days, but they…

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, interviews, and record review, the facility failed to prevent medication errors of less than 5% for three of eight sampled residents (Resident 37, Resident 31, and Resident 33) during medication pass observation with three licensed nurses (LN 1, LN 2 and LN 3) when: 1. LN 1 administered medications to Resident 37's gastronomy tube (G-tube: a surgical opening on the abdomen for nutritional and/or medication administration) omitting one medication to be administered and the full dose of medications administered (eight medication errors) . 2. LN 2 did not administer Resident 31's morning medications (9:00 A.M.) as scheduled for more than three hours (nine medication errors). 3. LN 3 did not administer Resident 33's Januvia (oral medication that lowers blood sugar) as scheduled due to medication not available in medication cart (one medication error). As a result, there were 18 medication errors and 36 total opportunities during a medication pass observation. The facility's medication error…

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 eight sampled residents (Resident 37, Resident 31, and Resident 33) were free from significant medication errors when: 1. LN 1 administered medications to Resident 37's gastronomy tube (G-tube: a surgical opening on the abdomen for nutritional and/or medication administration) omitting one medication to be administered and the full dose of medications administered. 2. LN 2 did not administer Resident 31's morning medications (9:00 A.M.) as scheduled for more than 3 hours. 3. LN 3 did not administer Resident 33's Januvia (oral medication that lowers blood sugar) as scheduled due to medication not available in medication cart. As a result, Resident 37, Resident 31 and Resident 33 had the potential for serious health complications to cause discomfort and/or jeopardizes his or her health and safety. Cross Reference 759 Findings: 1. A review of Resident 37's admission record indicated Resident 37 was re-admitted to 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.

Based on observation, interview, and record review the facility failed to ensure kitchen staff (dishwashers) had the competency to use, operate, document and check the water temperatures of two low temperature dishwashers. This failure increased the risk of food borne illness being transmitted via dirty dishware. On 8/21/24 at 8 A.M., a concurrent observation of low temperature dishwasher, interview with Dishwasher (DW) 11, and record review of Dish Machine Temperature Log was conducted. DW 11 stated that the process for washing the dishes was to spray the dishes in sink to rinse off food, place the dishes in the rack in the machine, turn on the machine to do it's rinse, then do a check for chlorine after the rinse cycle. DW 11 was observed taking chlorine sample at water exit site from the machine, not directly on dishes that had just been rinsed. DW 11 was unsure where to take temperature reading for the log. DW 11 pointed to the chlorine test strip when asked about the temperature. Review of Dish Machine Temperature Log with DW 11 indicated the temperature was logged at 120…

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

Based on observation, interview and record review, the facility failed to ensure food served to all residents was in a palatable, flavorful manner that maintained the nutritional value of the menu items served. This failure had the potential to decrease residents' meal intake and contribute to weight loss. The facility census was 55. Findings: During a dining observation and interviews with residents on 8/20/24 from 9:00 A.M. to 12:45 P.M., residents' food concerns included: .Cooks can't cook grilled cheese sandwich . .Macaroni and cheese were dry . Sometimes food can be cold . .Meat is bland, noodles come with no sauce, too many carrots . .I always get broccoli. I won't eat that . . Food is cold, had no taste . .Food had no taste; meat was hard to cut . .Food was gritty, not good . .I'm a Vegetarian and they keep giving me fish . .I get food for lunch that is salty, and I'm a on renal diet .it's unhealthy . .I always get chicken or ham sandwich for my lunch sack, but would prefer peanut butter and jelly sandwich . .Food was overcooked, oversalted, water-down soups, and not enough…

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

Based on observation, interview, and record review the facility failed to ensure: 1. Soy sauce and teriyaki glaze were stored per manufacturer's recommendation, 2. The low temperature dishwasher reached appropriate rinsing temperature for sanitization of dishware. These failures increased the chances of residents getting foodborne illness. Findings: 1. On 8/20/24 at 8:14 A.M., an observation of the kitchen storeroom and interview with Dietary Manager (DM) was conducted during the initial tour. Opened containers of soy sauce and teriyaki glaze were observed on a shelf in dry storeroom. Soy sauce was dated 8/6/24 and teriyaki glaze was dated 8/4/24. Review of manufacturer's recommendations on container labels indicated REFRIGERATE AFTER OPENING. DM stated that she was unaware that soy sauce and other soy based sauces needed to be refrigerated. DM disposed of sauces in the garbage. On 8/23/24 at 7:50 A.M., an interview with DM was conducted. DM stated that expectation was that her staff would read the food labels and follow the directions for storage on labels. DM stated the importance…

