Vineyard Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to ensure bathroom call lights (a system to notify nursing staff for help) were accessible when two pull strings to trigger the call light system were too short for residents to reach and four pull strings were missing in six sampled bathrooms.This failure decreased the facility's potential to respond to residents' calls for assistance and increased the risk for falls.During an observation on 12/15/25 at 9:13 a.m. in room [ROOM NUMBER] and subsequently in Rooms 21, 24, 25, and 26, the bathroom call light systems had no call light string.During an observation on 12/15/25 at 9:27 a.m. in room [ROOM NUMBER] the bathroom call light system had a short pull string measuring approximately 10 in. (inches- a unit of measure).During an observation and concurrent interview on 12/16/25 at 12:10 p.m. with Certified Nurse Assistant C (CNA C), in room [ROOM NUMBER], the bathroom call light system had a broken call light string. The call light string was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the state mental health authority after one resident (Resident 70) of six sampled residents experienced a decline in mental illness.This failure decreased the facility's potential to ensure Resident 70 received appropriate required mental health services and treatment.Findings:A review of Resident 70's admission Record indicated Resident 70 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities)), major depressive disorder (a mood disorder that causes persistent sadness and loss of interest in activities), psychosis (a state where a person loses touch with reality, characterized by symptoms like hallucinations (seeing/hearing things not there)) and delusions (strong false beliefs leading to disorganized thoughts and speech), and anxiety.A review of Resident 70's Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 11/3/25, indicated moderate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 72) of 27 sampled residents obtained informed consent (a voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for the use of bedrails when Resident 72's responsible party (RP- a person who makes health care decisions on behalf of the resident when the resident does not have the mental capacity to do so) did not give informed consent for the use of side/bed rails.This deficient practice decreased the facility's potential to decrease Resident 72's risk for falls, serious injury, and entrapment (when a person becomes trapped in the bed rail gaps, often resulting in serious injury or death).Findings:A review of Resident 72's admission record indicated she was admitted to the facility in May 2017 with medical diagnosis which included senile degeneration of the brain (dementia- a progressive state of decline in mental abilities)…

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 specialized rehabilitative services in accordance with the physician's orders for one resident (Resident 6) of four sampled residents when Resident 6 received physical therapy (PT) three times out of 12 scheduled sessions between 11/27/25 and 12/17/25 and received occupational therapy (OT) once out of three expected sessions between 11/27/25 and 12/3/25.This failure resulted in Resident 6 feeling frustrated and increased the risk of his physical deconditioning.Findings:During a review of Resident 6's Face Sheet (a summary of the resident's information), Resident 6 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD- a chronic lung condition caused by damage to the lungs and results in limited airflow into and out of the lungs), generalized muscle weakness, and depression (a serious mood condition causing persistent sadness and loss of interest, affecting thoughts, feelings, and daily life). A 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 to ensure respiratory equipment was clean and in a usable state for one resident (Resident 42) out of 27 sampled residents when the oxygen concentrator in Resident 42's room had visible dust and debris in the vents and needed a filter change.This failure decreased the facility's potential to prevent bacteria and debris from directly entering Resident 42's lungs, placing her at risk for infection.Findings:A review of Resident 42's face sheet indicated admission to the facility on [DATE] with diagnoses of pneumonitis (a condition in which the delicate tissue and tiny air sacs in the lungs become swollen and intensely irritated) and Acute Respiratory Failure with Hypoxia (a serious condition in which the respiratory system fails to provide enough oxygen to the blood to support vital organ function). A review of Resident 42's physician orders, dated 12/5/25, indicated, Oxygen 2 L [liters, a unit of measure] via nasal cannula [a flexible device…

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 four sampled residents (Resident 1) received care within professional standards of practice when licensed nursing staff failed to administer physician ordered pain medications to treat her moderate to severe pain, which led to ceaseless pain that worsened in numerical order and severity. This failure resulted in Resident 1 experiencing severe pain and had the potential to result in suffering and feelings of abandonment.A review of Resident 1's admission record indicated she was admitted to the facility in August, 2025 with medical diagnoses which included surgical aftercare of the digestive system (postoperative care after a procedure of the digestive system, which includes monitoring for complications, managing pain and medications, and regular follow-ups with a doctor).A review of Resident 1's clinical record included the following documents:A Nursing Care Plan initiated on 8/18/25, indicated Resident 1 had Pain, with the stated goal,…

