Gateway Post Acute

Based on interview, and record review, the facility failed to implement one of two sampled resident (Resident 9) physician order for colostomy ( a surgical procedure where an opening is made in the colon and brought to the surface of the abdomen to allow stool to exit the body) bag change every week. This failure had the potential to result in resident's care not being met with the likely of infection to the colostomy site.Findings:During a review of Resident 9's Order Summary Report (OSR), dated 2/27/26, the OSR indicated, Colostomy bag change every week and PRN (as needed) for leakage/soilage.During a concurrent interview and record review on 5/13/26 at 12:26 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 9's TREATMENT ADMINISTRATION RECORD (TAR), dated 4/26 through 5/26 was reviewed. The TAR indicated, for the month of May the colostomy bag was not changed. The TAR indicated, for the month of April the colostomy bag was changed only on 4/11/26. LVN 2 stated the colostomy bag should be changed every week per physician's orders and staff should be monitoring the site.During…

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

Based on observation, interview, and record review the facility failed to ensure one of two sampled resident (Resident 5), had a comprehensive (complete) care plan (CP). This failure had the potential to result in Resident 5 not having measurable objectives and timetables to meet the residents physical needs. Findings:During a review of Resident 5's admission Record (AR), dated 2/3/26, the AR indicated, SEIZURE (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) .TRAMATIC BRAIN INJURY.During a concurrent observation and record review on 5/12/26 at 12:32 p.m. with Licensed Vocational Nurse (LVN) 3, Resident 5 was sitting in the hallway in his wheelchair with a soft helmet on his head. LVN 3 stated Resident 5 wear's a soft helmet on his head to protect himself. LVN 3 stated Resident 5 is to wear the helmet out of bed. LVN 3 stated Resident 5 does not have a CP to indicate why Resident 5 is wearing a helmet, how long the helmet should be on, if Resident 5's skin or head should be evaluated for skin…

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 failed to follow its policy and procedure (P & P) tilted Elopements, for one of four sampled resident (Resident 38) when Resident 38 exited the building unsupervised. This failure had the potential for Resident 38 to cause harm to self or an injury.Findings:During an observation on 5/12/26 at 12:26 p.m. in residents hallway, Resident 38 with an alarm on back of wheelchair, pushed exit door open and self-propelled her wheelchair out of exit door. During an interview on 5/12/26 at 12:30 p.m. with Resident 54, Resident 54 stated you need to have staff with you when you go outside.During a concurrent observation and interview on 5/12/26 at 12:35 p.m. at 12:35 p.m. with Resident 38 and Certified Nursing Assistant (CNA) 1 at exit door hallway, CNA 1 was pushing Resident 38's wheelchair from outside into residents hallway with an audible alarm. CNA 1 stated Resident 38 should not be outside without staff. CNA 1 stated the Resident 38 pushed forward in her chair setting off the chair alarm.During an interview on 5/14/26 at 11: 20 a.m.…

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 there was accurate and consistent communication between departments regarding adaptive equipment for one of one sampled resident (Resident 51). This failure had the potential to result in unnecessary and/or unmet implementation of adaptive equipment per Resident 51's assessment and/or physician's orders, to meet Resident 51's specialized nutritional needs and enhance quality of life.Findings: During an observation on 5/11/26 at 12:20 p.m. in the dining room, Resident 51 had a clear cup with one blue colored handle and a blue lid, containing a red colored liquid. Resident 51's tray card indicated, Adap. [adaptive] Equip [equipment]: 2-Handle Cup with Lid.During a concurrent observation and interview on 5/11/26 at 12:38 p.m. with Occupational Therapist (OT) in the dining room, Resident 51's lunch plate, cup and tray card remained on the dining table. OT stated the one handled cup did not match the tray card that indicated a 2-Handle Cup.During a concurrent interview and record review on 5/11/26 at 12:40…

