Hollywood Premier Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to review/revise the care plans for two of two sampled residents (Resident 5 and Resident 27) by failing to: 1. Ensure to review/revise Resident 5's care plan when Resident 5's Foley catheter (a flexible tube inserted into the bladder to drain urine) was discontinued. 2. Ensure to review/revise Resident 27's care plan for smoking. This failure had the potential to result in a delay in care and interventions for Resident 5 and Resident 27.Findings:1. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 7/31/2025 with diagnoses that included diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), and dementia (a progressive state of decline in mental abilities). During a review of Resident 5's physician orders, dated 8/11/2025, 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 maintain safe resident smoking practices for two of three sampled residents (Resident 27 and Resident 79) investigated under the smoking care area by failing to: 1. Ensure Resident 27 did not to store smoking materials (cigarettes) in his room without supervision. 2. Ensure to provide Resident 79 with a smoking apron, ash tray, and an appropriate place to discard his used unlit cigarette butt (the end of a cigarette) while Resident 79 smoked outside the patio on 8/12/2025 at 9:37 AM. These failures had the potential for Resident 27 and Resident 79 to sustain injuries such as cigarette burns.Findings:1. During a review of Resident 27's admission Record, the admission Record indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer (a slow-healing open sore on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide appropriate assistance to residents using special eating equipment for two of four sampled residents by:1. Failing to place the plate guard (a crescent shaped dining aid designed to help prevent food from falling off the edge of a plate while eating) in the correct position for Residents 28 and 73.2. Failing to provide the correct assistive eating device for Resident 73.These failures had the potential to cause inadequate nutrition, weight loss, loss of dignity and confidence for Residents 28 and 73.Findings:1.During a review of Resident 28's admission Record, (undated), the admission Record indicated the facility admitted the resident on 9/13/24, with diagnoses including but not limited to generalized muscle weakness, dementia (a loss of brain function that occurs with certain diseases), and encephalopathy (a disease or condition that affects the brain's structure or function, causing it to not work properly).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 store food with a food label and/or date in one of four food storage areas. This failure had the potential to result in a foodborne illness (illness caused by the ingestion of contaminated food or beverages) for the residents.Findings:During a concurrent observation and interview on 8/11/2025 at 8:23 AM with the Dietary Supervisor (DS) in the facility kitchen, the following items were found in the freezer:1. 16 light brown meat patties in a freezer bag with no food label or date.2. A package of unopened frozen beef chorizo with manufacture date 10/24/2024 with no expiration date or best used by date.3. Frozen ham in a freezer bag dated 5/28/2025 with no expiration date or best used by date.4. A clear bag of chopped white pieces of meat with no food label or date.5. A freezer bag with meat had a food label whose ink had faded, making the name and date unreadable.During a concurrent observation and interview on 8/11/2025 at 8:23 AM with the DS, the DS stated there should be a label on the bags with the name of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control (a set of practices and procedures used to prevent the spread of infections, particularly in healthcare settings) practices for three of six sampled residents (Resident 2, Resident 70 and Resident 85), and for laundry services by failing to: - Ensure Certified Nursing Assistant 1 (CNA 1) washed/sanitized (clean it well enough to reduce germs to a safe, healthy level) her (CNA1) hands before and after she (CNA1) assisted Resident 2 on 8/11/2025 at 9:52 AM. -Ensure Resident 70's mattress and bed linen were not in direct contact with the facility's floor. -Ensure Certified Nursing Assistant 4 (CNA4) disinfected (cleaned) Resident 70's call light that was on the floor before CNA4 placed the call light (a device used by a patient to signal his or her need for assistance) on Resident 70's mattress on 8/12/2025 at 10:35 AM. -Ensure Resident 85's laundry was not folded in a non-designated (the hallway) for folding…

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 an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for antipsychotic medication (medication that affects brain activity and is used to treat mental health disorders) administration for one of two sampled residents (Resident 11) by failing to: -Ensure to complete an informed consent form (a formal conversation and a signed document that acknowledges the resident's understanding and agreement to the medication treatment plan) for the following medications: - risperidone (Risperdal, a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought])-quetiapine (Seroquel, a medication used to treat schizophrenia) -valproic acid (a medication used to treat bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs]).These failures had the potential for Resident 11 to experience…

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 provide an advanced directive (a legal document indicating resident preference on end-of-life treatment decisions) to the Responsible Party (RP, an individual who is responsible for handling a resident's finances and medical care) for one of three sampled residents (Resident 70).This failure had the potential for Resident 70 to receive unwanted medical treatments or experience a delay in medical care and had the potential to affect Resident 70's ability to exercise her right to formulate an advanced directiveFindings:During a review of Resident 70's admission Record (a document that collects essential information about a resident when they enter a healthcare facility), dated 8/13/2025, the admission Record indicated the facility admitted Resident 70 on 7/30/2025 with a diagnoses that included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), lack of expected normal physiological development (developmental delay or failure to reach expected physical, cognitive, or behavioral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident 's environment promoted and enhanced their quality of life when her bed mattress was placed directly on the floor for one of one sampled resident (Resident 70).This failure had the potential to result in Resident 70 acquiring a healthcare-associated infection (infections acquired during healthcare delivery and are not present at the time of admission), experiencing physical safety hazards and psychological harm; and affected the quality of care provided to Resident 70.Findings:During a review of Resident 70's admission Record (a document that collects essential information about a resident when they enter a healthcare facility), dated 8/13/2025, the record indicated Resident 70, a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis that included metabolic encephalopathy (brain dysfunction caused by underlying medical conditions that disrupt the body's metabolism [the process by which the body…