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, interviews, and record review, the facility failed to accurately code the Minimum Data Set (MDS: a nursing assessment tool) for one of five residents (Resident 31) reviewed for vaccination status. As a result, the facility sent Resident 31's MDS to the federal database with inaccurate vaccination status. Cross Reference F883 Findings: 1. A review of Resident 31's admission Record indicated Resident 31 was re-admitted to the facility on [DATE] with diagnoses which included a history of congestive heart failure (is a long-term condition that occurs when the heart is not able pump enough blood to meet the body's needs. This can happen when the heart is too weak or stiff to pump properly, or if it can't fill up with enough blood. As a result, blood backs up in the heart, or becomes congested). A record review of Resident 31's MDS dated [DATE], indicated a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points…

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 update a resident centered care plan for one resident (Resident 6) with a continuous positive airway pressure (CPAP - a machine that delivers mild air pressure through the nose to keep breathing airways open while asleep) machine reviewed for care plans. This deficient practice had the potential for Resident 6 to not receive a resident centered and appropriate care and treatment. Findings: Resident 6 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea (OSA- a problem in which breathing pauses during sleep due to blocked airways) according to the facility's admission Record. During an observation on 8/21/24 at 8:56 A.M. Resident 6 was in bed with a red hat covering her eyes. Resident 6 did not respond when greeted. A CPAP machine was observed on top of a plastic container with 2 drawers on the right side of the bed. The mask for the CPAP machine was on top of Resident 6's bed. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 2 of 9 residents (Resident 43 and Resident 30) reviewed for activities of daily living (ADL-basic tasks of everyday life) received assistance with nail care. This deficient practice had the potential to affect the residents' dignity, cause infection from the debris under the fingernails and cause injury from having long, jagged fingernails. Findings: 1. Review of Resident 43's admission record indicated Resident 43 was admitted on [DATE] with diagnoses which include Hemiplegia (Loss of strength in the arm, leg, and sometimes face on one side of the body) and Hemiparesis (one-sided muscle weakness). Review of Minimum Data Set (MDS-A standardized assessment tool used to evaluate the health status of residents in Medicare and Medicaid certified nursing homes) Section C-Cognitive Patterns dated June 20,2024 indicated a Brief Interview for Mental Status (BIMs-a test that assesses a patient's orientation, learning, and memory) score of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a physician's order for the settings of a continuous positive airway pressure (CPAP-a machine that delivers mild air pressure through the nose to keep breathing airways open while asleep) was ordered for one (Resident 6) of three residents reviewed for respiratory care. This deficient practice had the potential for Resident 6 to receive inappropriate care and treatment which could lead to a decline in Resident 6's respiratory status. Findings: Resident 6 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea (OSA- a problem in which breathing pauses during sleep due to blocked airways) according to the facility's admission Record. During an observation on 8/21/24 at 8:56 A.M. Resident 6 was in bed with a red hat covering her eyes. Resident 6 did not respond when greeted. A CPAP machine was observed on top of a plastic container with 2 drawers on the right side of the bed. The mask for the CPAP…

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 resident medications (Resident 1) were secured and locked during a medication storage inspection. This failure had the potential for medication misuse, divergence (another person taking medications or medications used wrongfully), and unauthorized person to have access to the medications. Findings: A review of Resident 1's admission Record indicated Resident 1 was re-admitted to the facility on [DATE] with diagnoses which included a history of epilepsy (also known as seizures - uncontrolled jerking, blank stares, loss of consciousness). A record review of Resident 1's Minimum Data Set (MDS- a nursing assessment tool that is used to develop a plan of care) dated 7/3/24, indicated a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven day period) score of 11 out of 15 possible points which indicated Resident 1 had moderate cognitive (pertaining to memory, judgement 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 implement and maintain infection control procedures for three (Resident 27, Resident 34 and Resident 6) of 17 residents reviewed for infection control when: 1. Oxygen tubing was not changed weekly for two residents (Resident 27 & 34) per policy and procedure . 2. CPAP mask for Resident 6 was not stored properly. These deficient practices had the potential for residents to transmit infectious microorganisms and increase the risk of infection for residents and staff. Findings: 1. a. Review of Resident 27's admission Record indicated that Resident 27 was admitted on [DATE] for diagnoses which included Chronic Respiratory Failure (a long-term condition that makes it difficult to breathe and exchange oxygen and carbon dioxide in the body), Chronic Obstructive Pulmonary Disease (COPD-a group of lung diseases that damage the airways and other parts of the lungs, making it difficult to breathe), and Congestive Heart Failure (a long-term condition…