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 ensure professional standards of practice were conducted for one resident (Resident 1) of four sampled residents when Resident 1 did not have: · A sliding scale (a method used to manage blood sugar levels in people with diabetes, where insulin doses are adjusted based on current blood sugar readings) for use of insulin (a hormone produced by the pancreas that helps regulate blood sugar levels) and · Blood sugar parameters (levels that indicate when blood sugar is considered too high or too low) ordered for insulin administration. These failures placed Resident 1 at risk for ineffective monitoring of insulin usage and worsening of Resident 1 ' s condition. Findings: Resident 1 was a [AGE] year-old male admitted to the facility on [DATE], with a medical diagnosis that included: Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, and dysphagia (difficulty swallowing). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one resident (Resident 1) of three sampled residents was provided a home-like environment with comfortable sound levels when Resident 4 was constantly yelling vulgar, offensive, and derogatory language. This resulted in Resident 1 being unable to get a full night of uninterrupted sleep and decreased Resident 1's potential to reach his maximum healthcare potential. Findings: A review of Resident 1 ' s admission record indicated he was admitted in 2/13/25 with diagnoses which included hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following a cerebral infarction (stroke) affecting the left non-dominant side. A review of a Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 2/19/25, indicated Resident 1 had moderate memory impairment (difficulty remembering recent events, trouble with problem-solving, and changes in judgment, but it does not typically interfere with daily functioning). A 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 maintain an effective infection prevention and control program, for a census of approximately 90 residents, when the facility did not report an influenza outbreak to the local public health department (LPHD) for nearly three weeks. This failure had the potential to increase the transmission of influenza among all residents in the facility. Findings: During a concurrent interview and record review on 2/25/25 at 11:05 a.m., with the Infection Preventionist (IP), the facility ' s document titled, Line List Acute Respiratory Illness Outbreak In Long-Term Care Facilities (Including Influenza) (line list, a table that summarizes information about each case of an outbreak), dated 1/29/25, was reviewed. The IP stated the line list indicated, the facility had an influenza outbreak starting on 1/29/25 when two residents tested positive for influenza. The IP stated on 1/31/25 seven more residents tested positive for influenza and, during the outbreak, 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, the facility failed to ensure one resident (Resident 1) of five sampled residents was free from physical abuse when Resident 2 intentionally struck resident one in the head and held him down on the floor. This failure resulted in a physical injury and confinement to Resident 1. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with the diagnosis of epilepsy (chronic, neurological condition characterized by recurrent, unprovoked seizures.) A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 10/3/24, indicated a Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgment status of the resident) score of 6, which indicated severe cognitive (relating to processes of thinking and reasoning) impairment. A review of Resident 2's admission record indicated Resident 2 was admitted to the facility 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 interview and record review, the facility failed to notify the physician when the resident consistently missed scheduled medications when out at dialysis for 1 (Resident #8) of 3 residents reviewed for dialysis. Findings included: On 11/23/2024 at 12:06 PM, the Director of Nursing (DON) stated the facility did not have a specific policy for notification of a change of condition but expected that the physician be notified of any change in status of the resident, and it should be documented. An admission Record indicated the facility admitted Resident #8 on 10/13/2021. According to the admission Record, the resident had a medical history that included a diagnosis of end stage renal disease with dependence on renal dialysis. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/20/2024, revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident…

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 facility policy review, the facility failed to ensure residents were free from significant medication errors for 1 (Resident #8) of 3 residents reviewed for dialysis services. Staff failed to ensure Resident #8 received medications that were used to treat low blood pressure, atrial fibrillation, prevent blood clots, and treat diabetes when the resident was scheduled for dialysis. Further, the facility failed to ensure that the medication to treat low blood pressure was given within the parameters set by the physician for treatment of low blood pressure. Findings included: A facility policy titled, End-Stage Renal Disease, Care of a Resident with, revised 09/2010, indicated, Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. The policy also indicated, 1. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. 2. Education and training of staff includes, specifically:…