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 develop and implement a care plan for one of 19 sampled residents (Resident 34) for fall prevention to address the resident's preference of raising his bed to the bed's maximum height.This deficient practice had the potential for Resident 34 to fall and sustain an injury.Findings:During a review of Resident 34's admission Record, the admission Record indicated the facility admitted the resident on 3/7/2025 with diagnoses that included lack of coordination, unsteadiness on feet, idiopathic aseptic necrosis (a medical condition where bone tissue dies because of a disruption in its blood supply, and no known cause for this disruption can be identified) of right femur (thigh bone), left wrist drop (you can't lift your left wrist or fingers, and your hand hangs down limply), other cord compression (pressure on your spinal cord - tube of tissue that carries nerve signals from your brain to the rest of your body and back), spinal stenosis cervical region (a narrowing of the spinal canal in the neck that can cause…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide appropriate treatment to prevent a urinary tract infection (UTI, an infection in the bladder/urinary tract) for one of 19 sampled residents (Resident 5), when there was missing documentation of a post void residual (PVR, the amount of urine remaining in the bladder after urination) every six hours as ordered by the physician. This failure had the potential to result in Resident 5 developing a UTI. Findings: During a review of Resident 5's Face Sheet (admission record), the Face Sheet indicated Resident 5 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), and dementia (a progressive state of decline in mental abilities). During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), the MDS 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 interview and record review, the facility failed to ensure that one of four sampled residents (Resident 50) received her 6AM dose of hydrocodone-acetaminophen (a pain medication to treat moderate to severe pain) on 8/11/2025. This failure had the potential to result in Resident 50 experiencing unrelieved pain. Findings:During a review of Resident 50's Facesheet (admission Record), dated 8/11/2025, the Facesheet indicated Resident 50, a [AGE] year old female, was admitted to the facility on [DATE], with diagnosis that included systemic lupus erythematosus (a condition where the body's immune system attacks its own healthy tissues and organs), chronic pain syndrome (a condition where someone experiences persistent pain), and unspecified dementia (a non-specific type of dementia where a person's thinking, memory and reasoning declines). During a review of Resident 50's Minimum Data Set (MDS, an assessment tool used to screen a resident), dated 8/1/2025, the MDS indicated Resident 50 experiences occasional…

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 medication bubble packs for three of 87 sampled residents (Resident 26, Resident 59, and Resident 69) were labeled with expiration dates. This failure had the potential to result in the administration of expired or deteriorated medications to the residents. Findings: During a review of Resident 26's Face Sheet (admission record), the Face Sheet indicated Resident 26 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought), hypothyroidism (a condition in which the thyroid gland does not make and release enough hormone into the bloodstream), and diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 26's Minimum Data Set (MDS, a resident assessment tool) dated 6/16/2025, the MDS indicated Resident 26 required moderate assistance with 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 one of 19 sampled resident (Resident 34) had the call light (a device used by a patient to signal his or her need for assistance) within reach.This failure had the potential for Resident 34 not to be able to call for assistance and had the potential not to meet Resident 34's needs. Findings:During a review of Resident 34's admission Record, the admission Record indicated the facility admitted the resident on 3/7/2025 with diagnoses that included right side sciatica (pain that travels from the buttocks down the leg), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), spinal stenosis (a narrowing of the spinal canal, the bony tunnel that protects the spinal cord and nerves in your back) cervical region (neck), idiopathic aseptic necrosis of the right femur (a condition where the bone death of the right thigh bone happens for no known reason because a loss of blood supply), other cord compression (something is squeezing or putting pressure on your spinal…

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 sampled resident (Resident 3) had a signed informed consent for psychotropic medications (drugs that affect the brain and nervous system, altering mood, behavior, and cognitive function). This failure had the potential for lack of education regarding the use of a psychotropic medication for Resident 3. Findings: A review of Resident 3 ' s admission record indicated the resident was admitted to the facility on [DATE], with diagnoses including anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and paraplegia (loss of movement and/or sensation, to some degree, of the legs). A review of Resident 3 ' s Minimum Data Set (MDS – a resident assessment tool) dated 9/9/24, indicated the resident was alert and oriented with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to allow one of two sampled residents (Resident 2) to return to the facility following hospitalization at the General Acute Care Hospital (GACH). Resident 2, who had a bipolar disorder (associated with mood swings), was deemed medically stable to return to the facility but remained at the GACH for over three weeks. This deficient practice placed Resident 2 at risk for discharge from the facility against her needs or wants and a potential for psychosocial harm of not returning to primary residence at the facility. Findings: A review of the admission record indicated Resident 2 was re-admitted to the facility on [DATE] with diagnoses including schizoaffective disorder bipolar type (combination of symptoms of schizophrenia and mood disorder), bipolar disorder, and anxiety disorder (intense, excessive, and persistent worry and fear about every day). A review of Resident 2's quarterly Minimum Data Set (MDS - a resident assessment tool) dated 12/11/2024,…

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

Based on observation, interview, and record review, the facility failed to maintain a clean, sanitary, and accident-free environment in two of two shower rooms, Shower room A and Shower room B. This deficient practice had the potential for residents to be exposed to dirt, spread of disease - causing organisms, and accidents. Findings: During an observation of Shower Room A on 11/5/2024 at 11:22 a.m., observed shower room A with Social Services Director (SSD) and observed soiled and wet Mepilex (foam dressing is designed to help manage non to low exuding acute and chronic wounds) on the floor. During an observation of Shower Room A on 11/5/2024 at 11:23 a.m., observed shower room B with SSD and observed soiled and wet face towel on the floor, and hair on the water drain. During an interview with Housekeeping 1 (HS 1) on 11/5/2024 at 11:28 a.m. Was called to observe the shower rooms and he stated the shower room are not clean, the mepilex should not be on the floor and should be tossed out after each shower. HS 1 further stated, the face towel and hairs should not be on the floor as…

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 residents receive adequate supervision and assistance based on the residents ' individual needs to prevent accidental injuries for one of five sampled residents (Resident 2) by failing to ensure Certified Nursing Assistant 3 (CNA 3) was awake and alert while in Resident 2's room. This deficient practice had the potential for resident to experience unavoidable accidents. Findings: A review of the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including urinary tract infection (UTI- an infection in the bladder/urinary tract), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and unspecified dementia (a progressive state of decline in mental abilities). A review of the Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/16/2024, indicated Resident 2 ' s cognitive (mental…