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 offer and/or administer an updated pneumococcal vaccine for two of five residents (Resident 31 and Resident 37) reviewed for immunization. These failures increased the risk to compromise the health and well-being of Resident 31 and Resident 37 with respiratory infections and other complications associated with pneumonia (a respiratory infection caused by bacteria, virus or fungi that causes the lungs to be inflamed making it hard for oxygen to circulate in the blood stream that can cause discomfort and difficult to breath). Cross Reference F641 Findings: 1. A review of Resident 31's admission Record indicated Resident 31 was re-admitted to the facility on [DATE] with diagnoses which included a history of congestive heart failure ( a long-term condition that occurs when the heart is not able pump enough blood to meet the body's needs). A record review of Resident 31's Minimum Data Set (MDS- a nursing assessment tool that is used to develop…

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 and interview, the facility failed to equip resident rooms with curtains to ensure complete visual privacy for one of two sampled residents (1). As a result, there was the risk of facility residents observing Resident 1 while she received personal care. Findings: Per the facility's admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include, heart failure, need for assistance with personal care, functional quadriplegia (inability to move the arms or legs). On 7/25/24 at 10:31 A.M., an observation and interview was conducted with Resident 1. There was a privacy curtain for Resident 1's bed that other residents would have had to enter in order to access the room's shared bathroom. The privacy curtain for Resident 1's bed, did not separate the walkway to the bathroom door from Resident 1's bed. Resident 1 stated, she did not have any privacy at the facility. Resident 1 further stated, if her roommate needed to use the bathroom while Resident 1 was receiving…

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 neuro checks (used to assess an individual's neurological functions and level of consciousness) was completed after a resident ' s (Resident 1) fall for one of three sampled residents. This failure had the potential to place Resident 1's health at risk. Findings: On 1/2/24, an unannounced onsite at the facility was conducted related to a complaint on quality of care. During a review of the facility's admission Record, dated 6/23/21, the admission Record, indicated, Resident 1 was admitted to the facility, with diagnoses which included dyskinesia (uncontrolled, involuntary movement). During a review of Resident 1 ' s minimum data set (MDS, an assessment tool), dated 6/30/21, indicated Resident 1's brief interview for mental status (BIMS, ability to recall) score was 14, which meant Resident 1's cognition was intact. During a review of Resident 1 ' s acute care hospital (ACH) record dated 8/19/21 at 6:59 A.M., the Emergency Department Physician documented Resident 1 had bruises on her head and scrapes to right…

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 a breathing treatment as ordered for two of two sampled residents (1, 2). As a result, the residents had a risk of decreased lung function. Findings: 1 Per the facility's admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include Chronic Respiratory Failure (difficulty breathing). Per the facility's Pulmonary Orders treatment log, dated 12/22/23, there was an order for staff to complete the incentive spirometer (a device to improve the ability to breathe) with Resident 1 four times per day. From 12/1 through 12/22/23 there were 85 opportunities to sign that the task was completed, and nine of the opportunities were left unsigned. 2 Per the facility's admission record, Resident 2 was admitted to the facility on [DATE] with diagnoses to include heart failure. Per the facility's Pulmonary Orders treatment log, dated 12/22/23, there was an order for staff to complete the incentive spirometer (a device to improve…