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 facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) for 2 (Resident #7 and Resident #10) of 2 sampled residents reviewed for preadmission screening and resident review (PASARR). Findings included: A facility policy titled, Certifying Accuracy of the Resident Assessment, revised 11/2022, indicated, Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of the portion of the assessment. 1. An admission Record indicated the facility admitted Resident #10 on 10/11/2024. According to the admission Record, the resident had a medical history that included diagnoses of schizoaffective disorder and dementia. An admission MDS, with an Assessment Reference Date (ARD) of 10/17/2024, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS revealed the resident was not considered by the state level II PASARR process to have a serious mental illness…

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, record review, and facility policy review, the facility failed to ensure physician orders were followed for supplemental oxygen flow rates for 1 (Resident #17) of 3 sampled residents reviewed for respiratory care. Findings included: A facility policy titled Oxygen Administration, revised 10/2010, indicated Purpose the purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. An admission Record revealed the facility admitted Resident #17 on 04/24/2023. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD) and heart failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/14/2024, revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident had shortness…

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, record review, and facility policy review, the facility failed to ensure medications were stored appropriately for 1 (Resident #11) of 20 sampled residents. Findings included: A facility policy titled, Self-Administration of Medications, revised 02/2021, indicated, Residents have the right to self-administer medication if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The policy also indicated, 7. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medication of residents permitted to self-administer are stored on a central medication cart or in the medication room. A licensed nurse transfers the unopened medication to the resident when the resident requests them. 8. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. An admission Record 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 interview, record review, and facility policy review, the facility failed to provide occupational therapy as ordered by the physician for 1 (Resident #20) of 2 sampled residents reviewed for rehabilitation and restorative services. Findings included: A facility policy titled, Scheduling Therapy Services, revised 07/2013, indicated, Therapy services shall be scheduled in accordance with the resident's treatment plan. An admission Record indicated the facility readmitted Resident #20 on 10/18/2024. According to the admission Record, the resident had a medical history that included diagnoses of congestive heart failure (CHF), generalized muscle weakness, and a need for assistance with personal care. A 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/24/2024, revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident started occupational therapy on 10/21/2024. Resident #20's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent abuse for one resident (Resident 3) of four sampled residents when Resident 4 threw water on Resident 3. This failure resulted in Resident 3 feeling unsafe at the facility. Findings: A review of an admission record indicated Resident 4 was admitted to the facility in 2023 with diagnoses which included neurocognitive disorder with Lewy Bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function) and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). A Minimum Data Set (MDS, an assessment tool) dated 9/3/24 indicated Resident 4 scored a 15 on a Brief Interview for Mental Status (BIMS, a questionaire used to determine if a person's cognition (the process of thinking) is intact. A score of 15 suggests intact cognition). A review of an admission record indicated Resident 3 was admitted to the facility in 2024 with diagnoses…

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 records review, the facility failed to develop a plan of interventions to address the risk of fall for one (1) of four (4) residents (Resident 1) when Resident 1 fell from his wheelchair at the nurses' station. This failure caused Resident 1 a bruise over his right forehead and a trip to the acute hospital for evaluation. Findings: On 3/21/24, the Department received a report of a resident who fell at the facility in the afternoon of 3/20/24, was brought to the acute hospital, brought back to the facility and was again found later that night on the floor by the nursing station wearing only a brief, refusing to be picked up by staff, and combative. During an interview with the Administrator on 4/4/24, at 3:53 PM, he stated he saw the incident happen on 3/20/24. The Administrator stated Resident 1 was in his wheelchair at the nurses' station with a Certified Nursing Attendant (CNA) who was helping him to make a call. The Administrator stated Resident 1 threw himself out of his chair after…

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 (1) or four (4) residents (Resident 2) was treated with respect and dignity and access to care to promote maintenance and enhance his quality of life when Resident 2 was not provided his medication in a timely manner. This failure caused Resident 2 to feel helpless and unimportant. Findings: During an interview on 4/4/24, at 5:55 PM, Resident 2 when asked if he felt safe in the facility, stated: Not entirely safe. When asked when he did not feel safe, Resident 2 stated there was a time he waited for an hour for his pain medication, but because the nurses were doing their shift change, he felt helpless and could do nothing about it. Resident 2 stated he felt it was more important for staff to prepare for their shift or to go home than the patients. During review of medical records, his quarterly minimum data set (MDS - federally mandated clinical assessment of all residents' functional capabilities helping nursing home staff identify health problems) dated 2/7/24 indicated his brief interview for mental status…