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 residents were served the food preferences listed on the lunch meal ticket (physician ordered diet with resident food preferences) and received substitute meal options of similar nutritive value when one of four sampled residents (Resident 1)'s food preferences were not honored when Resident 1 verbalized, she does not like Mocha Mix (liquid non-dairy creamers). This deficient practice had the potential to result in decreased meal satisfaction, decreased nutritive value for the meal and weight loss. Findings: A review of the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure) and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). A review of the Minimum Data Set (MDS - a federally mandated resident assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide and document preparation and orientation to ensure a safe and orderly facility-initiated discharge for one of two sampled residents (Resident 1). Resident 1 and/or Family Member 1 (FM 1) were not involved in the post-discharge planning process. There was no post discharge plan developed for 24 hours prior to Resident 1's discharge and the post discharge plan was not reviewed with Resident 1 and FM 1. This deficient practice had a potential for Resident 1 to have an unsafe facility-initiated discharge. Findings: A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including systemic lupus erythematosus (chronic disease that causes the body's immune system to attack healthy tissues and cells), schizophrenia (a mental illness that is characterized by disturbances in thought), prediabetes (condition where your blood sugar levels are higher than normal but not yet high…

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 resident ' s belongings were protected from loss for one of three sampled residents (Resident 1). For Resident 1 who reported on 8/17/24 that her money in the amount of 40 dollars ($) was missing, the facility failed to search and investigate Resident 1 ' s claim that Resident 1 lost $40. This deficient practice resulted in Resident 1 not given her right to keep her possessions safely while at the facility. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 6/25/24 and readmitted on [DATE] with diagnoses including congestive heart failure (CHF, a heart disorder which causes the heart not to pump blood efficiently sometimes resulting in leg swelling) and chronic obstructive pulmonary disease (COPD, a chronic lung [breathing organ] disease causing difficulty in breathing). During a review of the Nursing Progress Note dated 8/17/24 at 6:02 p.m. indicated Resident 1 stated that she lost $40. The Notes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow physician order for one of three sampled residents (Resident 1). For Resident 1, the facility failed to follow the physician order to monitor Resident 1 for sedation when Resident 1 was administered methocarbamol tablet (muscle relaxant) 500 milligrams (mg. metric unit of measurement, used for medication dosage and/or amount) orally three times a day and gabapentin (medication used to treat seizure or nerve pain) 300 mg. orally three times a day. These deficient practices had the potential to cause respiratory distress (slow and ineffective breathing) for Resident 1. Findings: During a review of the admission Record indicated the facility admitted Resident 1 on 6/25/24 and readmitted on [DATE] with diagnoses including congestive heart failure (CHF, a heart disorder which causes the heart not to pump blood efficiently sometimes resulting in leg swelling) and chronic obstructive pulmonary disease (COPD, a chronic lung [breathing organ] 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 interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had a diagnosis of congestive heart failure (the heart's inability to pump blood throughout the body efficiently), received treatment and care in accordance with professional standards of practice. Resident 1 did not have blood pressure parameters for the blood pressure medications administered. This deficient practice had the potential to jeopardize the safety and well-being of the resident. Findings: A review of Resident 1's history and physical dated 8/19/2024 indicated the resident was discharged from a General Acute Hospital (GACH) for cough and congestion, shortness of breath, and chest pain for one week. A review of Resident 1's face sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (a lung diseases that block airflow and make it difficult to breathe), cardiomyopathies (diseases that affect the heart muscle),…

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 revise the care plan (a document outlining a detailed approach to care customized to an individual resident's need) for two of six sampled residents (Resident 33 and Resident 83) as evidenced by: 1. Failing to update the tube feeding (TF, a form of nutrition that is delivered into the digestive system as a liquid) care plan for Resident 33 to reflect current physician orders. 2. Failing to update the antibiotic (medicines that help stop infections caused by bacteria) care plan for Resident 83 to reflect current physician orders. These deficient practices had the potential for Resident 33 and Resident 83 to not have their needs met and receive inadequate care. Findings: 1. A review of Resident 33's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included gastrostomy (G-Tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach), dysphagia (difficulty…

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

Based on interview and record review, the facility failed to maintain a yearly staff competency and mandated reporting elder and dependent adult abuse training for two of five sampled staff members. This deficient practice 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: During a review of Certified Nursing Assistant 3 `s (CNA 3) employee file on 7/25/2024, the employee file indicated missing annual employee competency skills check and mandated elder and dependent adults abuse reporting training records for the years from 2018 to 2022. During a review of CNA 4's employee file on 7/25/2024, the employee file indicated missing annual employee competency skills check and mandated elder and dependent adults abuse reporting training records for the year 2022. During a concurrent interview and record review on 7/25/2024 at 2 PM with Director of Staff Development (DSD), five sampled employees (CNA3, CNA 4, Licensed Vocational Nurse 2, Treatment Nurse 2, and Registered Nurse 1)…

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

Based on interview and record review, the facility failed to identify, address, and/or obtain necessary services for the behavioral health care needs for one of three sampled residents (Resident 9) . This deficient practice had the potential to lead to the inadequate care of Resident 9. Findings: A review of Resident 9's admission Record (Face Sheet) indicated the facility admitted the resident on 3/28/2024, with diagnoses including schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), and heart failure (a condition that develops when your heart does not pump enough blood for your body's needs). A review of Resident 9's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 7/3/2024, indicated the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 9 had diagnoses of schizophrenia, did not exhibit ( display) rejection of care (behavior that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure secure storage of controlled medications (a term used to describe prescription medications with high abuse potential) and non-controlled medications for one of six sampled residents (Resident 77) during medication administration. 2. Ensure proper labeling of insulin (a medication used to treat high blood sugar), per facility's policies and procedures (P&P) titled, Medication Labeling and Storage and manufacturer's requirements, affecting one resident (Resident 66) in one of two inspected medication carts (Middle Medication Cart). These failures had the potential to result in medication errors, misuse, drug loss, diversion, and accidental exposure to controlled substances, and increased the risk for Resident 66 to receive insulin that had become ineffective or toxic due to improper labeling possibly leading to health complications and hospitalization. Findings: 1. During a review of Resident 77's admission Record (a document…

