Garden Crest Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide safe care and services for one of three sampled residents (Resident 1) by failing to: 1.Ensure Certified Nursing Assistant 1 (CNA1) and CNA 2 provided two-person physical assistance (help from two person) when they (CNA1 and CNA2) assisted Resident 1 who had a diagnosis of osteoporosis (weak and brittle bones), contracture (a stiffness, shortening at any joint, that reduces the joint's range of motion) with activities of daily living (ADL's, activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, bathing, turning, and eating). This failure had a high potential for Resident 1 to sustain injuries and harm. Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 7/30/2021 with diagnoses that included dementia (a progressive state of decline in mental abilities), age -related…

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 report an allegation of staff to resident abuse to the State Survey Agency (SSA, the Bureau of Health Facility Licensing, Certification and Resident Assessment, within the Department of Health, which is responsible for nursing facility certification and for conducting surveys to determine compliance with Medicare and Medicaid requirements) and the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) within two hours for one of five sampled residents (Resident 1). This failure had the potential to result in a delay of an onsite inspection by the SSA and had the potential for Resident 1 to experience ongoing abuse. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 7/30/2021 with diagnoses that included dementia (a progressive state of decline in mental abilities), type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), anxiety (a feeling…

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 policy and procedures for discharge planning were followed for one of three sampled residents (Resident 1). This failure resulted in the resident not being properly informed and involved in their discharge plan. Findings: During a review of Resident 1 ' s admission Record dated 5/16/25 indicated the resident was admitted to the facility on [DATE] with diagnoses including; diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) hypertension (HTN— high blood pressure), atrial fibrillation (AFib— a heart rhythm disorder where the upper chambers of the heart [atria] beat irregularly and rapidly), hyperlipidemia (HLD— a condition characterized by elevated levels of fats in the bloodstream) and chronic kidney disease (CKD— a progressive and irreversible condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood). During a review of Resident 1 ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility to honor the right of a resident to be free from involuntary seclusion for one of the three sampled residents (Resident 1), by placing Resident 1 in isolation without a physician ' s order. This deficient practice had the potential to result in feelings of depression, loneliness, and psychological harm for Resident 1. Findings: During a review of Resident 1's admission record, the facility admitted Resident 1 on 12/30/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing), and dysphagia (difficulty swallowing). During a review of Resident 1 ' s physician orders dated 12/30/2024 at 5:15 pm, indicated, DROPLET (prevent the spread of infections that are spread through the air by coughing, sneezing, or talking. Precautions include wearing a mask, washing hands, and limiting movement outside of a patient's room) AND CONTACT…

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 implement its infection control policy by falling to ensure Certified Nursing Assistant (CNA) 1, Registered Nurse supervisor (RN) 1, and House Keeping (HK) performed hand hygiene (hand washing with soap and water and use alcohol-based hand sanitizer) while entering and exiting residents' rooms [ROOM NUMBERS], touching curtains, and bedside tables in the residents' rooms. These deficient practices had the potential to result in the spread of infectious disease (disorders that are caused by organisms, usually microscopic in size, such as bacteria, viruses, fungi, or parasites that are passed, directly or indirectly, from one person to another). Findings: During an observation on 2/1/2025 at 8:45 AM CNA 1, observed carrying a clear trash bag with bare hands, threw the trash in a trash receptacle next room [ROOM NUMBER]. CNA 1 entered room [ROOM NUMBER], pulled a curtain at room [ROOM NUMBER] bed B and pushed a bed side table. During an observation on…

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

Based on interview and record review, the facility failed to ensure to report the Payroll-Based Journal (PBJ - a method to collect staffing data from nursing facilities) for the 3rd quarter (April 1-June 30). This deficiency resulted in the inaccurate data reporting of direct care staff, providers, and vendors potentially placing the facility at risk of not implementing their policy. Findings: A review of the Certification and Survey Provider Enhanced Reports (CASPER) for the PBJ Staffing Data Report Fiscal Year Quarter 3 2024 (April 1 - June 30) indicated the metric was triggered for Failed to Submit Data for the Quarter. During an interview on 11/15/2024 at 12:28 p.m. with the Administrator (ADM) and payroll (Staff 1), Staff 1 stated she had been employed at the facility since 9/16/2024. The ADM stated there was no gap in between when Staff 1 started, and the last payroll staff exited. Staff 1 stated the PBJ was submitted quarterly and received from the payroll department. The ADM stated the previous payroll staff submitted the PBJ for the 3rd quarter in August 2024, but there…

