Princeton Manor Healthcare Center, LLC

Based interview and record review, for one of five (Resident 2) sampled residents reviewed for unnecessary medication use, the facility failed to act on the Consultant Pharmacist's (CP) recommendations for monthly Medication Regimen Review (MRR, in-depth evaluation of a patient's complete list of medications by a pharmacist to ensure safety and effectiveness) for three consecutive months.This failure had the potential to result in unnecessary medication use.Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility in December 2023 with diagnoses that included anxiety disorder (repeated episodes of sudden feelings of intense fear or worry) depression (persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities) and insomnia (difficulty falling or staying asleep). During a concurrent joint interview and record review on 10/2/25 at 1:48 p.m., with Registered Nurse (RN) 1 and Licensed Vocational Nurse (LVN) 7, Resident 2's Order Summary Report (OSR) and Medication Administration Record (MAR)…

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 safe storage and labeling of medications when:1. Three medications - Adult Gummies C, Extra strength D 3, and Magnesium Extra strength were observed at Resident 71's bedside.2. One over the counter (OTC) eye drop in the medication (med) cart 1 was not labeled with name.These failures had the potential for medication errors and unsafe use of medications and biologicals.Findings:1.During a concurrent observation and interview during an initial tour on 9/29/25 at 10:45 a.m., in Resident 71's room, there were three medication bottles containing vitamin supplements - Kirkland Adult Gummies C 250 mg, Kirkland extra strength D3 50 mcg, and Nature made magnesium extra strength 400mg inside a basin that contained other stuff on top of Resident 71's bedside table. Resident 71 stated they were his vitamins but did not elaborate.During an observation on 10/1/25 at 12:24 p.m. in Resident 71's room, the three medication bottles containing vitamin supplements - Kirkland Adult Gummies C 250 mg, Kirkland extra…

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

Based on observation, interview and record review, the facility failed to store food in a safe and sanitary manner when: 1. Fresh lettuce stored inside the reach-in refrigerator was exposed and had no cover 2. A plastic container bin with single packs of graham crackers had no use by date or open dates Failure to store food in accordance with facility policy and/or professional standards had the potential to not meet food service safety standards and prevent food borne illnesses for 76 residents who received food from the kitchen out of a facility census of 76. Findings: 1.During an initial kitchen tour observation and concurrent interview on 6/10/24 at 10:13 a.m., with the Dietary Supervisor (DS), the contents of Refrigerator 1, were inspected. The bottom rack had a clear storage bin with fresh lettuce inside. The lettuce was exposed and had no cover. DS stated the lettuce should be covered with a plastic wrap to keep it fresh and to make sure spills do not get in contact the lettuce. During an interview on 6/13/23 at 1:10 p.m., with the Regional Registered Dietitian (RRD), when…

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

Based on interview and record review, the facility failed to ensure there was Registered Nurse (RN) coverage eight hours a day, seven days a week. This failure had the potential to endanger the health and safety of residents. Findings: During a concurrent interview and record review on 6/13/24 at 9:54 a.m. with Payroll (PAYROLL), payroll data was reviewed from Q3/2023 (April 1 - June 30) until Q4/2023 (July 1 - September 30). Payroll confirmed there were no RN working for the following dates: 1. For the month of April 2023: 4/23/23 2. For the month of May 2023: 5/28/23 3. For the month of June 2023: 6/25/23 4. For the month of July 2023: 7/9/23 5. For the month of August 2023: 8/27/23 6. For the month of September 2023: 9/2/23 During a concurrent interview and record review on 6/13/24 at 10:17 a.m. with Central Supply/Scheduler (CS/S), staffing schedule was reviewed. CS/S confirmed a RN was not scheduled to work on 4/23/23, 5/28/23, 6/25/23, 7/9/23, 8/27/23, 9/2/23. During an interview on 6/12/24 at 3:56 p.m., with the Director of Nursing (DON), DON stated, it was important to have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide the Restorative Nursing Assistant (RNA) services as ordered by the physician for two of 20 sampled residents reviewed for Range Of Motion (ROM) functions (Resident 2 and 69). This failure had the potential for decline in the resident's range of motion and mobility. Findings: 1. During a review of Resident 2's face sheet dated, 6/12/24, showed Resident 2 was admitted to the facility in 10/2020 with multiple diagnoses that included Brain Stem Stroke Syndrome (when a blood supply to the base of the brain is stopped which can potentially affect many functions in the body). During a review of Resident 2's Physical Therapy (PT) Discharge summary, dated [DATE], revealed under Assessment and Summary of Skilled Services: Prognosis to maintain Current Level of Functioning (CLOF) = Excellent with consistent staff support, excellent with participation in Restorative Nursing Program (RNP). Under Discharge Recommendations: Functional Maintenance…