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 observe proper food storage and handling when: 1. A package of cookies was found left opened and undated on a shelf in the kitchen's pantry. 2. The [NAME] (Cook 1) went to rinse a towel in the sink and the cook did not wash his hands prior to serving prepared food during the facility's lunch tray line. These failures had the potential to result in residents acquiring food borne illnesses. Findings: During a concurrent observation and interview during the initial kitchen tour on 7/22/2024 at 7:50 AM, a package of cookies was found opened and undated in the back of a shelf in the kitchen's pantry. Showed [NAME] 1 the opened package of cookies and per [NAME] 1, all packaged foods that are opened should be stored in a new container and dated with the open date immediately after opening. [NAME] 1 then proceeded to discard the opened package of cookies. [NAME] 1 stated that it was important to properly store foods because the food is at risk of getting spoiled, which can potentially cause residents to get sick if…

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 2. A review of Resident 85's admission Record indicated the facility admitted the resident on 7/5/2024 with diagnoses including lack of coordination, unsteadiness on feet, and fatty liver (a condition in which fat builds up in your liver). A review of Resident 85's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 7/12/2024, indicated the resident was cognitively intact (has the ability to think, understand, and reason). The MDS indicated Resident 85 required partial/moderate assistance for eating, oral hygiene, and upper body dressing. The MDS indicated Resident 85 required substantial/maximal assistance for lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 85 was dependent on assistance for toileting hygiene, and showering/bathing self. The MD further indicated Resident 85 was frequently incontinent (unable to control) of urine and always incontinent of bowel. During a concurrent observation and interview on 7/22/2024 at 8:55 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain a safe and home like environment for one of two sampled residents (Residents 14) by not maintaining and repairing a damaged residents' floor surface. This failure had the potential for unsafe resident`s environment and placed the resident and staff at risk for fall hazard resulting in injury. Findings: During the survey initial tour observation on 7/22/2024 at 9:52 AM, Resident 14 room (room [ROOM NUMBER]) was observed with the following: a. The floor surface appeared to be made of vinyl flooring. b.There was a crack and chip across the entire floor length from entrance to the back wall. c. Uneven and slanted surface approximately by half inch. d.Approximately a third of the room's floor surface alongside the cracked and chipped line was slanted. During an interview on 7/22/2024 at 9:52 AM, Resident 14 stated that he has been in this room for the last few months and the damaged floor surface had been there since his admission 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 create a care plan for Diflucan (Fluconazole, a medication that treats and prevents fungal infections) for one of six sampled residents (Resident 83). This deficient practice had the potential for Resident 83 to not have their needs met and receive inadequate care. Findings: A review of Resident 83's admission Record indicated the resident was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included an elevated white blood cell count (an increase in cells in the blood that fight infections), adult failure to thrive (a decline in older adults that manifests as a downward spiral of health and ability), and urinary tract infection (UTI, an illness in any part of the urinary tract, the system of organs that makes urine). A review of Resident 83's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 6/4/2024, indicated the resident was cognitively intact (had the ability to think,…

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

Based on observation, interview, and record review the facility failed to provide services that promote the prevention of pressure ulcer injury (injury to the skin caused by pressure) for one of two sampled residents (Resident 190) as evidenced by failing to make sure the low air loss mattress (LALM-mattress designed to treat and prevent pressure ulcers) setting was correct. This deficient practice had the potential for worsening of pressure ulcer and harm to Resident 190. Findings: A review of Resident 190's admission Record indicated the facility admitted the resident on 7/10/2024, with diagnoses including stage three (full thickness skin loss) pressure ulcer (injury to the skin caused by pressure) of unspecified region of back, and unstageable pressure ulcer (a type of pressure injury that occurs due to prolonged pressure on a specific area of the skin, resulting in the lack of blood flow and oxygen to the tissue) of right ankle and right heel. A review of Resident 190's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 7/17/2024, indicated 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 clarify the strength and dose on a physician order for docusate sodium (a medication used to relieve difficulty passing stool and to treat constipation [a term used to describe difficulty passing stool]) liquid, for one of six sampled residents (Resident 1.) This failure had the potential to result in Resident 1 receiving inadequate or excessive dosage of docusate sodium and increased risk for adverse consequences such as constipation or diarrhea due to not receiving medication per physician orders. Findings: During a review of Resident 1's admission Record (a document containing demographic and diagnostic information), dated 07/23/2024, the admission record indicated, the facility admitted Resident 1 on 12/30/2013, and readmitted on [DATE], with diagnoses including gastro-esophageal reflux disease ([GERD] - a medical term for a condition when stomach acid flows back into esophagus [the tube connecting mouth and stomach] without…

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 Dietary staff had the appropriate competencies and skills when: 1. Dietary Aide (DA 1) failed to verbalize and follow the manufacturer's guidelines of QT-40 test paper (a type of test strip) when checking the Quaternary Ammonium Compounds (Quats, a group of chemicals used to disinfect surfaces and equipment) sanitizer concentration. This failure had a potential to result in potential cross-contamination (a transfer of bacteria from one object to another), unsanitized food preparation areas and bacterial growth to food that could lead to food borne illness (an illness caused by contaminated food and beverages) for the 88 residents who received food from the kitchen. Findings: During a concurrent observation and interview on 7/23/2024 at 9:05 AM, with DA 1, observed DA 1 demonstrate red bucket sanitizing solution testing. Observed DA 1 fill red bucket with a sanitizer solution labeled Keystone Multi-Quat Sanitizer by the three-compartment sink. DA 1 dropped sanitizer test strip in the red bucket with…

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

Based on observation, interview, and record review the facility failed to maintain sanitary environment and prevent infestation of flies in and around a waste segregation and disposal area by leaving a trash bin open and overfilled with food leftovers and waste materials. This failure had the potential to affect residents in the facility, flies infecting and causing disease outbreaks. Findings: During an observation on 7/23/2024 at 2:34 PM, the facility waste segregation and disposal area was observed with two open trash bins filled with food leftovers, trash spilled over, and flies swarming in and around the open trash bins. During an interview on 7/23/2024 at 2:40 PM, with the facility Maintenance Supervisor (MS), MS was shown the open trash bins filled with leftover food items and waste materials. There were at least ten or more flies swarming in and around the open trash bins. MS stated pest control is visiting the facility regularly. MS stated flies are potential risks for infection outbreak and having open and overfilled trash bins are not acceptable practice of the facility.…