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 registered nurse (RN) on duty for eight hours per day on 21 of 31 sampled days. As a result, there was a risk of decreased quality of care and facility and resident oversight. Findings: On 12/22/23 at 11:23 A.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated, their facility had an RN work on some days, but not every day. On 1/2/24 at 11:30 A.M., a telephone interview and record review was conducted with the Director of Staff Development (DSD) of the License Nurses Monthly Schedule for December 2023. The DSD stated, they had three RNs who worked at the facility, who were scheduled to work on a total of 10 of 31 days in the month of December. On 1/5/24 at 10 A.M., a telephone interview was conducted with the Administrator. The administrator stated, they should have had an RN scheduled for at least eight hours per day, but they were not able to schedule one every day in December.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain a safe and home-like environment when; A. Ten of 54 resident rooms (Rooms 5, 6A, 6B, 16, 17, 18, 20, 27, 28A, and 28B) had power strips that were not UL (Underwriters Laboratories, nationally recognized standards for safety) certified and had multiple electrical cords plugged into power strips that were not fastened to the wall or floor, B. Six of 24 resident rooms had a broken window ( Rooms 14, 16, 21, 24, 25, and 26). C. Six of 24 rooms had temperature levels that were not within a comfortable range (Rooms 12, 14, 16, 25, 26, and 27). D. One resident (36) had a space heater that was not UL certified, and E. The facility did not have a permanent generator. These failures to ensure a safe, comfortable and homelike environment may result in power outage, fire or hypothermia (A potentially dangerous drop in body temperature). Findings: A. On 12/15/21 at 8:30 A.M., a concurrent observation and interview was conducted with the MD…

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

Based on observation, interview, and record review, the facility failed to identify and consistently maintain a QAPI plan when: A. Current Infection control practice standards were not followed during medication administration and staff screening for COVID-19 (a highly contagious respiratory disease that could affect the entire body); B. Resident room windows were broken and not repaired, non certified for safe use power extension cords were used, and facility generator did not function during power outage; C. Facility staffing coverage not monitored and; D. Two emergency medication kits were not properly secured and accounted for. This failure had the potential to affect the safety, quality of life and care of all the residents in the facility. See F880, F584, F725, and F761. Findings: On 12/21/21 at 7:45 A.M., an interview was conducted with the SSD. The SSD stated she was not aware of any QAPI projects in the facility. The SSD stated, I was handed a paper yesterday indicating I was the project lead for anti-psychotic medication. On 12/21/21 at 8:19 A.M., an interview was…

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

Based on observation, interview and record review, the facility did not maintain proper infection control practices based on current standards when: A. Two staff members (CNA 11, CNA12) did not screen for COVID-19 prior to clocking in for work; B. Staff did not properly sanitize medical equipment and did not perform hand hygiene between residents during medication administration (LN 19, LN 41, LN 44). These failures to ensure proper infection control practices based on current standards had the potential to spread infection in the facility. Findings: A. Upon entering the front entrance of the facility on 12/14/2021 at 8:47 A.M., instructions were given by facility staff to check temperature and answer screening questions on an electronic tablet. On 12/15/2021 at 7:20 A.M., two staff members were observed entering a side gate of the facility from the parking lot, instead of the front entrance. On 12/16/2021 at 8:30 A.M., an interview was conducted with the ICP. The ICP stated all staff members are required to screen for COVID-19 at the front entrance of the facility prior to clocking…

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 six medication consents that required a physician's signature were signed for one of five sampled residents (16). As a result Resident 16 received medication without proper education. Findings: Resident 16 was admitted to the facility on [DATE] with diagnoses including Dementia (memory loss) and psychosis (a mental disorder characterized by a disconnection from reality) per facility's admission Record. Resident 16's clinical record titled, informed consents for Anxiolytic (medication to reduce anxiety); Hypnotic (medication for sleep); Antipsychotics (medication to treat mental disorder); Antidepressant (medication to treat mood disorder), all dated 9/14/21, was conducted. All the consents for Resident 16 did not have a physician's signature. On 12/17/21 at 4:23 P.M., a concurrent interview and record review of Resident 16's informed consent with LN 20 was conducted. LN 20 acknowledged Resident 16's medication consents, dated 9/14/21, did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to clarify a Physician's Order for Life Sustaining Treatment (POLST) for one of two sampled residents (19). This failure had the potential for residents to receive inaccurate life sustaining measures during an emergency. Findings: Resident 19 was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease (progressive disease that causes kidney damage) and malignant neoplasm of colon (progressively worsening cancer) per the facility's admission Record. A record review of Resident 19's history and physical notes was conducted. Per the physician's history and physical notes dated 9/28/21, Resident 19 had the capacity to understand and make decisions. Resident 19's clinical record had two POLST forms, both dated 9/28/21. One form was signed by Resident 19, and the other form was signed by a person with an unreadable relationship to the resident. On 12/14/21 at 3:02 P.M. a joint interview and record review with LN 41…