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 of 78 sampled residents' (Resident 2, Resident 6, and Resident 8), call lights were within reach and easily accessible. This failure placed the Resident 2, Resident 6 and Resident 8 at risk of not being able to ask for assistance. Findings: Resident 2 was admitted to the facility in late 2020, with diagnoses which included cerebral infarction (disrupted blood flow does to the brain), stenosis (narrowing of the spinal cord) and convulsions (irregular movement of arms and legs). Resident 6 was admitted to the facility in late 2020 with diagnoses which included heart disease, bradycardia (slow heartbeat) and blindness of the right eye (vision loss). Resident 8 was admitted to the facility in mid-2022, with diagnoses which included seizure (irregular body movement), Parkinson (tremors, stiffness, and loss of balance) and repeated falls. During an observation on 4/11/24 at 1:15 p.m. in Resident 2's, Resident 6's and Resident 8's rooms, the call lights were on the floor behind or under the beds. During…

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

Based on interview and record review the facility failed to ensure one out of three residents (Resident 1) had written Informed Consent (a process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention to help them decide if they want to authorize the given procedure or intervention) before they were administered a psychoactive medication (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). This failure had the potential to cause Resident 1 to take a psychoactive medication without knowledge of the medication ' s risks, benefits, and alternatives. A review of Resident 1's admission Record printed 3/21/24, indicated Resident 1 was admitted to the facility in 2022 with a diagnosis of Spastic Hemiplegia (a nerve and muscle condition that results in the muscles on one side of the body being in a constant state of contraction). The record indicated Resident 1 was their own Responsible Party (health care decision maker). During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received necessary care to maintain good grooming and personal hygiene when Resident 1 had long, sharp fingernails with brownish yellow matter underneath on both hands. This failure resulted in Resident 1 feeling helpless and placed her at risk for infections and hurting themselves with long fingernails. Findings: During a review of Resident 1's admission Record , printed on 9/26/23, the admission Record indicated Resident 1 was originally admitted to the facility on admitted to the facility on [DATE]. The admission records also indicated that Resident 1 had a medical diagnosis including spastic hemiplegia (a condition that that results in the muscles on one side of the body being in a constant state of contraction and weakness of one side of the body). During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to guide care), dated 8/27/23, the MDS…

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 a summary of the baseline care plan for one of two sampled residents (Resident 1). This failure resulted in the lack of information regarding care. Findings: During a review of Resident 1's admission Record, the document indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included severe protein calorie malnutrition, gastroenteritis (lining of the stomach and intestines are inflamed) and colitis (inflammation of the inner lining of the large bowels), cachexia (marked weight and muscle loss), esophagitis (inflammation of the esophagus/swallowing tube), diarrhea, and gastric ulcer (open sores develop on the stomach lining). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 7/6/23 indicated Resident 1's Brief Interview for Mental Status (BIMS, an assessment tool for resident's orientation to time and capacity to remember) score of 11 out of 15, indicating…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), maintained acceptable desirable body weight range when: 1. G-tube (gastrostomy tube, a tune inserted through the stomach that brings nutrition directly to the stomach) feeding was discontinued despite Resident 1's inability to maintain adequate oral intake. 2. G-tube feeding was not provided as ordered by the physician. These failures potentially resulted in Resident 1's significant weight loss of 5.8 pounds from 58 pounds (lbs.) on 7/7/23 to 52.2 lbs. on 7/23/23 (10 %) over two weeks. Findings: During a review of Resident 1's admission Record, the document indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included severe protein calorie malnutrition, gastroenteritis (lining of the stomach and intestines are inflamed) and colitis (inflammation of the inner lining of the large bowels), cachexia (marked weight and muscle loss), esophagitis (inflammation 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.