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 four sampled residents (Resident 9, 32, and 46), who received hemodialysis (a medical procedure to remove fluid and waste products from the body) had an emergency dialysis kit (a collection of supplies that people with kidney disease can use in case of an emergency) at the resident's bedside. This deficient practice had the potential for residents to receive a delayed intervention during accidental bleeding. Findings: a. A review of the admission Record indicated Resident 46 was admitted to the facility on [DATE], with diagnoses including end stage renal disease (kidneys suddenly become unable to filter waste products from your blood that can develop rapidly over a few hours or a few days) and dependence on renal dialysis (your blood is put through a filter outside your body, cleaned, and then returned to you). A review of Resident 46's dialysis care plan revised on 10/12/2024, indicated for the facility staff to check 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 interview and record review, the facility failed to ensure each resident was treated with dignity to promote enhancements of quality of life for one of three sampled residents (Resident 58). For Resident 58 the Physicians Order for Life-Sustaining Treatment (POLST) indicating Do Not Resuscitate (DNR, when the heart stops beating, or a person stops breathing, there are no rescue measures taken, including cardiopulmonary resuscitation [CPR] an emergency lifesaving procedure that is done when someone's breathing or heartbeat has stopped) was not honored. This deficient practice resulted in Resident 58 receiving CPR against his wishes and not in accordance with his documented POLST instructions ([DATE]) for DNR when Resident 58 was found unresponsive on [DATE]. Findings: A review of Resident 58's admission Record indicated the facility admitted the resident on [DATE] with diagnoses including chronic kidney disease (condition that occurs when the kidneys are damaged and cannot filter blood properly), benign…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan for one of three sampled residents (Resident 16). Resident 16's preferred activity preferences were not included in the Activities care plan. This deficient practice had the potential to prevent Resident 16 from having meaningful activity to promote and enhance the resident's quality of life. Findings: A review of the admission Record indicated Resident 16 was admitted to the facility on [DATE], with diagnoses including muscle wasting and atrophy (the loss or thinning of muscle tissue that can lead to a decrease in muscle mass and strength), sacral pressure ulcer (lower spine wound), and dependence on oxygen. A review of the Minimum Data Set (MDS, a federally mandated resident assessment tool) completed on 10/15/2024, indicated that while in the facility it was important for Resident 16 to have books, newspapers, and magazines to read. The MDS indicated Resident 16 did not have any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY b. A review of Resident 214's admission record indicated the resident was admitted to the facility on [DATE] with a diagnoses including nontraumatic intracerebral hemorrhage (a type of stroke that occurs when a blood clot forms in the brain), hemiparesis (a condition that causes weakness or an inability to move on one side of the body), and dysphagia (difficulty swallowing). A review of Resident 214's MDS dated [DATE], indicated Resident 214 did not have signs or symptoms of cognitive patterns, did not present with symptoms of depressed, hopelessness or feeling down, but presented with feelings of isolation. Resident 214's MDS indicated the resident was dependent for oral hygiene, toileting hygiene, showering, upper and lower body dressing, and personal hygiene. During concurrent observation and interview on 11/12/24 at 10:09 AM, in Resident 214's room, Resident 214 was laying in the bed, the call light within his reach. Resident 214 was on gastrostomy feeding (g-tube - a method of delivering food and medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents received a monthly drug regimen review for one sampled resident (Resident 6). Resident 6's psychotropic medications (drugs that affect a person's mental state,Venlafaxine [an antidepressant and nerve pain medication] and Quetiapine [Seroquel], used for bipolar disorder) were not reviewed by the facility pharmacist for three months. This deficient practice caused an increased risk of adverse consequences associated with medication therapy. Findings: A review of Resident 6's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including major depressive disorder (a serious but treatable mood disorder that impacts how a person feels, thinks, and acts) and bipolar disorder (a mental illness that causes extreme shifts in mood, energy, and activity levels). A review of Resident 6's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/24/24, indicated the resident 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.