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

Based on interview and record review, the facility failed to ensure residents were informed in advance of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior) and hypnotic medication (drugs that induce or prolong sleep in patients with sleep disorder) for one of three sampled residents (Resident 1). This deficient practice violated the resident ' s right to make an informed decision regarding the use of psychoactive medications. Findings: A review of Resident 1 ' s admission Record indicated the facility initially admitted Resident 1 on 6/12/2024 with diagnoses including schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), and diabetes type 2 (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly). A review of Resident 1 ' s History…

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 initiate a Zyprexa care plan (antipsychotic medication [a class of psychotropic medication used to manage psychosis [including delusions, hallucinations, paranoia, or disordered thought]) for one of three sampled resident (Resident 1). This deficient practice resulted in a failure to meet the resident ' s psychosocial needs. Findings: A review of Resident 1 ' s admission Record indicated that the facility initially admitted Resident 1 on 6/12/2024 with diagnoses including schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), and diabetes type 2 (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly). A review of Resident 1 ' s History and Physical, dated 6/20/2024, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide direct supervision of residents when smoking in the facility's smoking patio as indicated in the facility's policy and procedure (P&P) titled, Smoking Policy - Residents dated August 2022, for three of three sampled residents (Residents 1, 2 and 3). As a result, on 6/20/2024 Resident 1 hit Resident 2 on the chin and also hit Resident 3 on the forehead while unsupervised in the smoking patio. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 6/12/2024, with diagnoses including schizophrenia (a serious mental illness that affects how a person would think, feel, and behave), depression (constant feeling of sadness and loss of interest, which stops you doing your normal activities), and epilepsy (disorder of the brain characterized by repeated seizures). A review of Resident 1's Minimum Data Set (MDS - a standardized resident assessment and care screening tool) dated 6/19/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse (intentional bodily injury) for one sampled resident (Resident 1) by failing to ensure Resident 2's whereabouts every hour per the Physician's Order. This deficient practice resulted in Resident 1 being subjected to physical abuse after Resident 2 poked Resident 1 with a grabbing stick, resulting in Resident 1 having pain to the right knee. Findings: a. A review of the admission Record indicated the facility initially admitted Resident 1 on 9/5/2023 and re-admitted the resident on 3/16/2024 with diagnoses including cardiomyopathy (disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), heart failure and functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord). A review of the History and Physical (H&P) dated 5/13/2024, 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 interviews and record reviews the facility failed to follow physician orders for laboratory (labs) services for one out of three residents (Resident 1) receiving two anticonvulsant medications Keppra (levetiracetam) and Depakote (is made by combining valproic acid and sodium valproate). This deficient practice of failing to monitor Resident 1 ' s labs placed Resident 1 at risk for medication related adverse reactions. Findings: During a review of Resident 1's admission Record (a document containing demographic and diagnostic information), dated 5/22/2024, the admission record indicated that the resident was admitted on [DATE] and readmitted on [DATE], diagnoses included, Dementia (progressive loss of memory), Bipolar Disorder (a condition of major mood swings), and seizures (a sudden rush of abnormal electrical activity in your brain). A review of Resident 1's History and Physical (H&P), dated 3/12/2024, Resident 1 ' s H&P indicated the resident has fluctuating capacity to understand and make decisions.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the consultant pharmacist (CP) completed a thorough review of one of three sampled residents (Resident 1) medical records from 12/29/2022 to 5/22/2024. By failing to identify and report to physician when laboratory (labs) tests ordered for medication management, were not done. This deficient practice increased the risk that medication therapy for Resident 1 not being optimized for the best possible health outcomes and could have led to a negative impact on the resident ' s overall physical, mental, and psychosocial well-being. Findings: During a review of Resident 1's admission Record (a document containing demographic and diagnostic information), dated 5/22/2024, the admission record indicated that the resident was admitted on [DATE] and readmitted on [DATE], diagnoses included, Dementia (progressive loss of memory), bipolar disorder (a condition of major mood swings), and seizures (a sudden rush of abnormal electrical activity in your brain).…

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 it's policy and procedures (P & P) on abuse for two of four sampled residents (Resident 1 and Resident 2). The facility failed to report to the state survey agency (SSA) and the appropriate agencies as indicated in the facility Abuse Policy when on: 1. 5/8/24, Resident 1 and Resident 2 were verbally aggressive to one another, calling each other derogatory names and racial slur. 2. 5/9/24, Resident 1 threw a shower sponge on Resident 2 and the shower sponge hit Resident 2 ' s leg. Resident 2 called the police and wanted to press charges against Resident 1. 3. 5/14/24, Resident 1 alleged that Resident 2 wanted to kill and rape Resident 1. These deficient practices resulted in delay of investigation to ensure Resident 1, and Resident 2 felt safe while in the facility. Findings: 1.During a review of the admission Record indicated the facility admitted Resident 1 on 6/17/21 and readmitted on [DATE] with diagnoses including anxiety and bipolar…

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 sampled resident (Resident 1) had a comprehensive care plan that was updated and revised with effective interventions to prevent resident harm. Resident 1 refused padded side rails and laboratory tests, but there was no appropriate response from facility. This deficient practice caused an increased risk in harm to Resident 1. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 9/7/2021, with diagnoses including dementia (loss of memory, thinking, and reasoning), bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs to lows), anemia (a condition that develops when your blood produces a lower than normal amount of healthy red blood cells), and seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). A review of the Physician's Order dated 9/7/2021, indicated Resident 1 was to receive Keppra (an anti-epileptic drug, also called an…