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 clarify with the physician the use of physical restraint (any device that the individual cannot remove easily which restricts freedom of a person's bodily movement) for one of one sampled resident (23). As a result, Resident 23 complained of hand and shoulder pain. Findings: Resident 23 was admitted to the facility on [DATE] with diagnoses which included muscle weakness, cognitive (thinking) communication deficit, and hemiplegia and hemiparesis (one side of the body paralyzed) per the facility's admission Record. During the initial tour of the facility on 12/14/21, Resident 23 was heard screaming, Help, help, somebody please. Resident 23 was observed laying on her bed with her right arm raised. Resident 23's right hand was observed to have a white colored mitten. Resident 23 stated she had the mitten for, Five months, I'm not sure why they put it on me. Resident 23 stated she could only move her right arm and staff fed her 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 reevaluate the use of a hand mitten physical restraint (any device that the individual cannot remove easily which restricts freedom of a person's bodily movement) for one of one sampled resident (23). Failure to reassess the need of a physical restraint have the potential for residents to be placed for injury and affect their quality of life. Findings: Resident 23 was admitted to the facility on [DATE] with diagnoses which included muscle weakness, cognitive (thinking) communication deficit, and hemiplegia and hemiparesis (one side of the body paralyzed) per the facility's admission Record. Resident 23's clinical record was reviewed. Per the Nurse Practitioner's order dated 3/20/2020 at 17:48 (5:48 P.M.), Mittens/socks on both hands . Per the facility's care plan dated 3/20/2020, [Resident 23] have behavioral problem and the care plan had no time frame for the hand mitten use under the section, Interventions. Resident 23's Treatment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a resident centered care plan for antipsychotic medications (medication to treat mental illness) for two of five sampled residents (2, 32). This failure had the potential for the staff not to recognize behavioral changes and possible side/adverse effects in Resident 2 and 32. Findings: A. Resident 2 was admitted to the facility on [DATE] with diagnoses including anxiety disorder (excessive, and persistent worry and fear about everyday situations) and psychosis (a mental disorder characterized by a disconnection from reality) per facility's admission Record. Per Resident 2's Order Summary Report, dated 12/21/21, QUEtiapine Fumarate, an antipsychotic medication, was ordered on 3/15/21. Resident 2 did not have a care plan for this antipsychotic medication. B. Resident 32 was admitted to the facility on [DATE] with diagnoses including schizophrenia (mental disorder in which people interpret reality abnormally) per facility's admission Record. Per…

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 closed record reviews, the facility failed to develop a discharge plan for one of two sampled residents (49). Resident 49 left the facility against medical advice (AMA- leaving the facility without a doctor's approval) thirteen days after his admission date. This failure had the potential for Resident 49 to not receive appropriate coordination of care upon discharge. Findings: Resident 49 was admitted to the facility on [DATE] with diagnoses to include hypertensive urgency (high blood pressure with minimal to no symptoms and no signs or symptoms of organ damage) per the admission Record. A record review of Resident 49's clinical record was conducted. Resident 49's Nursing Note, dated 10/21/2021, indicated Resident 49 approached facility staff and, .will be leaving today to be picked up by his friend. Resident 49's progress notes did not show any documentation related to discharge planning. Resident 49 did not have a care plan focused on discharge planning. Resident 49's Physician Discharge…

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 coordinate a scheduled hospice visit and plan of care for one of two hospice residents reviewed for hospice care (39). This failure had the potential for miscommunication among health care givers. Findings: Resident 39 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm (progressively worsening cancer) of right lung, neoplasm of bone and spinal cord. Resident 39's clinical record was reviewed. The following information was obtained from the facility's hospice binder: A. November 2021 [Hospice] Personalized Visit Schedule calendar with signatures on 11/4, 11/5, and 11/12/21. B. An [unknown month] Personalized Visit Schedule Calendar with one signature on unknown month/13/unknown year. C. Two Interdisciplinary Plan of Care Revision/Physician Orders dated 11/12/21 and 12/2/21. On 12/20/21 at 9:30 A.M., an interview was conducted with the SC. The SC stated hospice visited the residents three times a week.…

