Laurel Park Behavioral Health Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain informed consents from the resident or the resident's responsible party for two of six sampled residents (Resident 7 and Resident 18) by failing to: A. Ensure the frequency (how many times per day and how often a medication is to be administered) of Clozapine (an antipsychotic medication [a drug used to treat serious mental health conditions]) was indicated in Resident 7's informed consent. B. Ensure an informed consent was obtained before increasing the dose of Olanzapine (an antipsychotic [main class of drugs used to treat people that have mental disorders like schizophrenia [mental disorder characterized by loss of contact with the environment]) medication, ordered for schizophrenia manifested by responding to internal stimuli (when someone exhibits behaviors that suggest they are perceiving or reacting to things that are not present in the external environment, often due to hallucinations [false perception of objects or events…

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 an individualized person-centered plan of care (care plan, CP) that included measurable objectives, timeframes, and interventions that met resident needs for two of two sampled residents (Resident 17 and Resident 24) by failing to: A. Develop a CP for Resident 17 in a timely manner to address Resident 17's refusal of the front wheel walker (FWW, a mobility device with two wheels in the front and two glide caps in the back that's used to help people with limited mobility walk and transfer) after several falls. B. Implement goals and care interventions in a timely manner to address Resident 24's need for supervision during smoking breaks. These deficient practices had the potential to result in unmet individualized needs for Resident 24 and the potential to affect the resident's physical and psychosocial well-being and negatively affect Residents 17 and 24. Findings A. During a review of Resident 17's admission Record (AR), the AR indicated the facility admitted Resident 17 on 10/3/2019,…

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 treatments and services were provided for two of two sampled residents (Resident 24 and Resident 39) as indicated in the facility policy and procedure (P&P) titled, Physician Order, and Medication Ordering and Receiving from Pharmacy, when, A. The facility failed to follow a physician's order from 2/2024 to 12/2024 for Resident 24, that indicated orthostatic blood pressure ([OBP], the measurement of BP taken when a person stands up from a lying or sitting position. The person lies down for at least five minutes, the BP and pulse are measured while lying or sitting, then the person stands up and the measurement is repeated after one and three minutes. The purpose is to compare the BPs taken in both positions and look for a significant drop in BP upon standing which would indicate orthostatic hypotension [low BP]) was to be taken . B. The facility failed to re-order Resident 39's Propranolol (medication used to treat severe restlessness, and agitation) 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, interview, and record review, the facility failed to ensure proper disposal (discarding of medications) of drugs (medications), for three of three sampled residents (Residents 7, 8, and 13), as indicated in the facility's Policy and Procedure (P&P) titled, Disposal of Medications and Medication-Related Supplies, when, 1. On 12/18/2024, three blister packs (a tamper-evident packaging where individually sealed tablets are pushed through foil to dispense the medication) of expired antibiotic (medications that fight bacterial infections) medications were found in the medication cart. This deficient practice had the potential to result in the accidental use of ineffective antibiotic medications and the potential to result in bacterial growth and physical declines to Residents 7, 8, and 13. Findings: On 12/18/2024 at 8:37 AM, during a Medication Cart inspection in Nursing Station 1 with Registered Nurse 2 (RN 2) and Licensed Psychiatric Technician 1 (LPT 1), there were three blister packs of antibiotic medications. The packs indicated the following antibiotic…

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 two of two sampled residents (Resident 2 and Resident 15) were free from physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm) as indicated in the facility's policy and procedure (P&P) titled, Abuse Prohibition Policy and Procedure, when on 12/11/2024 Resident 2 punched Resident 15 on the chest and Resident 15 pushed Resident 2 to the ground. This deficient practice resulted in physical abuse and had the potential to result in injury and harm to Resident 15 and Resident 2. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 4/8/2011, and re-admitted the resident on 5/28/2014, with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), moderate intellectual disabilities, and chronic (long standing) obstructive pulmonary disease (COPD-a common lung disease causing…