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 administer scheduled medications (medications to be administered at a specific time) for three of three sampled residents (Residents 1, 2, and 3) within the time frames required by the facility's policy on medication administration. 12 scheduled medications were administrated as late as three hours after their prescribed administration time for Residents 1, 2, and 3. These failures had the potential to cause discomfort and/or jeopardize the health and safety of Residents 1, 2, and 3. Findings: Record review of Policy and Procedure titled Administering Medications , revised April 2019, indicated Medications that are scheduled to be administered more frequently than daily .will be administered within one (1) hour before or after the prescribed time, unless otherwise specified . The document also stated: Medications that are scheduled to be administered daily, weekly, or monthly may be administered within two (2) hours before or after 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, the facility failed to meet professional standards of quality for one of three sampled residents (Resident 1), when a licensed nurse inputted a physician order for Glargine (Lantus) insulin (long-acting insulin (works throughout the day and night to provide you with low levels of insulin all the time) used to improve blood sugar control in people with Diabetes Mellitus (DM: a disease in which the body ' s ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose (sugar) in the blood) on Resident 1 ' s MAR (Medicine Administration Record) incorrectly. This resulted in: 1. A nurse attempting to administer to Resident 1 Glargine 55 units subcutaneous (Sub-Q injection is given in the fatty tissue, just under the skin) with his dinner instead of 10 units, and, 2. Resident 1 refusing Glargine 55 units because he told the nurse he was only supposed to receive Glargine 10 units, and, 3. Resident 1 becoming extremely upset knowing he…

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

Based on interview and record review, the facility failed to provide the required information to Resident 1, on a document titled 30 Day Notice to Vacate or Pay, when the document did not include Statement of Resident Appeal Rights and the Ombudsman contact information. Finding: During an interview, on 1/11/23, at 9:30 a.m., Director of Nursing stated, Resident 1 was a long-term resident. During an interview and record review on 1/11/23, at 9:44 a.m., Social Services stated Resident 1 was a long-term resident and the facility had a problem with the resident's billing and collecting share of costs after he was discharged from care. She stated she did not know if Resident 1 was provided a discharge notice. She reviewed Resident 1 ' s medical record and stated he was provided a 30-day notice to vacate on October 24, 2022. She stated he had to vacate the facility or pay the share of costs. She stated there was no documentation in the Social Services notes that indicated any discharge planning was provided. During an interview with Administrator, on 1/11/23, at 10:15 a.m., he stated 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 interview and record review, the facility failed to conduct annual competency and skills check to licensed nurses and Certified Nurse Aides (C.N.A.) for year 2020. This failure may have resulted in incompetent staff providing care to residents. Findings: During an interview on 5/25/21, at 10:30 a.m., Resident 33 stated, she was able to check her own blood sugar and aware of how much insulin she gets depending on the result of her blood sugar check. Resident 33 stated, Licensed Staff G attempted to administer an incorrect dose of insulin to her. Resident 33 stated, she argued with Licensed Staff G about the insulin dose and Licensed Staff G told her that the insulin dose got mixed up with another resident. During an interview on 5/26/21, at 8:42 a.m., Management Staff L stated, licensed nurses and C.N.A.'s competency and skills evaluation was not done for year 2020. During a review of facility's Competency of Nursing Staff Policy dated May 2019, indicated, Facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary.

Based on interview and record review, the facility failed to offer and document assistance with advanced directives for 10 out of 10 Sampled Residents (Resident 32, Resident 206, Resident 63, Resident 33, Resident 195, Resident 80, Resident 207, Resident 145, Resident 43, Resident 51). This failure had the potential to result in residents wishes for the provision of health care and choices for end of care treatment to not be met. Findings: During a medical record review on 5/25/21 at 10:00 a.m., three sampled residents (Resident 195, Resident 206, and Resident 207) did not have advanced directives in their charts. There was no indication in the Social Services notes that an advanced directive was discussed with the Residents or resident's representative. During a consecutive medical records review on 5/26/21 starting 3:52 p.m., four sampled residents (Resident 63, Resident 80, Resident 145, and Resident 43) had POLSTs but no advanced directives in their charts. A review of SSD and Nurses' notes in the electronic medical record of Resident 43 on 5/27/21 at 10:44 a.m. did not show…

