Heritage Gardens Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light (a device that allows residents' to communicate with nursing staff when they need assistance) was within resident reach for one of five sampled residents (Resident 91 ) when Resident 91 call light was wedged/stuck between the mattress and the side bed rail and not accessible to Resident 91.This failure had the potential to place Resident 91 at risk for their safety and well-being.Finding:A review of Resident 91's admission Record, (contains demographic and medical information), indicated Resident 91 was admitted to the facility on [DATE], with diagnoses which included epilepsy (a brain disorder that causes repeated, unprovoked seizures), anxiety disorder (persistent, and uncontrollable fear or worry that interferes with daily life) and altered mental status (any sudden or significant change in a person's normal thinking, awareness, or behavior). During a concurrent observation and interview on May 4, 2026, at 11:22…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with respect, kindness, and dignity, when a Certified Nursing Assistant (CNA 1) engaged in a verbal altercation with Resident 1. This failure resulted in Resident 1 ' s basic right to be violated, which had the potential for Resident 1 to feel disrespected and unsafe. Findings: During a review of Resident 1 ' s admission Record (contains demographic and medical information), it indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of hemiplegia (one side of the body paralyzed) and hemiparesis (weakness of one side of the body). During a review of Resident 1 ' s Change in Condition Evaluation, dated April 4, 2025, it indicated on April 4, 2025 at around 3 PM, Resident [Resident 1] had a derogatory verbal altercation with a staff member [CNA 1]. Both staff member and Resident educated on the importance of proper communication, mutual respect. Resident 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 the ice scoop used for the kitchen's ice machine was stored in a clean and sanitary manner as required by the facility's policy. This failure posed potential risk for contamination of ice, which could lead to foodborne illness (food poisoning, is a sickness caused by eating food or drinking water that is contaminated with harmful bacteria, viruses, parasites, or chemicals.) and negatively impact the health and safety of 96 of 96 vulnerable residents who received food and beverages from the kitchen. Findings: During a concurrent observation and interview, on January 14, 2025, at 8:20 AM, with the Dietary Services Supervisor (DSS), in the kitchen, the ice machine was inspected. The ice scoop was found resting inside an uncovered blue container located near the ice machine. The DSS stated the ice scoop must always be stored in a clean, covered container to ensure safety and prevent contamination. During a concurrent observation and interview on January 14, 2025, at 8:30 AM, in the kitchen, with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper and safe infection control practices were being followed for six of 25 sampled residents (Residents 44, 33, 65, 4, 484 and 47) when: 1. Resident 44's Central Venous Catheter (CVC- thin, flexible tube inserted into a vein to provide access to the heart) dressing was not changed in accordance with facility policy. 2. Resident 44's Intravenous tubing (IV- flexible tube used to give fluids, medicine, or nutrients through a vein) was not dated in accordance with facility policy. 3. Resident 33's oxygen tubing (flexible plastic tube that is used to deliver oxygen from an oxygen supply to a person who needs extra oxygen) was not changed in accordance with facility policy. 4. Resident 65's oxygen tubing was not dated in accordance with facility policy 5. License Vocational Nurse 1 (LVN 1) did not perform hand hygiene (practice of washing hands with soap and water or using an alcohol-based hand sanitizer to remove germs) during…