Based on observation, interview, and facility document review, the facility failed to provide adequate oversight of the kitchen when multiple issues were identified with kitchen safety and sanitation; equipment was not maintained; food was not served so it was palatable and cooked to maintain nutritive value; and staff were not trained and competent for calibrating thermometers and cooking food to a safe temperature. These failures had the potential to result in food being served to residents in a safe and sanitary manner resulting in food borne illness; attract pests to the kitchen resulting in contamination of food, utensils, and equipment; and decrease the amount of food intake for residents resulting in nutritional related medical issues, for 71 residents who received food from the kitchen out of a facility census of 71. Findings: Review of the undated job description provided for the Dietary Supervisor (DS), titled, Director of Nutritional Services, indicated this position ensured the preparation of nutritious meals to all residents, maintained a safe and sanitary work…

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 vegetables were palatable and cooked in a manner to conserve nutritive value for 71 residents who received food from the kitchen out of a facility census of 71. This failure had the potential for residents to not consume the amount of nutrients planned for the menu. Findings: An observation and concurrent interview with [NAME] 1, on 5/16/22, at 10:30 a.m., [NAME] 1 was observed pureeing food in a food processor. [NAME] 1 stated she was pureeing the turkey for lunch. [NAME] 1 said she just put the pureed green beans and pureed bread on the oven. [NAME] 1 stated the regular green beans were in the oven too. Inside the oven, was one large pan covered with foil and two smaller pans covered with foil. [NAME] 1 lifted the foil off the large pan to show it held green beans. [NAME] 1 stated she had to heat them up and planned to take them out at 11:45 a.m. to place on tray-line which started at 12 p.m. [NAME] 1 confirmed the oven was set…

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

Based on observation, interview, and facility document review, the facility failed to ensure a safe and sanitary environment in the kitchen when: 1. Food was not frozen when stored in a reach-in freezer; 2. Two door screens were not intact and sealed properly to help prevent insects and rodents from entering the kitchen; 3. Cooking pans were in poor condition; 4. The ice machine was not stored in an area to help prevent contamination of the ice; 5. There were no air-gaps for the food preparation sink and the 2-compartment warewashing sink; 6. Staff did not practice appropriate hand hygiene; and 7. Soiled oven mitts came into contact with food. This failure had the potential to cause contamination of food resulting in food borne illness for 71 residents who received food from the kitchen out of a facility census of 71. Findings: 1. An observation and concurrent interview with the Dietary Supervisor (DS), on 5/16/22 at 10 a.m., showed food stored in the 2-door, reach-in freezer number 2 was not frozen solid when the food was pressed, and it was soft. Foods that were not frozen solid…

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 facility document review, the facility failed to ensure a drainpipe from the 2-compartment kitchen sink was in good repair. This had the potential to attract pests resulting in contamination of food and utensils for 71 residents who received food from the kitchen out of a facility census of 71. Findings: An observation and concurrent interview with Dietary Aide 1 (DA 1) and [NAME] 2, on 5/17/22, at 8:32 a.m., showed a drainpipe under the 2-compartment sink, used for manual warewashing, was plumbed into the floor. When the sink was drained, water leaked from the pipe, which was caught in a plastic dome plate cover on the floor under the sink and drainpipe. DA 1 and [NAME] 2 stated, there was a terrible odor that came from the drainpipe area under the sink, especially when the 2-compartment sink drained. [NAME] 2 said the drain was like that since she started working at the facility six months ago. In an interview on 5/17/22, at 10:25 a.m., Environmental Manager (EM) stated there was a maintenance logbook in station 1. EM said kitchen staff were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure the comprehensive care plan for falls were updated and implemented for one of one sampled resident (Resident 67), when Resident 67 was identified as a high risk for falls and experienced multiple falls. This failure resulted in Resident 67 experiencing a fractured left femoral neck (hip bone), requiring a left hemiarthroplasty (hip replacement surgery) from the fall, and was transferred to the acute care hospital for treatment. Findings: A review of Resident 67's admission Record, dated 5/19/22, indicated Resident 67 was admitted to the facility on [DATE] with diagnoses that included paralysis (the loss of the ability to move (and sometimes to feel anything) in part or most of the body and weakness of the left side of the body. A review of Resident 67's Minimum Data Set (an assessment tool to guide care), dated 7/21/21, indicated Resident 67's Brief Interview for Mental Status (BIMS, a screening tool to assess cognitive function)…