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 a [NAME] followed standardized texture modified recipes for seven of 56 residents (Resident 7, Resident 8, Resident 21, Resident 26, Resident 31, Resident 49, and Resident 56) as a method to maintain nutritive value. This failure had the potential to result in texture modified food with less nutritive value than planned, placing residents on a pureed diet at risk for nutritional impairment. Findings:During a concurrent observation and interview on 5/11/26 at 11:19 a.m. with Cook, in the presence of the Registered Dietitian (RD), in the kitchen, [NAME] stated she placed seven pieces of bread in the food processor. [NAME] added an unmeasured quantity of milk into the food processor. Next, [NAME] added an unmeasured quantity of thickener into the food processor, in which the [NAME] determined the need to add an additional amount of unmeasured thickener. [NAME] stated she prepared six servings of pureed bread.During an interview on 5/11/26 at 11:22 a.m. with Cook, [NAME] stated she was unable to state how…

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 18 sampled residents (Resident 57) had accurate wound records due to unclear physician's order (PO). This failure resulted in Resident 57 having documentation that did not accurately represent the care provided.Findings:During a review of Resident 57's Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns] with scores ranging from 0 - 15, the higher the score the more intact the resident's cognition. A score of 0 - 7 suggests severe cognitive impairment, 8 - 12 suggests moderate cognitive impairment and 13 - 15 suggests the cognition is intact), dated 4/16/26 the BIMS indicated Resident 57's score was 13.During a review of Resident 57's Order Summary Report (OSR), dated 5/5/26, the OSR indicated, Cleanse abdominal wound with dakins [a diluted, hospital-grade [bleach] antiseptic used to clean wounds] quarter strength gauze, leave in place for 2 minutes, then remove gauze and apply black foam for wound vac [a medical device that uses controlled…

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 meet the needs for one of two sampled residents (Resident 1) when a STAT (immediately) x-ray (takes pictures of areas inside the body) ordered by the physician was not completed timely. This failure has the potential for a delay in care for Resident 1. Findings: During a concurrent observation and interview on 6/4/25 at 10:53 a.m. with Resident 1 in resident's room, Resident 1 was lying in bed with her left arm wrapped in an immobilizer sling (device used to support and keep still an injured part of the body). Resident 1 stated her left arm was broken. During a concurrent interview and record review on 6/4/29 at 11:09 a.m. with Licensed Vocation Nurse (LVN), LVN stated Resident 1 had a fall on 5/28/25. LVN stated on 5/29/25 at 3:19 p.m. a physician's order was obtained for a stat x-ray to the left hip and the left shoulder. LVN stated the x-ray technician arrived on 5/30/25 at approximately 10:30 a.m. (approximately 19 hours after the stat physician's order was obtained) to obtain the x-ray of Resident 1's…

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

Based on observation, interview, and record review, the facility failed to implement infection control practices when: 1. The Infection Preventionist (IP) did not use appropriate personal protective equipment (PPE-refers to gowns, gloves, masks, face shields, goggles to protect the individual from injury or infection) and did not perform appropriate hand hygiene for one of one sampled Residents (Resident 51), 2. Conduct an effective infection control surveillance activity through data collection, data analysis, track, and trending for 57 of 57 residents residing in the facility. These failures had the potential to transmit infectious diseases. Findings: 1. During a concurrent observation and interview on 10/15/24 at 9:15 a.m. with IP in Resident 51's room a sign on the door indicated Enhanced Barrier Precaution (EBP- precautionary measure to reduce the spread of bacteria). IP put on an isolation gown and gloves before entering Resident 51's room. IP irrigated the open wound of the amputated left toe and the vascular wound (wounds caused by poor blood circulation) on the left ankle.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement Antibiotic Stewardship (pharmacy-driven initiative dedicated to improve antibiotic [medications to treat bacteria] / antifungal [medications to treat fungus] use in nursing homes). This failure had the potential for residents to receive antibiotic and/or antifungal medications unnecessarily, which could be detrimental to residents' health. Findings: 1. During an interview on 10/17/24 at 8:20 a.m. with Infection Preventionist (IP), IP stated she was responsible for the antibiotic stewardship program in the facility. IP stated the pharmacist did not participate in the antibiotic stewardship progrm. IP stated there were no antibiotic stewardship meetings. During a concurrent interview and record review on 10/17/24 at 9 a.m. with IP, the Infection Control Committee Meeting Attendance Records (ICCMAR), dated 8/2024, 9/2024, and 10/2024, were reviewed. The ICCMAR for the last three months did not include a pharmacist, a medical director, or 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 one of one sampled resident (Resident 51) was assessed and determined to be competent to self-administer medication. This failure had the potential for medication administration error and serious health risk. Findings: During a concurrent observation and interview on 10/14/24 at 11:34 a.m. with Resident 51 in Resident 51's room, a bottle of eye drops was on top of the bedside table. Resident 51 stated the nurse leaves the eye drops there so he can put the eye drops in his eyes. Resident 51 stated he had the eye drops in his room for over two months. During a concurrent observation and interview on 10/14/24 at 11:40 a.m. with Licensed Vocational Nurse (LVN) 1 in Resident 51's room, LVN 1 removed the bottle eye drops from Resident 51's bedside table and stated Resident 51 was not to have the eye drops at the bedside. LVN 1 stated it was not acceptable to have the eye drops on Resident 51's bedside table. During a concurrent interview and record review on 10/16/24 at 8:58 a.m. with Minimum Data Set…