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 assessment entry in the general (refers to the initial observation of the patient's overall appearance, including their level of comfort, posture, hygiene, skin color, and any noticeable physical characteristics) section on a physical and history (H&P) exam was accurately documented to reflect the Resident's ability to hear and verbalize with others for one of one sampled resident (Resident 2). This deficient practice had the potential to negatively affect Resident 2's plan of care and delivery of necessary care and services. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 4/28/2011 and re-admitted the resident on 5/28/2014 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), moderate intellectual disabilities, and chronic (long standing) obstructive pulmonary disease (COPD-a common lung disease causing restricted airflow and breathing problems). During a review of Resident 2's History 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 interview, and record review, the facility failed to update a care plan (CP) and include new interventions, for one of two sampled residents (Resident 36), after Resident 36 sustained a fall on10/30/2024 and as indicated in the facility's policy and procedure titled, Care Plan Comprehensive, and Fall Management. This deficient practice had the potential to result in unmet individualized needs for Resident 36 and the potential to affect the resident's physical and psychosocial well-being. Findings: During a review of Resident 36's admission Record (AR), the AR indicated the facility admitted Resident 36 on 3/26/2024, with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and psychoactive (altering the mind or consciousness) substance abuse. During a review of Resident 36's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 10/1/2024, the MDS indicated Resident 36's cognition (the ability to think and process information) was moderately intact. The MDS indicated Resident 36 was independent (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 and record review the facility failed to evaluate and ensure one of four Certified Nursing Assistants (CNA 3) had completed annual skills training. This failure had the potential to result in unsafe resident care. Findings: During a concurrent interview and record review on 12/20/2024 at 12:25 PM with Director of Staff Development (DSD), CNA 3's employee file and Employee Orientation IMD Checklist, (EOIC) dated 5/2/2023 was reviewed. The EOIC indicated CNA 3 was hired on 5/2/2023 and CNA 3 completed trainings on 5/2/2023, 5/3/2023 and 5/5/2023. The DSD stated skills training needed to be updated annually to ensure staff was update for any changes and ensure safety and care were done correctly. The DSD stated the DSD did not see any documentation indicating skills training was completed by CNA 3 in 2024. The DSD stated CNA 3 should not have cared for residents until CNA 3's skills trainings were up to date. During a review CNA 3's Timecard, (TC) dated from 11/01/2024 to 12/16/2024, the TC indicated CNA 3's most recent days of work were 12/7/2024 11:12 PM through…

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, one of one facility (the facility) failed to ensure a full-time Director of Nursing (DON) was employed by the facility. This failure had the potential to lead to a lack of oversight of the facility's nursing practices and effect the care provide to the residents residing at the facility. Findings: During an interview on 12/17/2024 at 8:41 AM with the Administrator (ADM), the ADM stated currently, the facility had no DON, and the DON role was being filled by multiple Registered Nurses (RNs). During an interview on 12/20/2024 at 10:45 AM with Registered Nurse (RN) 1, RN 1 stated it was important to have a DON onsite because the DON generally had more knowledge, training, and experience and could handle oversight of resident treatments and medications correctly. During a review of the facility's offer of employment letter, dated 12/11/2024, the letter indicated the full-time position for DON would start 12/23/2024. The letter indicated a signature on the returned copy and verified acceptance of the position. The letter indicated the potential DON'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 adequately monitor one of five sampled resident's (Resident 40) use of psychotropic (drug or substance that changes mood, awareness, thoughts feelings or behavior) medication haloperidol (medication used to treat nervous, emotional, and mental conditions) as evidenced by failure to limit PRN (as needed) haloperidol to 14 days per the facility's policy and procedure (P&P) and failure to monitor Resident 40's anxious behavior and side effects of haloperidol. This failure had the potential to result in Resident 40 to experience adverse (unwanted) effects of haloperidol. Findings: During a review of Resident 40's admission Record, (AR), the AR indicated Resident 40 was admitted to the facility on [DATE] with multiple diagnoses schizoaffective disorder, bipolar type (a mental illness that can affect thoughts, mood, and behavior) and anxiety disorder (condition in which a person has excessive worry and feelings of fear, dread, and uneasiness.) 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.

Based on observation, interview, and record review, the facility failed to ensure foods were labeled in one of one kitchen (Kitchen 1) when: 1. A bowl, wrapped in plastic, was observed in the reach-in refrigerator, and the bowl was not dated. This deficient practice had the potential to result in foodborne illness (illness caused by food contaminated with bacteria) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever for the residents residing at the facility. Findings: On 12/17/2024 at 9:01 AM, during a Kitchen tour, one Styrofoam bowl wrapped in plastic was observed in the reach-in refrigerator. Inside the bowl there was a white substance, and the bowl or wrapping were not dated. The words Tayler no eggs toast were handwritten with black marker on the plastic wrapping. During a concurrent interview and observation with the [NAME] on 12/17/2024 at 9:06 AM, the [NAME] stated the bowl wrapped in plastic had cottage cheese in it, and the cottage cheese was for a resident's (unidentified) breakfast this morning. The [NAME] stated the resident did…