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 resident call lights for six residents (Resident 80, 43, 145, 33, 31 and 75) were answered in a timely manner. This failure resulted in three residents' (Resident 80, 145, and 43) inability to control their bowel and bladder while waiting for help to use the bathroom. Findings: During interview on 05/24/21 at 1:22 PM, Resident 80 stated the facility did not have enough nurses at night and he has had to wait a long time for assistance. Resident 80 stated waiting time could be up to an hour, and he once soiled his bedding when he was unable to control his bowel while waiting for assistance. During interview on 05/24/21 01:43 PM, Resident 145 stated waiting time can be up to three hours. Resident 145 stated staff will come in and turn off the call light and leave. During interview on 5/24/21 at 3:58 PM, Resident 43 stated she had to wait 45 minutes for a nurse to bring her pain medication. Resident 43 added it took staff a long time to respond to her call light and she soiled her bedding as she was unable to control…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement their infection prevention and control program policies and procedures when: 1. Disposal bins for Personal Protective Equipment (PPE) were located outside of the resident rooms in the Yellow Zone and, 2. Two staff members were observed wearing incomplete PPE. These cumulative failures had the potential to increase the risk of transmission of communicable diseases such as the COVID-19 virus among the facility residents and staff, which may lead to severe illness and even death. Findings: 1. During initial tour of the yellow zone on 5/24/21 at 10:30 a.m., bins for doffing cloth gowns were located outside of the residents rooms next to the cart with clean gowns. During an interview on 5/24/21 at 12:00 noon, Licensed Staff L was asked why the bins for doffing (removing) dirty cloth gowns used in resident rooms were located outside the rooms next to the clean gown bin. Licensed Staff L stated the bins used to be inside the rooms but I…

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 interviews and records review, the facility failed to provide timely assistance to two of 18 sampled residents (Resident 80 and Resident 43). This failure caused the residents to lose control of bowel while waiting thereby lowering their self-worth and feeling bad. Findings: During interview on 05/24/21 at 1:22 PM, Resident 80 stated that he had to wait for a long time for staff assistance especially at night. Resident 80 stated that waiting time could be up to an hour, he had once lost control of bowel and soiled his bedding while waiting for assistance. During interview on 5/24/21 at 3:58 PM, Resident 43 stated she had to wait 45 minutes for a nurse to bring her pain medication. One night when she was suffering from nausea, vomiting and diarrhea, it took staff a long time to come, she lost control of bowel and soiled her bedding while waiting. During follow-up interview on 5/28/21 at 2:16 PM, Resident 80 was asked how he felt during that time when he lost control of bowel while waiting for assistance. Resident 80 responded he felt bad and dirty. A review of the facility's…

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

Based on observation, interview, and record review the facility failed to assess and assist one resident (Resident 61) for medical equipment needs upon admission. This failure resulted in the resident not receiving the necessary equipment to get out of bed for activities of daily living and receive the highest level of care for health improvement. Findings: During an observation and concurrent interview on 5/25/21 at 10:16 a.m., Resident (61), was an obese male who is bed bound and could not move around in bed much due to his weight. When speaking with Resident 61 he stated he was never out of bed because he does not have a wheelchair that fits him. He stated, this has been an ongoing issue with the facility, and he would like to sit-up in a chair occasionally. During an interview on 5/27/21 at 13:00 p.m., the Physical Therapy Interim Director (PT Director W) stated, a needs assessment for all patients is conducted upon admission. The needs assessment includes a patient assessment for medical equipment and physical therapy needs. PT Director W stated she documented and submitted 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 interviews and record reviews, the facility failed to ensure care plan interventions were implemented for two sampled residents (Resident 215 and Resident 82), and that a care plan was formulated upon one resident's (Resident 37) admission. These failures resulted in: a. Missed opportunities for the staff to timely identify Resident 215's changes in condition and therefore, not to provide potentially necessary interventions prior to his death, b. Potential for inconsistent and/or inadequate care provision for Resident 82's needs, and c. Increased potential for impaired communication that may negatively affect the delivery of care for Resident 37. Findings: Resident 215 On [DATE], the Department received a report regarding a resident death (Resident 215) on [DATE]. Record review of Resident 215's Face Sheet indicated he was a [AGE] year old male admitted to the facility on [DATE] with diagnoses that included COPD ([Chronic Obstructive Pulmonary Disease] is a disease characterized by long-term breathing…