Based on observation and interview, the facility failed to store food properly in accordance with professional standards of practice when several food items in the kitchen were observed unlabeled and undated. These failures placed the residents at risk for food borne illness or contamination. Findings: a. During the initial kitchen tour with the Dietary Supervisor (DS) on 11/11/2024 8:22 AM, one full pitcher of brown liquid was observed undated and unlabeled in the walk-in refrigerator. During a concurrent interview, the DS stated the pitcher contained apple juice and confirmed the pitcher was unlabeled and undated. The DS stated it was important to label the pitcher of juice because there was a potential for foodborne illness when resident receive food after the used by date. During an observation and concurrent interview with the DS on 11/11/2024 at 8:32 AM in the Dry Storage Room, three packs of bread were observed undated. The DS stated it was important the bread was labeled with a delivery date, so the staff knew when it was delivered. During a follow-up visit and observation…

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

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had dizziness and was administered Meclizine (medication used to prevent and control nausea, vomiting, and dizziness) four times a day, had a comprehensive person-centered care plan with appropriate interventions for Resident 1's physical, mental and psychological wellbeing. This deficient practice caused an increased risk in adverse reactions (unwanted, uncomfortable, or dangerous effects that a drug may have) to Resident 1. Findings: A review of Resident 1's admission Record (Face Sheet) indicated the facility admitted the resident on 12/30/2022, with diagnoses including dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that the loss interferes with a person's daily life and activities), chronic pain syndrome (pain that lasts for longer than three months), and Type II diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). A review of Resident 1's Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who was diagnosed with chronic pain syndrome (pain that lasts for longer than three months), received a Pain Assessment after a change of condition (a decline / worsening or improvement in a resident's mental, psychosocial, or physical functioning). This deficient practice had the potential to negatively affect Resident 1's psychosocial wellbeing and quality of life. Findings: A review of Resident 1's admission Record (Face Sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses including dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that the loss interferes with a person's daily life and activities), chronic pain syndrome and Type II diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). A review of the Minimum Data Set (MDS - a standardized assessment 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 interview and record review, the facility failed to ensure the facility's Pharmacy Consultant (PC) thoroughly completed a monthly Medication Regimen Review (MRR - a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences [unwanted, uncomfortable, or dangerous effects that a drug may have] and potential risks associated with medications) for one of two sampled residents (Resident 1). This deficient practice caused Resident 1 to receive medication that was not optimal his medical condition and increased the risk of adverse consequences from the medication therapy. Findings: A review of Resident 1's admission Record (Face Sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses including dementia (loss of cognitive functioning - thinking, remembering, and reasoning to such an extent that the loss interferes with a person's daily life and activities), chronic pain syndrome (pain that lasts 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 implement interventions to prevent and control the spread of COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person) in accordance to the facility's infection control policies and procedures and the facility Mitigation Plan (MP, a plan to reduce loss of life and impact of COVID-19 in the facility) titled Garden Crest Rehabilitation Center COVID-19 Mitigation Plan revised on 7/22/2024, for 3 of 6 sampled residents (Resident 2, Resident 3, and Resident 4) by failing to: 1. Ensure staff discarded and did not reuse their N95 mask (a respiratory protective device designed to form a seal around nose and mouth to achieve very efficient filtration) after exiting a room in the Red Zone (RZ, area for residents who have tested positive for COVID-19). 2. Perform fit testing (the method for finding the respirator that fits your face and making sure it provides a tight seal to help keep you protected…

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 maintain documentation of state licensure for one of two sampled Licensed Vocation Nurses (LVN 2). These deficient practices had the potential for residents to not receive the appropriate level of care needed affecting quality of care and potentially leading to resident harm. Findings: A review of LVN 2 ' s employee file indicated LVN 2 ' s nursing license expired on [DATE]. A review of the facility ' s staffing assignment sheet dated [DATE] from 7AM to 3PM indicated LVN 2 was assigned to care and administer medications to 31residents. A review of the facility ' s staffing assignment sheet dated [DATE] from 7AM to 3PM, indicated LVN 2 was assigned to care and administer medications to 34 residents. A review of the facility ' s staffing assignment sheet dated [DATE] from 7AM to 3PM, indicated LVN 2 was assigned to care and administer medications to 33 residents. A review of the facility ' s staffing assignment sheet dated [DATE] from 7AM to 3PM,…

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 licensed nurses documented that: 1) 26 of 26 medications were administered on residents' medication administration record (MAR - a report detailing the drugs administered to a patient by a licensed healthcare professional at a facility) for Residents 2, 5, and 9. 2) Eight of Eight removed narcotic medications on the controlled drug record (narcotic sheet - a document to track the administration of controlled substances [narcotic medications which have a potential for abuse and may also lead to physical or psychological dependence]) for Residents 2, 5, 8, and 9. 3) The blood pressures (BP) were taken and or readings recorded prior to the administration of BP medications for Residents 2, 5. These deficiencies had the potential to: 1. Misrepresent the actual medications administered to residents, 2. Undercount the actual narcotics taken, residents may receive double doses of medications, and 3. 3. Misrepresentation of the narcotic…