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 Significant Change of Status Assessments (SCSA- comprehensive assessment that must be completed when the Interdisciplinary Team (IDT) has determined that a resident meets the significant change guidelines for either major improvement or decline) Minimum Data Set (MDS- a computerized assessment instrument) were completed within 14 days for one of two residents (Resident 5) reviewed for hospice (services to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care.). This failure resulted on Resident 5's care plan not being updated and revised to reflect her current status, and had the potential to delay identification and implementation of the resident's care and support needs. Findings: During a review of Resident 5's admission Record (a document that contains demographic and clinical data), it indicated Resident 5 was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS- a computerized assessment instrument) Assessments were completed accurately for two of two residents (Residents 9 and 19) reviewed for insulin (hormone that helps the body use sugar and starches for energy or store them for later use) and antibiotic (medication used to treat bacterial infections) use when: 1. Resident 9's insulin injections were not coded on the MDS assessment. 2. Resident 19's antibiotic therapy was not coded on the MDS assessment. These failures had the potential to cause inaccuracy in identifying Residents 9 and 19's care and support needs. Findings: 1. During a review of Resident 9's admission Record (contains demographic and medical information), it indicated Resident 9 was admitted to the facility on [DATE], with diagnoses of Type 2 diabetes mellitus (when the body has trouble using insulin properly, causing high blood sugar levels.), and long term use of insulin. 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.

Based on observation, interview, and record review, the facility failed to ensure a physician's order was carried out timely for one of two residents (Resident 62) reviewed for hospice (services to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care) when Resident 62's order for a Speech Therapy (ST- assessment and treatment of communication problems and speech disorders) evaluation was not communicated with the hospice provider. This failure had the potential to place Resident 62 at risk for aspiration (when food, liquid, or other material is accidentally inhaled into the lungs), weight loss and further nutritional decline. Findings: During an observation on January 13, 2025, at 8:29 AM, outside of Resident 62's room, Resident 62 was yelling out nonsensically. During a review of Resident 62's admission Record (contains demographic and medical information), it indicated Resident 62 was admitted to the facility with the diagnoses of cerebral atherosclerosis (disease…

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 necessary care and services to ensure activities of daily living were being provided for two of four residents (Residents 44 and 54) reviewed for position and mobility when: 1. Resident 44's Restorative Nursing Program (RNP- planned healthcare approach within long-term care facilities that aims to help residents maintain or regain their independence by providing targeted interventions to improve their functional abilities) recommendation from the Physical Therapist (PT- healthcare provider who helps you improve how your body performs physical movements) was not implemented. 2. Resident 54's RNP recommendation from the PT and Occupational Therapist (OT- healthcare provider who helps you improve your ability to perform daily tasks) were not implemented. These failures had the potential to delay the continuity of care for Residents 44 and 54, which could prevent them from maintaining or improving the activities of daily living.…

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 physician's order for oxygen therapy (administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of decreased perfusion of oxygen to the tissues) was obtained for one of three residents (Resident 33) reviewed for oxygen. This failure had the potential for Resident 33 to develop oxygen toxicity (conditions that occurs when someone breaths too much oxygen, damaging lungs and potential for death) from the lack of monitoring from a physician. Findings: During a review of Resident 33's admission Record, it indicated Resident 33 was admitted to the facility with the diagnoses of dementia (medical condition that causes a person to lose ability to think, remember, and reason), retropharyngeal and parapharyngeal abscess (severe infection in the neck that involve a collection of pus in the deep neck spaces), and shortness of breath (difficulty breathing). During an observation on January 13, 2025, at 10:11 AM, 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 review, the facility failed to ensure their professional staff maintained an active and current license (legal permit that allows a person to practice nursing) when a Licensed Vocational Nurse (LVN 2) worked with an expired license on [DATE], through [DATE]. This failure had the potential to place 101 highly vulnerable residents whose health conditions are already compromised at risk of receiving care from an unqualified nurse with an expired license, which could have affected and altered their health and well-being. Findings: During a review of a facility provided document titled Board of Vocational Nursing and Psychiatric Technicians Licensing Details dated [DATE], it indicated LVN 2 nursing license was delinquent (license that is not renewed within the allotted timeframe). During a concurrent interview and record review on [DATE], at 1:32 PM, with the Director of Nursing (DON), the DON reviewed and acknowledged a facility document titled Nursing Staff Assignment and Sign-in Sheet…