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 that its medication error rate was not five percent or greater. During the medication pass (med pass) observation, there were six medication errors observed out of 36 opportunities which resulted to a med pass error rate of 16.6 percent. This failure had the potential for Resident 54 not getting the full therapeutic benefit of the medications. Findings: During a medication pass observation on 5/17/22 at 8:40 a.m., Registered Nurse 1 (RN1) crushed six medications of Resident 54: Metoprolol 25mg (used to treat high blood pressure), Lovastatin 20mg (used to lower cholesterol), Tamsulosin 0.4mg (for the treatment of enlarged prostate), Metformin 500mg (used to treat high blood sugar levels), Memantine 10mg (for dementia), Lisinopril 40mg (used to treat high blood pressure and heart failure). A review of Resident 54's admission Record, dated 5/19/22, indicated Resident 54 was admitted to the facility on [DATE], with diagnoses which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 54) was free of significant medication error, when Resident 54's oral medications were all crushed and administered together without a physician's order. This deficient practice had the potential for Resident 54 not receiving the full benefits of the medications. Findings: During a medication pass observation on 5/17/22, at 8:40 a.m., Registered Nurse 1 (RN1) crushed all of Resident 54's prescribed medication in a plastic pouch: Metoprolol 25mg (used to treat high blood pressure), Lovastatin 20mg (used to lower cholesterol), Tamsulosin 0.4mg (for the treatment of enlarged prostate), Metformin 500mg (used to treat high blood sugar levels), Memantine 10mg (for dementia), Lisinopril 40mg (used to treat high blood pressure and heart failure) poured them in a medicine cup, mixed it with apple sauce, then served it to Resident 54, followed by a teaspoonful of Medpass Plus 2.0 (a medication pass drink…