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

Based on observation, interview, and record review the facility failed to ensure safe respiratory care and oxygen therapy was provided to one resident (Resident 81). This failure had the potential to cause respiratory distress and further compromise the resident's health. Findings: During an observation on 5/25/21 at 12:00 noon., Resident (81) was observed sitting up in bed eating lunch. When asked how he was feeling he stated, ok. Resident (81)'s oxygen (02) nasal cannula (tubing that provides 02 into the nose) was positioned slightly to the left of his face and below his nostrils. Further inspection of the oxygen machine revealed the humidifier bottle (a bottle typically filled with sterile water used during oxygen therapy, to provide moisture for patients) was empty. The oxygen tubing and humidifier bottle were dated 5/23/21. During an interview on 5/25/21 at 1:00 p.m., Licensed Staff L was asked to come to Resident (81)'s bedside. Licensed Staff L was asked how often the humidifier bottle was checked and the tubing changed on the oxygen machine. Licensed Staff L observed the…

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

Based on observation, interview, and record review, the facility failed to obtain consent for a psychotropic medication for one resident (Resident 195). This failure had the potential for the resident to be over medicated and not have the correct medication or dosage for his diagnosis. Findings: During an initial tour of the yellow zone on 5/24/21/ at 9:30 a.m., Resident 195 was observed to be in bed sleeping. The bed was low to the floor with a floor mat next to the bed. The resident was clean and resting comfortably. Licensed Staff L stated the resident was admitted over the weekend from the hospital. Throughout the day several attempts were made to interview Resident 195, unsuccessfully. Resident 195 remained in bed throughout the day, and feeding was provided by the CNA. During an observation on 5/25/21 at 10:00 a.m., Resident 195 was in bed, eyes closed and moving extremities. An attempt to speak with Resident 195 was unsuccessful, the resident did not respond to his name or questions asked. During an observation on 5/26/21 at 10:30 a.m., Resident 195 was in bed eyes closed 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 practice hand hygiene during meal services. This failure may have resulted to cross-contamination of residents' food and drinks and increase the potential for food-borne illness. Findings: During a concurrent observation and interview on 5/24/21 at 12:29 p.m., with Unlicensed Staff I, Resident 66 was observed eating lunch. Resident 66 needed help removing the lids of the glasses with his drinks. Unlicensed Staff I went into Resident 66's room with plate cover on one hand and removed the lids from two glasses of drinks with the other hand. Unlicensed Staff I did not sanitize hands prior to removing the lids from the glasses and after touching the glasses on the meal tray. Unlicensed Staff I exited Resident 66's room and took a meal tray from the lunch cart and brought it inside another resident's room. Unlicensed Staff I stated, he forgot to sanitize his hands before touching the lids of the glasses and after touching the lids and before getting a new meal tray for another resident. During a review of facility'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.

Deficiency Text Not Available

Based on observations, interviews and record reviews, the facility failed to provide a sanitary environment for one sampled resident (Resident 71) when his bedside equipment were left dirty for three days. This failure could potentially contribute to cross-transmission by contamination of staff from hand contact with dirty surfaces, and medical equipment, or residents. Findings: During an observation on 5/24/21 at 10:53 a.m., Resident 71's bed control and call light cords appeared dirty and discolored. Red material resembling dried blood crusted over the length of the cords and part of the bed control keypad. During an observation on 5/25/21 at 8:37 a.m., Resident 71's bed control and call light cords' surfaces appeared unchanged. During a concurrent interview and observation of the still-dirty cords on 5/26/21 at 9:25 a.m., Resident 71 shrugged and stated, They never clean it. During an interview on 5/26/21 at 12:02 p.m., Unlicensed Staff O stated resident rooms and bedsides were cleaned daily. Unlicensed Staff O confirmed Resident's call light and cords were dirty and stated, I…

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.