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 reviews, the facility failed to implement its policy for blood glucose monitoring, when one of four sampled residents (Resident 1) was not checked at the scheduled time, which potentially resulted in a change in Resident 1's condition leading to being transferred to a general acute hospital for evaluation and treatment. This failure had the potential to jeopardize the health and well-being of Resident 1 who is medically compromised. During a review of Resident's 1 admission Record (document containing clinical and demographic data), it indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis which included type 2 diabetes mellitus (a condition where the body doesn't use insulin [ a hormone that helps sugar from food to get into the cells for energy] properly, causing blood sugar levels to get too high ). During a review of the clinical record for Resident 1's, the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its policy and procedure for activities of daily living (ADL) to ensure the proper maintenance of grooming and personal hygiene services for one of the three sampled residents. This failure had the potential to put clinically compromised resident (Resident 1) at risk for infection when Resident 1 ' s unclean and untrimmed fingernails were not adequately maintained. Findings: 1.During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE] with a diagnosis that included unspecified dementia (the 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 the clinical record for Resident 1 ' s the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated 08/09/2024, 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 follow the policy and procedure for restraints, for one of three sampled residents (Resident 1) when Certified Nursing Assistant (CNA 1) wrapped Resident 1 ' s waist and legs in linen sheets on April 15, 2024. This failure had the potential to place Resident 1 at risk for decreased mobility, circulation, psychological harm and even death. Findings: During a review of Resident 1's Face Sheet (contains demographic and medical information), it indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (condition that affects the way the person's brain is working), unspecified fracture of right lower leg (unknown break in bone) and schizoaffective disorder, bipolar type (person experiences hallucinations with manic/depressive moments). During a review of Resident 1 ' s Annual H & P dated April 13, 2023, it indicated .resident is unable to make decisions concerning health care because dementia . the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of the three sampled residents (Resident 1) was treated with respect, and dignity when Certified Nursing Assistant 1 (CNA1) used profanity around Resident 1. This failure compromised Resident's 1 dignity and violated her rights to respect, which had the potential for Resident 1 to experience psychosocial harm (mental harm and suffering). Findings: A review of Resident's 1 admission Record (a document containing clinical and demographic data) indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis Alzheimer's disease (most common type of dementia, it is a progressive disease that begins with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). A review of Resident 1's History and Physical, dated October 3, 2023, at 11:36 AM, documented by Resident's 1 Family Nurse Practitioner (FNP), it indicated Resident 1 does not have the capacity to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure immediate protective measure was put into place to provide protections to one of three sampled resident (Resident 3) when a Certified Nurse Assistant (CNA) was not suspended immediately after an alleged abuse to Resident 3 was reported. This failure had the potential for further abuse, neglect, exploitation, or mistreatment in a vulnerable population of 94 residents as the alleged perpetrator, CNA, continued to have access to the alleged victim, Resident 3, and to other residents while the investigation was still in process. Findings: During a review of Resident 3's admission Record (clinical record with demographic information), it indicated, Resident 3 was admitted to the facility on [DATE], with diagnoses of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), hyperlipidemia (too many lipids (fats) in the blood), and hypertension (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect 92 clinically compromised residents when the treatment cart was left unlocked and unattended by a licensed nurse. This failure had the potential for a vulnerable population of 92 residents to gain direct access to harmful chemicals, placing them at risk for ingestion of harmful chemicals, which could lead to poisoning and even death. Findings: During an observation on September 29, 2023, at 10:49 AM, Treatment Nurse (TN 1) opened the drawers of the treatment cart. Inside the treatment cart were biological's, medication ointments, and solutions. TN 1 applied medication ointment on a clean dressing, grabbed additional dressing supplies from the next drawer, and then proceeded to enter room [ROOM NUMBER] to provide wound treatment to a resident. The treatment cart was parked at the door of room [ROOM NUMBER] and was left unlocked and unattended by TN 1. During a concurrent observation and interview, on September 29, 2023, at 10:55…