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, facility failed to follow its policy and procedure on Oxygen Therapy when there was no date on the oxygen tubings of Resident 62. This deficient practice had the potential of delivering oxygen in an unsafe and unsanitary condition to resident. Findings: During the initial tour of the facility on 5/16/22 at 11:55 a.m., Resident 62 had two (2) oxygen concentrators ( a device that concentrates oxygen by removing nitrogen to supply oxygen-enriched gas), and two(2) small oxygen tanks in her room. The two(2) concentrators each had 25 feet tubings connected by a Y tube to deliver a high dose of oxygen to Resident 62. The two(2) oxygen tanks were set up with tubings and were a back up source of oxygen, in case of a power outage. The oxygen tubings connected to the two(2) concentrators and two(2) oxygen tanks were not dated. In an interview with Registered Nurse (RN)1 on 5/16/22 at 12:10 p.m., she stated she was not sure when the tubings were changed. She stated there were no labels indicating the date the tubings were changed. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for two of five (Resident 26 and 34) sampled resident vaccination record, the facility failed to follow their immunization policy and procedure when the pneumococcal vaccine was not offered or documented for Resident 26 and 24 as recommended by the Advisory Committee on Immunizations Practices (ACIP, group of medical public health experts). This deficient practice had the potential to increase the risk for Resident 26 and 34 to acquire, transmit or experience complications from pneumococcal disease. Findings: During a concurrent interview and vaccine record review, on 5/18/22, at 10:55 a.m., Resident 26 and 34's pneumococcal vaccination records were reviewed with the Infection Preventionist (IP). The vaccination record indicated Resident 26 received the pneumococcal vaccine on 6/10/16. The vaccination record did not indicate which pneumonia vaccine was administered to Resident 34. The newly appointed IP stated she would search through records for Resident 26 and 34. 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 observation, interview, and record review, the facility failed obtain a doctor's order and assess one of one resident (Resident 67) ability to self-administer medications when Resident 67 had a bottle of Sore Throat Oral Anesthetic Spray (medication to temporarily relieve sore throat pain) bottle at the bedside. This deficient practice had the potential to result in Resident 67 using the Sore Throat Oral Anesthetic Spray against safe dosing recommendations. It also had the potential to result in the use of the medication by other residents, who could potentially obtain Resident 67's medication from the bedside table where it was stored. Findings: During a concurrent observation and interview on 6/16/22, at 11:35 a.m., with Resident 67, at Resident 67's bedside, a bottle of Sore Throat Oral Anesthetic Spray was observed on Resident 67's overbed table. Resident 67 stated she used the Sore Throat Oral Anesthetic Spray whenever she felt throat pain. Resident 67 further stated she did not remember how often…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of one sampled resident's (Resident 27) preferences for showers were followed, when Resident 27's scheduled shower days were missed from April through May 2022. This failure resulted in Resident 27's request and preference for showers not being honored. Findings: During an interview on 5/16/22, at 12:30 p.m., with Resident 27, Resident 27 stated he does not receive showers as scheduled. Resident 27 stated he told the Administrator (ADM) and the Interim Director of Nursing (IDON) about missed showers. Resident 27 stated he was scheduled to have showers twice a week on Tuesdays and Fridays and prefers to take them on his scheduled days. Resident 27 stated his scheduled shower last Friday was missed because of short staff and had to wait until Monday for a shower. Resident 27 further stated it makes him feel annoyed and agitated when his showers are missed because he wants to be clean. During a review of Resident 27's admission Record, dated…

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

Based on observation and interview, the facility failed to follow infection control policies and procedures when the Infection Preventionist (IP) did not properly disinfect and store reusable ice bags. This deficient practive had the potential to place residents at risk for spread of infection and cross contamination. Findings: During a concurrent observation and interview on 5/17/22, at 11:20 a.m., at the medication room in Nurses Station 1, with Licensed Vocational Nurse 1 (LVN 1), the Nurses Station 1 resident food refrigerator was observed. The refrigerator did not have food inside. There were four re-useable ice packs in the refrigerator compartment and five re-useable ice packs in the freezer compartment. LVN 1 stated the ice packs were for residents, for issues such as pain, and residents needed a doctors order for them. During an interview on 5/18/22, at 9:45 a.m., with LVN 1, LVN 1 stated the ice packs in the Nurses Station 1 fridge were from physical therapy. During an interview on 5/18/22, at 9:52 a.m. with Physical Therapist (PT), PT stated the ice packs were reusable,…

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, record review, and document review, the facility failed to ensure one of four staff (Dietary Aide 1 [DA 1]) followed the COVID-19 (an infectious respiratory disease) vaccination policies and procedures when DA 1 did not complete COVID-19 vaccine series with a booster dose. This failure had the potential to result in the spread of COVID-19 infections to residents, staff, and visitors in the facility. Findings: During a concurrent interview and document review on 5/18/22, at 10:55 a.m., the Employee COVID-19 Vaccination Log, was reviewed with Infection Preventionist (IP). The vaccination log indicated DA 1 received the Pfizer vaccine (a COVID-19 vaccine) on 8/13/21 and 10/20/21. A COVID-19 vaccine booster result was not recorded for DA 1. IP confirmed DA 1's booster was due and not logged. IP stated, DA 1 received the COVID-19 booster vaccine, however, DA 1 has not brought in the vaccine record for verification. IP stated DA 1 still worked in the facility and last worked sometime last week. During a follow-up interview and concurrent document review on 5/19/22, at…

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