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 care plan for conferences were held on a regular basis for one of three sampled residents (Resident 1). For Resident 1 the facility failed to: 1. Ensure the care plan meetings were held on a regular basis and as needed. 2. Ensure the care plan were updated after the meeting that would include the discharge goal and discharge preferences of Resident 1 and his Responsible Party (RP). These deficient practices had the potential to fail to meet the needs and preferences of Resident 1 and his RP. Findings: A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 6/20/23 with diagnoses including anxiety disorder and anorexia (loss of appetite and inability to eat). A review of Resident 1's Interdisciplinary Team Review (IDT, group of health care professionals with various areas of expertise who work together toward the goals of the resident) dated 6/27/23 at 6:16 p.m., indicated Resident 1's RP had a plan of transferring Resident 1 to a facility closer to the RP's home. The IDT review…

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 resident received treatment and care in accordance with professional standards of practice for one of five sampled residents, Resident 1 by failing to: 1. Implement facility 's policy and procedures (P&P) titled, Death of a Resident, Documenting when Resident 1 expired on [DATE]. 2. Report the unusual occurrence as required by federal or state regulations which affect the health, safety, or welfare of residents, employees or visitors. This deficient practice placed Resident 1 in incomplete assessment and documentation required per facility's P&P upon death and resulted in delay of onsite inspection by the State Agency to ensure resident's death was thoroughly investigated. Findings: A review of Resident 1's admission Record indicated resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including unspecified atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to revise the care plan (written guide that organizes information about the resident's care) for one of three sampled residents (Resident 1) who was a moderate risk for elopement, after the resident eloped (departs the health care facility unsupervised and undetected) from the facility on 10/12/2023. This deficient practice had the potential to place Resident 1 at further risk for elopement and injury related to elopement. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (chronic and severe mental disorder that affects how a person thinks, feels, and behaves), unsteadiness of feet, and generalized muscle weakness (lack of physical or muscle strength and the feeling that extra effort is required to move your arms, legs, or other muscles). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop a comprehensive care plan for two of five sampled residents (Resident 4, and Resident 5) when Resident 4 refused the influenza (a high contagious viral infection of the respiratory passages), pneumococcal (lung inflammation caused by infection), and COVID-19 (Coronavirus disease 2019 is an infectious disease caused by virus that can result in different symptoms from mild to severe respiratory illnesses and is spread during close contact and through the air from person to person) vaccinations. The facility failed to develop a care plan when Resident 5 refused the influenza vaccination. These deficient practices had the potential to negatively affect Resident 4, and Resident 5's quality of care and services received. Findings: a.)A review of Resident 4's admission Record indicated the facility admitted the resident on 8/5/2022, with diagnoses including multiple sclerosis (a condition that affects the brain and spinal cord), and muscle 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 interview, and record review, the facility failed to implement policies and procedures related to COVID-19 (Coronavirus disease 2019 is an infectious disease caused by virus that can result in different symptoms from mild to severe respiratory illnesses and is spread during close contact and through the air from person to person) vaccination for one of five sampled residents (Resident 2). Resident 2 received the COVID-19 Bivalent Booster (an extra dose of vaccine after the original doses that protects against two strains of COVID-19) without the informed consent of his Responsible Party (RP). This deficient practice resulted in excluding Resident 2's Responsible Party in making an informed decision for Resident 2 regarding COVID-19 vaccination. Findings: A review of Resident 2's admission Record indicated the facility admitted the resident on 6/30/2023, with diagnoses including Parkinson's disease (a brain disorder that causes uncontrollable movement such as shaking) and suicidal ideation (thoughts…

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 Resident 4 who was admitted with pressure injury stage 2 (PI -when the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful) does not worsen to stage 3 (full-thickness skin loss potentially extending into the subcutaneous tissue layer) for 1 of two sampled resident (Residents 4). This deficient practice had the potential for Resident 4 not to receive appropriate care and treatment for the pressure injury (sores (ulcers) that happen on areas of the skin that are under pressure). Findings: A Review of Resident 4's admission Record, indicated the facility admitted the resident on 6/20/2020, readmitted [DATE], and 12/29/2021, with diagnoses including Pneumonia (infection in the lungs), pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) of unspecified site). A review of Resident 4's Minimum Data Set (MDS- a standardized assessment and care -screening…

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 medication error rate was less than five percent for two of four sampled residents who did not receive their scheduled medications (Lexapro 10 milligrams (mg) - used to treat depression and generalized anxiety disorder) and Folic Acid (used to or prevent anemia (making red blood cells) and Renvela (medication to lower high blood phosphorus (phosphate) levels in patients who are on dialysis) that were not available in the facility at the time of medication administration. This failure of not administering resident 56's and 41's medications resulted to three medication errors out of twenty-nine (29) opportunities resulted to medication administration error rate of (10.3) percent (%), that exceeded the 5% threshold. Findings: a. A review of Resident 56's admission Record indicated the resident was readmitted to the facility on [DATE], with diagnoses that included but were not limited to major depressive disorder and rhabdomyolysis…

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 menu as written for residents who were on regular and mechanical soft diets. The residents received less Corn bread stuffing than what was written on menu. This deficient practice had the potential to result in weight loss in 61 residents due to inadequate calorie intake. Findings: During an observation of the tray line served for lunch on 1/4/22, at 12:03 p. m., residents who were on mechanical soft and regular diet. The cook was observed serving using #12 scoop that provided 2.5 ounces (oz.) of corn bread dressing instead of #8 scoop or 4 ounces (oz). A review of the facility's lunch menu dated 1/4/22, the following items was to be served: Chicken, Maple with gravy, Corn bread stuffing (#8 scoop) ½ cup, green beans (#8 scoop) ½ cup, pumpkin gingerbread with whipped cream and milk. During an interview with cook 2 on 1/4/22, at 12:30 p. m., stated the menu was checked to verify the portion sizes and which size scoops needed 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, staff interviews, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1.Food contact surfaces and food preparation counters were not sanitized with adequate amount of sanitizer per manufacture guidelines. Sanitizers and disinfectants are used on food contact surfaces to prevent foodborne illness. Sanitizers are used to reduce microorganisms to safe levels determined by public health codes and regulations. 2. Large amount of ice buildup inside the walk-in freezer door, vinyl strip air curtains (air curtains are devices used to separate two spaces from each other, particularly at an exterior entrance. An air curtain is commonly used as walk-in cooler or freezer doors, usually to keep cold temperature and even food odors and aromas from escaping the refrigeration unit), door frame, floor and on the food box. This had the potential to affect food quality and the inappropriate storage for food. These failures had the potential to result in harmful bacteria growth and cross contamination…