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 two licensed nurses (licensed Vocational Nurse 4 [LVN 4] did not continue to provide care to residents in the facility during the period LVN 4's Cardiopulmonary resuscitation (CPR - is a lifesaving technique that's useful in many emergencies in which someone's breathing or heartbeat has stopped) certification had expired (no longer valid). This deficiency had the potential for LVN 4 not to stay up to date on the latest CPR techniques and placing the residents at increased risk to experience a decline in health status, function, hospitalization, and death. Findings: During a concurrent observation and record review of LVN 4's CPR card, indicated LVN 4's CPR card had expired on [DATE]. During an interview of LVN 4 on [DATE] at 4:04 PM, LVN 4 acknowledged that LVN 4's CPR card expired on [DATE]. LVN 4 stated LVN 4 took a CPR class on [DATE] but had not yet received the renewed CPR card via email but will follow-up. LVN 4 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and / or implement a resident specific care plan for one of three sampled residents (Resident 1) to monitor and provide interventions for Resident 1 ' s right leg contracture (tightening of muscle to prevent normal movement to a body part). This deficient practice caused an increased risk in the worsening of the right leg contracture. Findings: A review of Resident 1 ' s admission Record indicated the resident was originally admitted to the facility on [DATE], with diagnoses including Type II diabetes mellitus with diabetic chronic kidney disease (high blood sugar levels that is not well controlled and caused blood vessels in kidneys to become damage), unspecified osteoarthritis, unspecified site (a joint disease most common in older persons), and other specified disorders of bone density and structure unspecified site (a progressive bone disease that decreases bone mass and weakens bone structure). A review of Resident 1's Care…

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 maintain an infection control measure and prevention by failing to: 1. Ensure two of 16 sampled facility staff (Maintenance Assistant [MA] and Laundry 1 [LD1]) were wearing a mask while working together at the laundry room. 2. Ensure one of 16 sampled facility staff (Dietary Aid [DA1]) was wearing proper N95 (filtering facepiece respirator). DA1 modified the N95 mask with straps placed around his both ears. DA1 ' s N95 was also observed not covering his nose. 3. Ensure two of six sampled facility staff (Licensed Vocational Nurse 1 [LVN1] and Certified Nursing Assistant 2 [CNA2]) were wearing proper N95 fit tested mask when entering a COVID-19 (Coronavirus- a deadly respiratory disease transmitted from person to person) isolation room. LVN1 was observed wearing a Honeywell DC365 (type of N95 mask) and was fit tested for a BYD (type of mask). CNA2 was wearing Honeywell DC365 and was unsure of which N95 mask she was supposed to wear. These deficient practices had the potential to result in the spread of COVID-19…

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 observations, interviews, and record review, the facility failed to ensure their medication error rate was less than five percent (%). Five medication errors out of 30 total opportunities contributed to an overall medication error rate of 16.67 % affecting two of six residents observed for medication administration (Residents 113 and 363). The deficient practice of failing to administer medications in accordance with the attending physician's orders increased the risk that Residents 113 and 363 can potentially experience health complications related to delayed medication administration times and one missed medication which could have negatively impacted Resident 113's health and well-being. Findings: During an observation of medication administration for Resident 113 on 11/13/2023 at 9:02 AM, the Licensed Vocational Nurse (LVN 2) was observed administering the following medications to Resident 113: -Metformin (medication used to treat high blood sugar levels) 500 milligrams (mg, unit of weight) -Apixaban 2.5 mg (medication used to treat and prevent blood clots) -Cozaar 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.

Based on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent the growth of microorganisms that could cause food borne illness as evidenced by failing to label and date various food items and failing to dispose of food items past their use by and/or expiration date. These deficient practices had the potential to place residents in the facility at risk for food borne illness and/or contamination. Findings: During an initial kitchen tour on 11/13/2023 at 7:5 AM, the following were observed: -An undated and unlabled open bag of hamburger buns in the dry storage area. -Nine cartons of prune juice with a receive date of 8/11/2023, and a use by date of 9/16/2023 in the dry storage area. -An undated jar of mayonnaise in the walk-in refrigerator. -Undated frozen packages of roast beef, pork ribs, and corned beef in the meat freezer. -Six boxes of undated ice cream in Freezer 1. -An undated and unlabeled open bag of frozen French fries, an undated and unlabeled bag of frozen corn, and an undated and unlabeled open bag of frozen bread…