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, one of one facility (the facility) failed to have all required members of the Quality Assessment and Assurance committee present by not having an employed Director of Nursing (DON). This failure had the potential to lead to areas of deficiency in nursing without correction or oversight at the facility. Cross Reference F727 Findings: During a concurrent interview and record review on 12/20/2024 at 4:30 PM with the Administrator (ADM), the Quality Assurance Performance Improvement (QAPI) Meeting attendance records dated 9/20/2024 and 10/24/2024 were reviewed. The attendance records did not indicate a DON attended the meeting. The ADM stated there was no DON on the attendance record because the facility did not have a DON employed. The ADM stated having a DON employed was important because the DON over-saw nursing services which is the direct care given to the patients. During a review of the facility's policy and procedure (P&P) titled, Quality Assurance and Performance Improvement [QAPI] Program - Governance and Leadership, revised 3/2020,…

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 two of two sampled residents (Resident 1 and Resident 2), were free from physical abuse (willful infliction of injury, deliberately aggressive or violent behavior with the intention to cause harm) in accordance with the facility's policy and procedure (P&P) titled Abuse Prohibition Policy and Procedure when on 11/19/24 Resident 1 pushed Resident 2 and Resident 2 reacted by hitting Resident 1 back. This deficient practice resulted in physical abuse, pain, and a bloody nose to Resident 1. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), unspecified, autistic disorder (a developmental brain disorder that affects how people interact with others, communicate, learn, and behave) and essential (primary) hypertension…

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 designate a registered nurse (RN, a nurse who has graduated from a college's nursing program or from a school of nursing and has passed a national licensing exam) to serve as a full-time Director of Nursing (DON, an RN who leads and supervises the care of all patients at a health care facility) to oversee nursing service personnel that included six of six Registered Nurses (RNs) for September and October 2024. This deficient practice left the facility without oversight for nursing care provided for all residents residing at facility. This failure placed the residents at risk for harm due to lack of clinical oversight. Findings: During a review an email titled Resignation, from the former Director of Nursing (FDON) to the Administrator (ADM), dated 5/23/2024, timed at 9:49 AM, the email indicted the FDON resigned (quit) from the position of Director of Nursing (DON). During review of the facility's RN Schedule - 8 Hour Shifts, from September 1, 2024 to September 30, 2024, the schedule did not indicate a DON was on duty. 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 protect the residents' right to be free from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one of two sampled residents (Resident 1). On 9/12/24, Resident 1 was hit by Resident 2. This deficient practice resulted in a skin tear/abrasion to Resident 1's anterior left hand and a scratch to Resident 1's right lower leg. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted the Resident 1 on 10/12/11 and readmitted the resident on 5/12/17, with diagnoses that included myopia (a condition in which close objects appear clearly but far one objects do not appear clear), and history of COVID-19 (Coronavirus, a highly contagious respiratory disease caused by SARS-CoV-2 virus that spreads from person to person and can cause mild to severe respiratory illness). During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning 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 ensure one of one sampled resident (Resident 1), was free from sexual (non-consensual sexual contact of any type with a resident) abuse in accordance with the facility's policies and procedures (P&P). Resident 2 placed Resident 1's hand on Resident 2's crotch (the part of the body that includes the groin and genitals [the sexual organs located on the outside of the body]) without Resident 1's consent (permission for something to happen or agreement to do something). This deficient practice violated Resident 1's right and resulted in Resident 1 feeling bad and unsafe in the facility around Resident 2. Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was admitted to the facility on [DATE] with multiple diagnoses including schizophrenia (a serious mental health condition that affects how people think, feel and behave), hypothyroidism (the thyroid gland can't make enough thyroid hormone [controls metabolism,…

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

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) according to the facility's policies and procedure (P&P), when Resident 2 hit Resident 1 on Resident 1's arm. This deficient practice resulted in Residents 1 to experience physical abuse while in the care of the facility. Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 4/6/2023 with multiple diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), hypertension (high blood pressure), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 1's Minimum Data Set (MDS, standardized assessment and care-screening tool), dated 4/19/2024, 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.