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

Based on observation, interview and record review, the facility failed to ensure that staff was not standing and bending over when assisting the resident with meal during lunch time in a manner that will promote or enhance the resident's dignity and respect for one of one sampled resident (Resident 8). This deficient practice had the potential to cause psychosocial harm to the residents and violates Residents' right to be treated with dignity. Findings: A review of Resident 8's admission Record indicated the facility admitted the resident on 7/6/2020, with diagnoses that included but were not limited to cerebral infarction (stroke-when blood supply to part of the brain is interrupted or reduced preventing brain tissue from getting oxygen), hemiplegia (paralysis of one side of the body), and muscle weakness, A review of Resident 8's Minimum Data Set (MDS-a standardized assessment and care-screening tool) dated 1/7/2022, indicated the resident had severely impaired cognition (never/rarely made decisions), required total dependence and one-person physical assistance for toilet use, and…

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

Based on observation and interview, the facility failed to provide a safe, clean, and comfortable home like environment for two of three sampled residents, (Residents 32 & 75). This deficient practice had the potential for Residents 32 and 75 leaving in unsanitary environment which had the potential resulting to poor quality of life. Findings: During an initial tour of the facility on 1/4/2022, at 9:30 a.m., a bedside curtain with a brown stain was observed in Resident 75's room. A pale of water with brown substance was observed next to Resident 75's bed who was receiving enteral feeding (way of delivering nutrition directly to your stomach or small intestine). On 1/4/2022, at 9:40 a.m., during an interview with the maintenance director (MD), who stated and confirmed that the bed side curtain had brown stain which made the environment uncomfortable and not home like for the residents. A review of the facility's policy and procedures titled, Homelike Environment, undated, indicated the facility staff and management shall maximize, to the extent possible, the characteristics of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a plan of care for pressure injury stage 2 (PI -when the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful) was developed, implemented and revised when the resident stage 2 PI was reclassified as stage 3 (full-thickness skin loss potentially extending into the subcutaneous tissue layer) with measurable objectives, timeframe, and nursing interventions to meet the residents' needs for one of two sampled resident (Residents 4). This deficient practice had the potential for Resident 4 not to receive appropriate care and treatment for the pressure injury (sores (ulcers) that happen on areas of the skin that are under pressure). Findings: A Review of Resident 4's admission Record, indicated the facility admitted the resident on 6/20/2020, readmitted [DATE], and 12/29/2021, with diagnoses that included but were not to Pneumonia (infection in the lungs), pressure ulcer (injuries to skin and underlying…

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 review and revise the psychotropic medication (medication that affects behavior, mood, thoughts, or perception) care plan for one sampled resident (Resident 47). This deficient practice had the potential to cause inadequate care and harm to Resident 47. Findings: A review of Resident 47's admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included but were not limited to schizophrenia (a mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions, and relate to others), bipolar (a mental health condition that causes extreme mood swings), and anxiety (a disorder that causes intense, excessive, and persistent worry and fear about everyday situations). A review of Resident 47's Minimum Data Set (MDS - a standardized assessment and care- screening tool) dated 11/23/2021, indicated the resident's cognitive skills of daily decision making…

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 resident's medication Lexapro (a medication used to treat depressive disorder) 10 milligrams (mg) and folic acid (vitamin) 1 milligram (mg) were refilled in a timely manner for one of 21 sampled residents (Resident 56). This deficient practice had the potential for the resident missing and not receiving the medications as scheduled and could resulted to ineffective therapeutic level of the medication in Resident 4's blood stream thereby not treatment the resident's anxiety and anemia (low red blood cell in the body) Findings: A review of Resident 56's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 12/6/2021, indicated the resident's cognitive skills of daily decision making were intact. The MDS indicated the resident required assistants with activities of daily living. On 1/6/2022, at 10:30 a.m., during medication observation, Licensed Vocational Nurse 5 (LVN 5) was observed administering 9 a.m. medications at 11 a.m. LVN 5 late medication passes was due to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide showers according to pre-determined schedule for one of 25 sampled residents (Resident 51), who required assistance with activities of daily living (ADL). This deficient practice resulted in Resident 51 not receiving a shower and had the potential to negatively impact Resident 51s self-esteem. Findings: A review of the admission record indicated Resident 51 was admitted to the facility on [DATE], with diagnoses that included dementia (memory loss), muscle weakness, dysphagia (inability to swallow), and end stage renal disease (loss of kidney function). A review of Resident 51's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated 11/30/2021, indicated the resident was cognitively intact. Resident 51 required extensive one-person assist with toilet use, personal hygiene, and transfers. A review of Resident 51's Plan of Care, dated 11/23/2021, indicated Resident 51 required extensive one-person assistance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide supervision to prevent injury and harm when Residents 18 &73 were smoking in the patio for two of four sampled residents. This deficient practice had the potential of placing Residents 18 & 78 at risk for injuries and harm related to unsupervised smoking. Findings: a. A review of Resident 18's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included but were not limited to type 2 diabetes (high blood sugar), hypertension (high blood pressure), and hyperlipidemia (elevated levels of fat in the blood). A review of Resident 18's Minimum Data Set (MDS- a standardized assessment and care-screening tool) dated 10/27/2021, indicated the resident's cognitive skills of daily decision making were intact. The MDS indicated the resident required limited assistance with one-person assist for activities of daily living (personal hygiene, toileting, and transfer). A review of Resident 18's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prepare the formula (milk) and feeding tubing (cannula) with date, time, and staff's initials four hours before the administration for two of two sampled residents (Resident 4 and Resident 33). This deficient practice had the potential for the residents to develop tube feeding associated complications such as infection, diarrhea, and this could lead to serious illness, hospitalization, and death. Findings: A review of Resident 33's admission Record indicated the resident was initially admitted to the facility on [DATE], and readmitted on [DATE], to the facility with diagnoses that included but not limited to malignant neoplasm of the thyroid gland (cancer [abnormal growth of cells] of the thyroid gland), gastrostomy (G-tube, a small tube inserted to the stomach that is used to deliver fluid and formula) and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).…