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 there was enough staff coverage to meet the residents' needs. This failure had the potential to affect the quality of care and life of all the residents in the facility. Findings: During the survey entrance on 12/14/21 at 8:47 A.M., the ADM and the DON was not present in the facility. Subsequently, the ADM was not in the facility on 12/15, 12/16, and 12/17/21. On 12/20/21 at 7:11 A.M., an interview and record review with LN 44 was conducted of the facility's staffing schedule. The night shift schedule for CNAs dated 12/19/21 indicated there were three CNAs scheduled to work. LN 44 stated there was one CNA left in the building from night shift and the two CNAs, Just left. On 12/20/21 at 7:14 A.M., an interview was conducted with CNA 42. CNA 42 stated his shift started at 11 at night and ended at 7:30 in the morning. CNA 42 stated that staff should finish their full eight hour shift to make sure residents' needs were met. On 12/20/21 at 7:29 A.M., an interview was conducted with the SC. The SC stated staff who worked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a medication that required titration(gradually lowering a drug's dosage over a prolonged period) as ordered by a physician for one of three sampled residents (2). As a result Resident 2 did not receive the full benefits of the drug treatment. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses including ulcerative colitis (inflammation in the digestive tract) per facility's admission Record. On 12/20/21 at 9:46 A.M., a medication administration observation was conducted with LN 19. LN 19 stated Resident 2 had a scheduled dose of prednisone (a medication to reduce inflammation). LN 19 was observed searching for Resident 2's prednisone in the medication cart. LN 19 stated she needed to contact the pharmacy because Resident 2's prednisone was out of stock. Per Resident 2's Order Summary Report, dated 12/20/21, .prednisone 20 mg give 1 tablet by mouth one time a day for COLITIS . Per Resident 2's MAR, 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.

Based on observation, interview, and record review, the facility failed to ensure two emergency kits (Ekits) were locked, secured, and accounted for. Failure to secure Ekits had the potential for drug diversion and inappropriate medication use. Findings: On 12/16/21 at 11:07 A.M., a joint observation and interview was conducted with the ICP in the facility's medication storage. Inside the medication room were a total of six Ekits, one of which was not sealed, and the other was partially sealed with a string tie. In addition, there was a medium-sized container that contained multiple bubble packs that had medications with resident names. Inside the medication refrigerator were two opened vials of medication labeled Daptomycin (an antibiotic) that both contained approximately 1/3 of yellow-tan colored fluid inside. Per the ICP, when a medication was taken out of the Ekit, the seal should be replaced and the medications should be reordered from the pharmacy. The ICP further stated she was not sure why the Ekits were not sealed properly, and what medications were taken out. On 12/16/21…

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 review of facility documents the facility failed to ensure food was stored in accordance with professional standards of food service safety when: A. multiple food items were in the refrigerator or freezer with no dates and not properly sealed; B. staff's personal items were stored in the kitchen next to the refrigerator; C. a window sill in the food storage room was not clean; and D. two dented cans. These failures to ensure effective food and nutrition service operations may result in placing residents at risk for food borne illness and the growth of harmful organisms. Findings: A. On 12/14/2021 at 9:20 A.M., a joint observation and interview was conducted with the Cook. There were three trays holding plastic cups filled with white, red, and amber colored fluid with no labels with date and description. Upon observation of the freezer, was a blue plastic bag with frozen carrots with no label. In the same freezer, was an open box with an open plastic bag of beef patties. The [NAME] stated the bag of carrots and beef patties should have been put…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain accurate physician's progress notes for one of one sampled resident (23). This failure had the potential for Resident 23 to receive inaccurate treatments and wrong medical information. Findings: Resident 23 was admitted to the facility on [DATE] with diagnoses which included muscle weakness, cognitive (thinking) communication deficit, and hemiplegia and hemiparesis (one side of the body paralyzed) per the facility's admission Record. Resident 23's clinical record was reviewed. Resident 23's three pages of physician's progress notes dated April 2021 indicated a different resident's name on the first two pages. The progress notes contained resident's history of present illness, review of systems, exam, and data review. In addition, the physician progress notes contained assessment, plans, and goals. On 12/20/21 at 10:34 A.M., a joint interview was conducted with the ICP and the RMRC. The ICP stated the physician's progress notes…

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.