Based on interview and record review, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week on 4/29/2024 for one of 35 days. This deficient practice had the potential to affect the quality of nursing care provided to residents. Findings: During a concurrent interview and record review on 5/9/2024 at 12 pm with the Administrator (ADM), the nurse staffing sign-in sheet for 4/29/2024 indicated there was no RN on duty for one day. The ADM stated the facility did not have a Registered Nurse (RN) on 4/29/2024. The ADM stated the importance of an RN being on duty in the facility was to oversee the safety and care of residents daily. During a concurrent interview and record review on 5/9/2024 at 2:27 pm with the Director of Staff Development (DSD), the nurse staffing sign-in sheet for 4/29/2024 was reviewed. The nurse staffing sign-in sheet dated 4/29/2024 indicated there was no RN on duty for eight hours for one day on 4/29/2024. The DSD stated a full time RN was important to oversee resident's assessment and care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from physical and verbal abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) according to the facility's policies and procedure (P&P), when Resident 1 hit the back of Resident 2's head. This deficient practice resulted in Resident 1 experiencing verbal and physical abuse. Findings: During a review of Resident 1's admission Record (AR), the admission record indicated Resident 1 was admitted to facility on 7/24/23 with multiple diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and psychoactive substance dependence (a strong desire or sense of compulsion to take the substance). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment and care-screening tool) dated 2/2/24, the MDS indicated Resident 1 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.

Based on interview and record review, the facility failed to prevent abuse for one of seven sampled residents (Resident 2). This deficient practice had the potential to cause a negative impact on Resident 2's psychosocial well-being related to possible recollection of past trauma or reluctance to reach out to staff when feeling distressed. Findings: During a review of Resident 2's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 12/15/2023, the MDS indicated Resident 2 had moderate impairment in cognition (ability to acquire knowledge and understand information). The MDS indicated Resident 2 was independent with self-care activities and independent in terms of mobility (ability to move). During a review of Resident 2's admission Record (AR), the AR indicated the facility initially admitted Resident 2 on 2/28/2023 with multiple diagnoses including schizophrenia (serious mental illness characterized by loss of touch with reality, disorganized speech or behavior, and decreased participation in daily activities). During a review of Resident 2'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 ensure necessary dietary services were provided to 43 of 43 residents in the facility in accordance with the facility's Policy and Procedure (P&P) titled Menus, by failing to: A. Ensure the facility's Registered Dietitian (RD) reviewed and approved the menus for nutritional adequacy prior to the implementation of the menu changes on 12/11/23. B. Ensure the facility menus were followed, prepared in advance, and met the nutritional needs of residents. Findings: A. During a review of the facility's December 2023 menu, the lunch menu consisted of chicken pot pie, tossed salad with dressing, and deluxe fruit salad. During an observation on 12/11/23 at 12:28 p.m., the facility's kitchen staff started distributing the meal trays to the residents in the dining room. The kitchen served chicken patty with salad, and fruits to the residents. During a telephone interview on 12/11/23 at 2:12 p.m., Registered Dietitian 1 (RD 1) stated she was not notified by the facility regarding the scheduled power outage and menu…

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 three of three sampled residents (Residents 16, 24, and 41) and/or their representatives were provided information regarding the right to formulate an advance directive (AD, legal documents that provide instructions for medical care and only go into effect if you cannot communicate your own wishes) by failing to: 1. Ensure Resident 16's conservator (CON 1, court appointed person to act or make decisions for another person)/Family Member (FM) 1 was notified regarding Resident 16's AD. 2. Ensure Resident 24's conservator was notified regarding Resident 24's AD. 3. Ensure Resident 41's conservator was notified regarding Resident 41's AD. This failure had the potential to result in Residents 16, 24, and 41 to receive undertreatment (not enough medical treatment) or overtreatment (interventions that do not benefit the patient, or where the risk of harm from the intervention is likely to outweigh any benefit the patient will receive) 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 observation, interview, and record review, the facility failed to ensure all services provided by the facility for two of two sampled residents met professional standards of quality. A. For Resident 36, the facility failed to ensure all licensed staff were aware of the facility's policy and procedures (P&P) and national standards regarding the treatment of hypoglycemia (blood sugar levels below 70 milligrams per deciliter [mg/dl, a unit of measure that shows the concentration of a substance in a specific amount of fluid] that could prevent bodily functions to continue). B. For Resident 34, Licensed Psychiatric Technician 1 (LPT 1) did not check Resident 34's heart rate (heartbeats per minute) as ordered by the physician prior to administering the blood pressure medication. These failures had the potential to cause a decline in the resident's physical well-being related to inappropriate treatment or services provided by lowering Resident 36's blood sugar and lowering Resident 34's heart rate to the point…