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 infection control practices when A Certified Nursing Assistant (CNA 1) and A License Vocational Nurse (LVN 2) did not perform COVID-19 (a highly contagious illness caused by a virus) precautions upon entry into Covid positive room on September 19, 2023, in accordance with the facility's policy and procedure. This failure increased the risk of the transmission of Covid 19 to a compromised resident (Resident 1). Findings: During a review of Resident 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include, urinary tract infection (urine infection), difficulty walking, chronic atrial fibrillation (irregular heart rate, poor blood flow), congested heart failure (heart cannot pump blood as well), (COVID-19 (a highly contagious illness caused by a virus). During an observation on September 19, 2023, at 10:43 AM, License Vocational Nurse 1 (LVN1),…

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

Based on interview and record review, the facility failed to provide sufficient numbers of staff when three out of 12 sampled days (August 5, 2023, August 6, 2023, and August 20, 2023) had less than 3.5 direct care service hours per patient day (DHPPD- the total number of hours worked per patient day divided by the average daily number of residents in the facility). This failure had the potential to result in unmet needs, such as psychosocial and physical needs, and safety concerns for 101 residents. Findings: During a concurrent interview and record review on September 1, 2023, at 11:50 AM, with the Payroll Coordinator (PC) and the Director of Nursing (DON), the facility ' s document titled, Census and Direct Care Service Hours Per Patient Day (DHPPD- the number that results from dividing the actual nursing hours perform by direct caregivers per patient day and the number of residents in the facility), for dates: August 5, 2023, August 6, 2023, and August 20, 2023, were reviewed. The DHPPD indicated, the Actual DHPPD was 3.17 (facility was short of 0.33) on August 5, 2023, Actual…

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 preparation and storage practices in the kitchen when: 1. The ice machine was not kept in sanitary condition. 2. The microwave had food residue. 3. Seven out of seven shelves in the walk-in refrigerator had dust and grime, and the floor inside walk-in refrigerator had old food, black grime, and trash. 4. The reach in refrigerators #1 and # 2 had sticky handles. The gaskets had black grime. The ventilation fans were dusty with black debris. 5. The food warmer had food crumbs and residue on bottom shelves. 6. The shelf storing the spices had dust. 7. The area behind the stove had dust, grease build-up and black grime. 8. In the dry storage room, four lid covers for thickener, flour, sugar, and brown sugar had dust. 9. There were unlabeled and undated food items in the resident refrigerator at Nursing Station 1. The refrigerator had food residue and spilled liquid. These failures had the potential to cause food borne illness (illness from eating contaminated food) to 84 medically…

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 safe and effective pharmaceutical services for 86 medically compromised residents when: 1. Outdated medications were observed stored and was available for resident use: 1.a. For Resident 634, a syringe of outdated ABHR gel (mixed medication containing Ativan/Benadryl/Haldol/Reglan; medication used for nausea and vomiting or agitation), with an expiration date of [DATE], was observed stored in the Medication Room refrigerator. 1.b. For Resident 36, four (4) bags of outdated Vancomycin (antibiotic), with an expiration date of [DATE], was observed stored in the Medication Room refrigerator. 1.c. For Resident 34, a vial of outdated Nitroglycerin (medication to treat chest pain), with an expiration date of [DATE], was observed stored in the Medication Cart 300. 1.d. A bottle of Aspirin (blood thinner medication) 81 milligrams (mg - a unit of measurement for dose), with the expiration date smeared off, was observed stored in 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 appropriate food textures were provided for 12 of 12 residents (Residents 1, 8, 14, 20, 39, 46, 47, 57, 74, 82, 534, and 635) with puree textured diet (a diet with smooth food texture like pudding or mashed potatoes designed for someone who has difficulty swallowing and/or chewing) when Residents 1, 8, 14, 20, 39, 46, 47, 57, 74, 82, 534, and 635 received cheese and vegetable lasagna pureed entrée, that was not smooth, for lunch on July 13, 2022. This failure had the potential to place the residents that received this diet at risk of choking. Findings: During a review of a facility document titled, Physician Orders List, dated July 13, 2022, the order list indicated Residents 1, 8, 14, 20, 39, 46, 47, 57, 74, 82, 534, and 635 have a physician's order to receive a pureed diet. During a concurrent observation and interview, with Dietary [NAME] 1, on July 13, 2022, at 10:23 AM, Diet [NAME] 1 was preparing cheese and vegetable lasagna puree entrée. Dietary [NAME] 1 placed designated portions of lasagna…