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 at least 80 square feet (sq. ft.) per resident for 14 of 29 resident rooms (Rooms 21, 22, 23, 24, 25, 26, 27, 28, 33, 34, 35, 36, 37, 38). This deficient practice resulted in inadequate maneuvering space for one of thirty three sampled residents (Resident 113) and insufficient working space for provision of care. Findings: A review of the Room Size Waiver letter, dated December 13, 2022, submitted by the former Administrator for Rooms 21, 22, 23, 24, 25, 26, 27, 28, 33, 34, 35, 36, 37 and 38 was indicated the rooms did not meet the 80 square foot requirement per federal regulation. The letter indicated that all residents in these rooms were not hindered or affected by the size of the rooms and have mobility with walkers and/or wheelchairs. All of the basic furnishings were available to each resident, and they have sufficient closet, drawer, and storage spaces. The letter indicated bathrooms were easily accessible to all residents.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced residents' dignity and respect for two of six sampled residents (Resident 30 and Resident 39) by standing over the residents while assisting them during a meal. This deficient practice had the potential to affect residents' sense of self-worth and self-esteem. Findings: a. A review of Resident 30's admission Record indicated the facility admitted the resident on 1/18/2021, with diagnoses including Parkinsonism (a brain condition that causes slowed movements, stiffness, and tremors) and repeated falls. A review of Resident 30's Quarterly Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 10/25/2023, indicated the resident had intact cognition (decisions consistent/reasonable) and was dependent for eating, toileting hygiene, showering and personal hygiene. During an observation on 11/13/2023 at 12:35 PM, in Resident 30's room, Certified Nursing Assistant 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.

Based on observation, interview, and record review, the facility failed to follow its policy titled Answering the Call Light, for one of 36 sampled residents (Residents 263). This deficient practice had the potential to result in a delay in care and services and the resident's inability to ask for assistance. Findings: A review of Resident 263's admission Record indicated the facility admitted the resident on 11/12/2023, with diagnoses including muscle wasting and atrophy (thinning of muscle mass) and hyperlipidemia (too many lipids [fats] in the blood). A review of the Physician's History and Physical of Resident 263, dated 11/13/2023, indicated Resident 263 had the capacity to understand and make decisions. During an observation on 11/13/2023 at 8:05 AM, Resident 263 was observed in his bed. Resident 263's call light was hanging down from his bed and not within his reach. Resident 263 was unable to find his call light to call for assistance. During an observation on 11/13/2023 at 8:07 AM with the facility's Director of Staff Development (DSD), Resident 263's call light was 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.

Based on interview and record review, the facility failed to ensure a resident's notice of transfer was provided to the resident's responsible party and to the State Long Term Care Ombudsman (public advocate) as soon as practicable for one of three sampled residents (Resident 46). This deficient practice had the potential to result in the resident's responsible party being unaware of how to contact the State agency and how to appeal a discharge or transfer if necessary. Findings: A review of Resident 46's admission Record indicated the facility admitted the resident on 1/7/2023 with diagnoses including acute respiratory failure (a condition when the lungs cannot release enough oxygen into the blood), congestive heart failure (a condition in which the heart does not pump blood as efficiently as it should), Type II diabetes (a condition that occurs when the body cannot use insulin properly resulting in persistently high blood sugar levels), atrial fibrillation (an irregular and often very rapid heart rhythm), malignant neoplasm of the right breast (breast cancer), hemiplegia (weakness…

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 correct tube feeding (TF, a form of nutrition that is delivered into the digestive system as a liquid) was administered as ordered for one of 33 sampled residents (Resident 165). This failure had the potential to cause malnutrition and increase Resident 165's blood sugar. Findings: A review of Resident 165's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing), intracerebral hemorrhage (a life-threatening type of stroke) and Type II Diabetes Mellitus (a disease that results in too much sugar in the blood). A review of the Physician's Orders for Resident 165, dated 10/30/2023, indicated to administer every shift Diabetisource AC (enteral feeding to help with the nutritional management of patients with diabetes or stress-induced hyperglycemia) at 55 milliliters per hour (ml/h, a unit of measurement for rates of administration) via enteral pump (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its Oxygen Administration policy and procedure for one of 36 sampled residents (Resident 24). Resident 24 was administered oxygen with no physician's order. This deficient practice had the potential to cause complications associated with oxygen therapy. Findings: A review of Resident 24's admission Record indicated the facility originally admitted the resident on 4/14/2022, and readmitted on [DATE], with diagnoses including acute respiratory failure ( a condition where there's not enough oxygen in the body) with hypoxia (low levels of oxygen in your body tissues). A review of Resident 24's Care Plan dated 4/10/2023, indicated Resident 24 had altered respiratory status (abnormal breathing) / difficulty breathing related to sleep apnea (a condition that causes you to stop breathing while sleeping) and acute respiratory failure. Resident 24's Care Plan further indicated the physician's order to administer oxygen at two liters 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.