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 adequate staffing for licensed nurse of 3.5 Direct Care Service Hours Per Patient (Resident) day (DHPPD) and certified nursing attendant (CNA) staff of 2.4 DHPPD. This deficient practice resulted in call lights not being answered in a timely manner, late administration of medications and had the potential of affecting the quality of life and treatment for 77 residents residing the facility, including two of two sampled residents. Findings: a. A review of Resident 50's admission Record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included but were not limited to chronic obstructive pulmonary disease (a group of lung diseases that block airflow), type 2 diabetes (high blood sugar), hypertension (high blood pressure), and anemia (a lack of red blood cells) A review of Resident 50's Minimum Data Set (MDS- a standardized assessment and care- screening tool) dated…

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

Based on interview and record review, the facility failed to ensure a complete Daily Nursing Staffing (posting information that contains the calculation of the number of hours worked by staff for resident care) was posted daily. This deficient practice resulted in the total number of staff and the actual hours worked by the staff not to be readily accessible to residents and visitors. On 1/4/2021, at 11:00 a. m., during an interview and record review with the Director of Nursing (DON) stated, the Staff Developer was responsible for posting the nursing staffing breakdown with their actual working hours, but currently not in the facility. DON stated not posting the daily staffing hours, resident and visitors would not know how is providing care to their love ones. A review of the facility's policy and procedure titled, Posting Direct Care Staffing Numbers, revised on 7/16, indicated the facility will post daily for each shift, the number of nursing personnel responsible for providing direct care to residents. Within two hours of the beginning of each shift, the number of Licensed…

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

Based on interview and record review, the facility failed to ensure the practitioner had documentation and rationale for the extension of the 14 days administration for as need psychotropic medication (medication that affects behavior, mood, thoughts, or perception) of Xanax (medication used to treat anxiety, a disorder that causes intense, excessive, and persistent worry and fear about everyday situations) for one sampled resident (Resident 54). This deficient practice had the potential to cause Resident 54 to receive a medication more than necessary leading to serious illness, hospitalization, or death. Findings: A review of Resident 54's admission Record indicated the facility originally admitted the resident on 10/5/2021, and re-admitted the resident on 11/8/2021, with diagnoses that included but were not limited to depression (a mood disorder that causes a persistent feeling of sadness and loss of interest that can interfere with daily functioning). A review of Resident 54's History and Physical dated 11/9/2021, indicated the resident had a history of schizophrenia (a mental…

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 three staff members properly donned (put on) or doffed (took off) Personal Protective Equipment (PPE, specialized clothing or equipment worn by health care workers for their protection and to help prevent the spread of germs between patients) before entering or exiting a resident's room in the yellow zone (area of the facility where residents who are suspected of having Coronavirus [COVID-19, a virus that causes respiratory illness that can spread from person to person] reside). This deficient practice had the potential to expose residents, staff, and the community to COVID-19. Findings: During an observation on 1/4/2022, at 12:46 p. m., Certified Nursing Assistant 3 (CNA 3) was observed wearing a gown, N95 mask, and face shield while delivering a tray to a resident's room. CNA 3 was observed not wearing gloves and touching belongings the resident's room. CNA 3 doffed gown and exited room. During an interview on 1/4/2022 at 12:50 p. m., CNA 3 stated the resident's room was in the yellow zone. CNA 3…

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 employ a full-time designated Infection Preventionist (IP). This deficient practice had the potential to lead to the spread of infection and Coronavirus disease (COVID-19, a virus that causes respiratory illness that can spread from person to person) between residents, staff, and the community. Findings: During an interview on 1/6/2022, at 11:10 a.m., the Director of Nursing (DON) stated the facility did not have a dedicated full time IP. The DON stated the facility's Director of Staff Development (DSD) was also the IP. The DON stated the DSD was full time 40 hours, but also dedicated half her time to DSD duties and half to IP duties. The DON stated occasionally the facility's treatment nurse will help with IP tasks because he used to be IP, but that was not his main role. The DON stated she hoped she can find an IP soon. A review of Infection Preventionist (IP) 1's timecard for 12/2021, indicated IP 1's title at the facility was Treatment Nurse - LVN (Licensed Vocational Nurse). A review of IP 2's timecard for 12/2021,…

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 walk-in freezer was maintained in a good operating condition. The walk-in freezer had ice buildup inside the walk-in freezer vinyl strip air curtains, ceiling, floor, and boxes of food. There was ice buildup on the door and the parameters of the door. The gasket was loose not allowing for the freezer door to close shut (gasket-a flexible elastic strip attached to the outer edge of a freezer door. Gasket is designed to form an air-tight seal that serves as a barrier between the cool air inside the appliance and the warmer external environment). The reach in freezer was operational in a manner that had the potential to affect food quality and or increase the potential of growth of microorganism that could cause food borne illness. This deficient practice resulted in the inappropriate storage of food and had the potential to affect 70 residents who eat food from the facility kitchen. Findings: During an observation in the kitchen on 1/4/22, at 9:00 a. m., there was large amount of ice buildup inside…

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

Based on observation, interview, and record review, the facility failed to provide one of three sampled residents (Resident 52) access to call light. Resident 52 did not have a call light in her room. This deficient practice caused Resident 52 not being able to obtain staff assistance during times of need or emergencies which could lead to harm to Resident 52. Findings: A review of Resident 52's admission Record indicated the facility admitted the resident on 2/26/2021 with a medical history including unspecified abnormalities of gait and mobility (unable to walk in the usual way), schizophrenia (a mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions, and relate to others), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest that can interfere with daily functioning). A review of Resident 52's Minimum Data Set (MDS-a standardized assessment and care-screening tool) dated 1/6/2022, indicated Resident 52 had moderately impaired cognition (decisions poor; cues/supervision…

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.