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 call light was within reach for three of three residents (Residents 634, 47, and 8) reviewed for call lights. This failure resulted in Residents 634, 47, and 8 not to have means of contacting the staff for assistance. Findings: 1. During a review of Resident 634's clinical record, the face sheet (contains demographic and medical information) indicated Resident 634 was admitted to the facility on [DATE], with diagnoses that included weakness, anxiety disorder (disorder characterized by significant and uncontrollable feelings of anxiety and fear), and schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly). During an observation, in Resident 634's room, on July 14, 2022, at 8:45 AM, Resident 634 was lying in bed in a semi-upright position. Resident 634 did not have her call light next to her. Her call light was on the floor behind her bed's headboard. During a concurrent 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to safeguard the privacy and confidentiality of personal and medical records for one of six residents (Resident 36) reviewed for medication administration when a licensed nurse used her personal cell phone to text the physician regarding Resident 36's protected health information with the resident's full name in the text message. This failure had the potential for unauthorized individuals to view Resident 36's protected health information on facility's staff personal cell phone. Findings: During a review of Resident 36's clinical record, the face sheet (contains demographic and medical information) indicated Resident 36 was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus (increased blood sugar levels), and kidney disease (kidneys are damaged and can't filter blood the way they should). During an observation, on July 13, 2022, at 8:50 AM, a Licensed Vocational Nurse (LVN 2) used their personal cell…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately code the Resident Assessment Instrument-Minimum Data Set (RAI-MDS - a computerized resident assessment tool) for one of three residents (Resident 48) reviewed for tube feedings (a tube inserted into the stomach used to administer liquid nutrition) when Resident 48's RAI-MDS dated [DATE], did not indicate Resident 48 was receiving enteral nutrition (liquid nutrition) through a feeding tube. This failure had the potential to result in unmet care needs for Resident 48 which can potentially jeopardize the residents' health and safety. Findings: During an observation, on July 13, 2022, at 3:32 PM, Resident 48 was receiving enteral nutrition through a feeding tube that was being administered by an infusion pump at the resident's bedside. During a review of Resident 48's physician's order sheet, dated January 11, 2022, it indicated, [Brand name of enteral nutrition] 1.2 via G-tube [gastric tube - tube inserted into the stomach] & 50…

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 five residents (Resident 13) reviewed for rehabilitation services was provided physical therapy services (PT services - specially designed exercises and equipment to help patients regain or improve their physical abilities) as ordered by a physician. This failure had the potential for Resident 13 not to obtain services intended to help the resident achieve and maintain his highest level of mobility functioning. Findings: During a review of Resident 13's clinical record, the face sheet (contains demographic and medical information) indicated Resident 13 was admitted to the facility on [DATE], with diagnoses which included difficulty in walking, tear of unspecified meniscus (tear of one of the connective tissues of the knee), pain in right and left knees, and dementia (a brain disease that causes memory disorders, personality changes, and impaired reasoning). During a concurrent observation and interview, on July 12, 2022, 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 maintain acceptable parameters of nutritional status (nutrition and hydration status) for three of seven residents (Residents 11, 71 and 48) reviewed for nutrition when: 1. Resident 11, who was at risk for weight loss, was not assessed by the Registered Dietitian (RD) upon admission. (RD assessments are essential to determine the overall nutritional status of residents, diagnose malnutrition (lack of proper nutrition), identify underlying issues that could lead to malnutrition, and plan necessary interventions.) 2. Resident 71, who was at risk for weight loss, was not assessed by the RD quarterly, after the facility failed to inform the RD about the resident's refusal to be weighed. 3. Resident 48's tube feeding (a tube inserted directly into the stomach for the administration of liquid nutrition) rate was not administered according to the physician's order on July 13, 2022. These failures had the potential for Residents 11, 71 and 48 to…