Based on interview, and record review, the facility failed to obtain informed consent (a process by which residents or their responsible parties have the choice to accept or decline certain medication therapy or treatments once they are educated about the risks and benefits) prior to administering psychotropic medications (medications that affect brain activities associated with mental processes and behavior) for one of five sampled residents (Resident 25). This deficient practice denied Residents 25's right to be informed regarding the risks and benefits of psychotropic medication therapy. Findings: A review of Resident 25's admission Record indicated the facility admitted the resident on 10/17/2023, with diagnoses including anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with one's daily activities) and pneumonia. It also indicated the resident was discharged from the facility on 11/13/2023. A review of Resident 25's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 10/23/2023, indicated the resident'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 discard a bottle of Humulin R U-100 insulin (a short-acting medication used to treat high blood sugar) with an opened date of 10/1/2023 according to the manufacturer's requirements, affecting Resident 8 in one of two medication carts inspected (Medication Cart A). The deficient practice of failing to discard opened bottle of Humulin insulin within the date recommended by manufacturer (28 days after the open date) resulted in Resident 8 receiving 12 expired doses between 10/30/2023 and 11/14/2023. Findings: During an observation on 11/14/2023 at 11:55 AM of medication cart A with Licensed Vocational Nurse (LVN 3), the following medication was found expired more than the 28 days as per manufacturer's requirements. -One vial (a small container made of glass for holding liquid medications) of Humalog insulin for Resident 8 was found opened and dated 10/1/2023. During a concurrent interview, LVN 3 stated routine checks of the medication cart for expired medications occurred on the 11 PM - 7 AM shift. LVN 3 stated…

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 nursing staff failed to revise a care plan for at risk for falls for one of two sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for recurrent falls. Findings: A review of Resident 1's admission record indicated the facility readmitted Resident 1 was re-admitted to the facility on [DATE], with diagnoses that included a history of falling, osteoporosis and dementia (is a brain disorder that affects a person's ability to carry out daily activities and that may cause changes in mood and personality). A review of Resident 1 ' s high risk for falls care plan initiated 5/5/2020, indicated Resident 1 was at risk for falls related to dementia, poor safety judgement and a history of multiple falls. The goal indicated Resident 1 would be free of falls through the review date. The care plan interventions included to anticipate and meet the resident's needs, landing pads on floor, bed in low position, physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its Abuse Reporting and Investigation policy and procedure by failing to report an injury of unknown origin to the Department of Public Health (DPH) for one of three sampled residents (Resident 1). On 7/5/2023, Resident 1 developed skin discoloration, with a bump on the forehead and right upper eye lid. This deficient practice caused an increased risk of further injury for Resident 1. Cross Reference: F610, F689 Findings: A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including congestive heart failure (a condition where the body cannot pump blood well enough to give the body a normal body supply), end stage renal disease (occurs when the kidneys are no longer able to work at a level needed for day-to-day life), dependence on renal dialysis (a treatment to clean the body ' s blood when the kidneys are not able to), dementia (the loss of cognitive functioning, thinking,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its Abuse Reporting and Investigation policy and procedure by failing to investigate an injury of unknown origin for one of three sampled residents (Resident 1). On 7/5/2023, Resident 1 developed skin discoloration, with a bump on the forehead and right upper eye lid which was not investigated by the facility to determine if abuse was the cause. This deficient practice caused an increased risk of further injury for Resident 1. Cross Reference: F609, F689 Findings: A review of Resident 1's admission Record indicated the resident was re-admitted to the facility on [DATE] with diagnoses including congestive heart failure (a condition where the body cannot pump blood well enough to give the body a normal body supply), end stage renal disease (occurs when the kidneys are no longer able to work at a level needed for day-to-day life), dependence on renal dialysis (a treatment to clean the body's blood when the kidneys are not able to), 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.