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 record review, the facility failed to ensure the facility had a Registered Nurse at least 8 consecutive hours a day for 7 days a week for five of 30 days in the month of June 2023 (6/10/2023, 6/13/2023, 6/15/2023, 6/18/2023, and 6/30/2023) from staffing assignments and payroll-based data reviewed. This failure had the potential to cause a decline in the residents' physical and/or psychosocial well-being related to insufficient supervision, monitoring, and coordination of care and services by the registered nurse. Findings: During an interview on 12/13/2023 at 3:55 p.m., the Director of Nursing (DON) stated a Registered Nurse (RN) must always be available in the facility daily for 8 consecutive hours to supervise staff, conduct resident assessments as necessary, and coordinate care and services for the residents. During a concurrent interview and record review on 12/14/2023 at 11:36 a.m. with the Director of Staff Development (DSD), the licensed nurse assignment sheets were reviewed. The DSD stated there was no documented evidence that a registered nurse 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.

Based on observation, interview, and record review the facility failed to ensure resident's food was held at a safe temperature in two of two facility freezers, during a scheduled power outage. This deficient practice had the potential to result in unsafe consumption of food served to the residents. Findings: During an observation of the facility's kitchen, on 12/11/23, at 11:17 a.m., Freezer A & Freezer B's internal thermometer reading was at 29 degrees Fahrenheit. Freezer A contained meats and Freezer B contained vegetables to be served to the residents. During a concurrent observation and interview, on 12/11/23, at 12:31 p.m., with the Maintenance Supervisor (MS), MS stated a portable generator was on the way, to be used for the two freezers observed in the dining room. MS stated Electric Company 1 (EC1) did not notify MS of the electrical outage. During an observation, on 12/11/23, at 12:45 p.m., Freezer A's temperature was 30 degrees Fahrenheit. During an observation, on 12/11/23, at 12:47 p.m., Freezer B's temperature was between 38 and 41 degrees Fahrenheit 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.

Based on interview and record review, the facility failed to ensure the minimum required member, the Medical Director (MD, physician who provides guidance and leadership in a healthcare organization), was present for two of two quarterly Quality Assurance Performance Improvement (QAPI, data driven and proactive approach to quality improvement) meetings. This deficient practice had the potential to impact facility residents as the Medical Director was not involved in identifying and responding to quality deficiencies within the facility. Findings: During record review of a submitted document titled, Quality Assurance Committee, indicated a list of facility staff members that were part of the QAPI committee. However, the facility's MD was not included on the list. During the QAPI interview and record review of the facility's Quality Assurance Performance Improvement Meeting, dated 7/26/23 and 10/19/23, with the facility administrator (ADM), on 12/14/23 at 6:09 pm, The facility's Quality Assurance Performance Improvement Meeting indicated the MD was not present for the QAPI meetings.…