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

Based on observation, interview, and record review, the facility failed to ensure an enteral nutrition bottle (container with liquid nutritional formula administered to a resident through a feeding tube inserted directly into the stomach) for one of three residents (Resident 48) reviewed for tube feeding (a tube inserted directly into the stomach for the administration of liquid nutrition) was labeled with nurse initials and date (when the feeding was started) in accordance with the facility's policy and procedure. This failure had the potential for the enteral nutrition bottle to exceed the manufacturer's prescribed hang-time (amount of time a feeding is safe to use after opened), and for Resident 48 to not receive the prescribed amount of nutritional calories resulting in weight loss. Findings: During an observation, on July 13, 2022, at 3:32 PM, Resident 48 was receiving enteral nutrition through a tube feeding that was being administered by an infusion pump at her bedside. The enteral nutrition bottle was not labeled with a date, or the initials of the nurse who started the tube…

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 appropriate respiratory care and treatment for one resident (Resident 9) reviewed for respiratory care when Resident 9 received oxygen therapy (use of oxygen as medical treatment) without a physician's order. This failure had the potential for Resident 9 to receive improper oxygen therapy and potentially missed opportunities to identify Resident 9's significant change in condition. Findings: During a review of Resident 9's clinical record, the face sheet (contains demographic and medical information) indicated Resident 9 was readmitted to the facility on [DATE], with diagnoses that included end-stage renal disease (a condition in which a person's kidneys cease functioning), and type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar). During a concurrent observation and interview with a Licensed Vocational Nurse (LVN 1) on July 13, 2022, at 10:04 AM, Resident 9 was on oxygen therapy at 5…

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) knew how to properly assess the arterio-venous fistula (AVF- a site on resident's arm used to connect a blood filtering machine) for two residents (Resident 5 and Resident 9) reviewed for hemodialysis (dialysis- a process of purifying the blood of a person whose kidneys are not working normally). This failure increased the potential for staff to have delayed detections, reporting and/or management of complications from the hemodialysis access site for Resident 5 and 9. Findings: 1. A review of Resident 5's clinical record, the face sheet indicated Resident 5 was readmitted to the facility on [DATE], with diagnoses that included dependance on renal dialysis (procedure of removing toxins from the body) and hypertension (blood pressure that is higher than normal). A review of Resident 5's care plan, dated March 7, 2022, indicated to monitor dialysis access site on the left arm AV fistula 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 did not ensure the medication error rate was less than 5%. This occurred when three errors for Resident 55 occurred out of 27 opportunities for a medication administration error rate of 11.1%. This failure had the potential to expose residents to preventable medication errors which could adversely affect their health and safety. Findings: During a review of Resident 55's clinical record, the face sheet (contains demographic and medical information) indicated Resident 55 was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus with diabetic neuropathy (high blood sugar values causing nerve damage), anemia (low red blood cells), and constipation (difficult bowel movement). During a review of Resident 55's Physician Order, dated July 20, 2021, it indicated, TUMS TABLET 500 mg CHEWABLE 2 tab [tablets] PO [by mouth] BID [twice a day] for gas pain . During a review of Resident 55's Physician Order, dated June 10,…

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 the observation, interview, and record review, the facility failed to ensure medications were appropriately labeled in accordance with the facility's policies and procedures and standards of practice when: 1. For Resident 36, two opened and undated insulin (drug used to lower blood sugar) pens were observed stored in the Medication Cart 300. 2. For Resident 484, an opened foil of Budesonide (steroid medication) inhalation pouches observed in the Medication Cart 300 did not have an open date. 3. An incomplete prescription label for a controlled substance (highly regulated medication due to potential for abuse or misuse), Morphine Sulfate (strong pain medication), was observed stored in the Medication Room Refrigerator. It was not labeled with important information such as prescription number and expiration date. These failures placed Residents 36 and 484 at risk for receiving ineffective or outdated medications, and/or had the potential for drug diversion (illegal use). Findings: 1. 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.

Based on observation, interview, and record review, the facility failed to ensure their dietary staff had the appropriate competencies and skill sets to carry out the functions of the Food and Nutrition Services, when three Dietary Aides (Dietary Aides 1, 2, and 3) did not know the manufacturer's guidelines related to the sanitizer testing of the dishwasher. This failure had the potential to cause foodborne illness (illness caused by eating contaminated foods) or food contamination for 84 residents who received foods from the kitchen. Findings: During a review of the facility's policy and procedure titled, Dishwashing Machine Use, dated March 2010, it indicated, Dishwashing machine chemical sanitizer concentrations and contact times will be as follows: Chlorine 50-100 ppm. During a concurrent observation, and interview, with Dietary Aide 1 (DA 1), on July 12, 2022, at 8:36 AM, in the dishwashing area of kitchen, DA 1 tested the sanitation level of the dishwasher. DA 1 dipped the chlorine strip directly into the dish water inside of the open compartment on the front of dishwasher,…

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 medical records for five residents (Residents 284, 11, 13, 15, and 29) of 24 sampled residents, were complete and accurately documented when: 1. For Resident 284, a controlled substance (highly regulated medication due to potential for abuse or misuse) pain medication was removed from the drug supply and logged out of the Control Drug Record (CDR - narcotic count sheet) but not documented as administered on the Medication Administration Record (MAR) at the time of removal. This failure had the potential for inadequate controlled substance accountability in the facility or to expose the resident to preventable medication errors. 2. The Physicians Orders for Life Sustaining Treatment (POLST- written medical orders that addresses a limited number of critical medical decisions) for four of seven residents (Residents 11, 13, 15 and 29) reviewed for advance directives (a legal document that explains how an individual wants medical…

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 safe infection control program for 86 medically compromised residents when: 1. A licensed nurse did not clean and disinfect the glucometer (devices measures blood sugar values) after using it on Resident 36. 2. Outdated supplies were available for resident use in the Medication Room. These failures had the potential for cross-contamination (unintentional transfer) of blood borne pathogens (microorganisms that cause serious disease present in human blood) due to an improperly cleaned glucometer and/or to be treated with ineffective or deteriorated (reduced quality) supplies which could negatively impact the residents' clinical conditions. Findings: 1. During a review of Resident 36's clinical record, the face sheet (contains demographic and medical information) indicated Resident 36 was admitted to the facility on [DATE], with diagnoses that included methicillin resistant staphylococcus infection (infection), type 2 diabetes…

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 their kitchen equipment was maintained in a safe operating condition when: 1. The light for the walk-in freezer and refrigerator was dim. 2. The walk-in freezer was noted with a chunk of ice around the black pipe behind the ventilator fans. 3. The walk-in refrigerator was noted with a copper pipe dripping water behind the ventilator fans. These failures had the potential to negatively affect the quality of food served to 84 medically compromised residents who received food from the kitchen. Findings: 1. During an observation, on July 12, 2022, at 9:23 AM, the light in the walk-in refrigerator and the walk-in freezer were found to be dim. Only one small light bulb was noted above the entrance door of the walk-in refrigerator and walk-in freezer. Flashlights were needed to inspect the walk-in refrigerator and walk-in freezer. During an interview with the Maintenance Staff (MS 1), on July 12, 2022, at 3:31 PM, the MS 1 stated it was dark in the walk-in refrigerator and the walk-in freezer, and it was hard…

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.