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

Based on observation, interview, and record review, the facility failed to follow the infection prevention and control practices by failing to implement interventions to prevent and control the spread of infections in the facility in accordance with their own policies and procedures and national health guidelines. A. One (1) of two (2) staff members was not wearing a mask while serving food to the residents. B. One (1) of three (3) staff members did not perform hand hygiene upon entering the kitchen. C. Ensure personal belonging was not kept in food storage area. These failures had the potential to result in an increased spread of infection in the facility. Findings: a. During an observation on 12/11/2023 at 12:27 p.m. in the dining hall, the [NAME] was observed not wearing a mask while serving food to the residents. During an observation on 12/13/2023 at 12:30 p.m. in the dining hall, the [NAME] was observed not wearing a mask while in the kitchen during lunch pass. During an interview on 11/13/2023 at 12:50 p.m. with the Cook, the [NAME] stated she did not wear a mask today or 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 licensed nursing staff failed to ensure one of two sampled resident (Resident 8) was informed in advance, of the risks and benefits of taking psychotherapeutic medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior). This deficient practice violated the resident's right to make an informed decision regarding the use of psychotherapeutic medications. Findings: During a review of Resident 8's Admissions Record, dated 9/14/2016, Admissions Record, indicated Resident 8 was admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder (combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder), and unspecified convulsions (rapid involuntary muscle contractions). A review of Resident 8's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 10/18/2023, indicated a BIMS (Brief Interview for Mental Status) score 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 develop a comprehensive plan of care for one of one sampled resident (Resident 41) who was observed to have yellow-colored teeth (change in the color of the teeth, looking less bright and white) and yellow plaque (sticky film of bacteria that constantly forms on your teeth) buildup. This failure resulted in Resident 41 not receiving individualized care and/or treatment for activities of daily living (ADL, activities related to personal care) and did not maintain the residents' highest practical physical and mental well-being. Findings: During a review of Resident 41's AR, the AR indicated Resident 41 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia (affects ability to think, feel, and behave clearly and a person feels distrustful and suspicious of other people). During a review of Resident 41's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 10/26/23, indicated 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 observation, interview, and record review, the facility failed to obtain proper footwear to prevent falls by failing to follow up with the Orthopedics (Ortho, medical specialty focusing on treating injuries and diseases of the musculoskeletal system) consultation, ordered by the primary care provider 1 (PCP 1) after a fall incident for one of 12 sampled residents (Resident 36). This failure had the potential to increase Resident 36's risks for injury and repeated falls. Findings: During a review of Resident 36's admission Record (AR), the facility initially admitted Resident 36 on 12/15/2021 with multiple diagnoses including type 2 diabetes mellitus (chronic condition wherein the body does not produce enough or resists insulin, causing high blood sugar), schizophrenia (mental disorder usually involving false beliefs, seeing/hearing things that don't exist, unusual physical behavior, and disorganized thinking and speech), and drug-induced subacute dyskinesia (involuntary, erratic, writhing movements of the face, arms, legs, or trunk). During a review of Resident 36'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 schedule a neurologist (a doctor who treats and diagnoses conditions in the brain and nervous system) consultation for one of one resident (Resident 8). This failure resulted in Resident 8 not being examined by a neurologist. Findings: During a review of Resident 8's Admissions Record, dated 9/14/2016, Admissions Record, indicated, Resident 8 was admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder (combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder), unspecified convulsions (rapid involuntary muscle contractions), and essential (primary) hypertension (a condition characterized by abnormally high levels of glucose in the blood, usually as a result of untreated or improperly controlled diabetes mellitus). A review of Resident 8's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 10/18/2023, indicated a BIMS (Brief Interview for Mental Status) score…

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 (Resident 16) was free from unnecessary medications. Resident 16 was prescribed and received Erythromycin (an antibiotic used to treat infections) ointment to both eyes since 4/8/21 without adequate monitoring. This deficient practice had the potential for Resident 16 to receive unnecessary medication for an excessive period of time and could result in antibiotic resistance. Findings: During a review of Resident 16's admission Record (AR), the AR indicated Resident 16 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and ocular hypertension ( the pressure within the eye increases without affecting a person's vision) to the left eye. During a review of Resident 16's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 11/6/23, the MDS indicated Resident 16 had clear speech, had…

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 monitor the antibiotic use for one (1) of one (1) sampled residents (Resident 16). This failure had the potential for the resident to develop an antibiotic resistance (when germs like bacteria and fungi develop the ability to defeat the drugs designated to kill them). Findings: During a review of Resident 16's admission Record Face Sheet dated 12/14/2023, the admission Record Face Sheet indicated the resident was admitted on [DATE], with a diagnosis of schizophrenia (seeing or hearing things that do not exist, unusual physical behavior, and disorganized thinking and speech) and unspecified subjective visual disturbances (short spell of flashing or shimmering of light in your sight). During a review of Resident 16's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 11/6/2023, the MDS indicated Resident 16 is cognitively intact (a participant who has sufficient judgment for daily decision making). The MDS also 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 notify the physician for one of four sampled resident (Resident 1) regarding the development of an eye contusion (black eye-deep bruise of the eye) after a physical altercation with another resident. This deficient practice may have resulted in Resident 1 delay treatment for an eye injury and having to be transferred to a general acute care hospital's emergency room. Findings: During a review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included schizoprenia (a mental disorder effecting how a person thinks and feels) and myopia (nearsightedness). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment and care-screening tool) dated 10/18/23, indicated Resident 1 was cognitively intact (the ability to think and reason), had clear speech, made self-understood and had the ability to understand others. During a review of Resident 1's Body Check Form dated 10/12/23,…

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 six sampled residents (Resident 4) was free from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) according to the facility ' s policies and procedure (P&P), when Resident 5 punched Resident 4 in his eye. This deficient practice resulted in Residents 4 to experience physical abuse. Findings: During a review of Resident 4's admission Record dated 9/18/23, indicated Resident 4 was admitted to facility on 3/14/11, and readmitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), and unspecific convulsions (a sudden, violent, irregular movement of a limb or of the body). 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.