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

Based on interview and record review, the facility failed to: 1. Notify the physician for the discontinuation of the restorative therapy (therapeutic and rehabilitative techniques provided by specially trained restorative nursing assistant [RNA]) for one of one sampled resident (Resident 21). This failure had the potential for Resident 21 to not meet his full potential for mobility. 2. Notify the physician for the swelling and purplish discoloration of the left big toe and wounds on the left big toe for one of one sampled resident (Resident 2). This failure had the potential for Resident 2's wounds to be untreated. Findings: 1. During a review of Resident 21's admission Record (AR), dated 2/21/20, the AR indicated, Resident 21 was admitted with diagnosis including post-laminectomy syndrome (chronic pain following spinal surgery), cord compression (happens when pressure on the spinal cord stops the nerves from working normally causing back pain, arm or leg weakness, and difficulty walking) and muscle weakness. During a concurrent observation and interview on 10/14/24 at 3:48 p.m.…

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

Based on observation, interview, and record review, the facility failed to maintain a homelike environment for two of 15 sampled residents (Resident 46 and Resident 162). This failure resulted in these residents living in an unkempt environment. Findings: a. During a concurrent observation and interview on 10/14/24 at 3:39 p.m. with Resident 162 in Resident 162's restroom, a dark brown ring was on the inside of the toilet bowl. Resident 162 stated she did not know the last time her toilet had been cleaned. During a concurrent observation and interview on 10/15/24 at 8:32 a.m. with Maintenance Supervisor (MS) and Housekeeping staff member (HSM) in Resident 162's restroom, MS and HSM observed the toilet and confirmed there was a dark brown ring on the inside of the toilet bowl MS and HSM stated the toilet was stained and should be replaced. During a concurrent observation and interview on 10/15/24 at 8:56 a.m. with Administrator in Resident 162's restroom, Administrator stated the toilet was stained and should be replaced. b. During a concurrent observation and interview on 10/15/24…

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 their policy and procedures (P&P) titled, Certifying Accuracy of the Resident Assessment, for one of one sampled resident (Resident 35). This failure had the potential to not meet Resident 35's dental needs. Findings: During a concurrent observation and interview on 10/15/24 at 8:43 a.m. with Resident 35 in Resident 35's room, Resident 35 pointed to his upper tooth and complained of pain. During a concurrent interview and record review on 10/17/24 at 9:01 a.m. with Minimum Data Set (resident assessment tool) Consultant (MDSC) 2, Resident 35's MDS, Section K (Swallowing/Nutritional Status), dated 8/15/24 was reviewed. The MDS indicated Resident 35 had Broken or loosely fitting full or partial denture and no natural teeth or tooth fragment(s). MDSC 2 stated Resident 35's MDS was incorrect. During a review of Resident 35's COMPREHENSIVE SKILLED REVIEW NOTE [CSRN], dated 1/15/24 was reviewed. The CSRN indicated, III. SOCIAL SERVICES. [Resident 35] has his own teeth with some missing. During a review of the…

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

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 3) had a psychiatric and a Preadmission Screening and Resident Review (PASRR- a federal requirement to help ensure placement in nursing facility was appropriate) Level 2 evaluation after a PASRR Level 1 indicated the need for evaluation of his mental disorder. This failure had the potential for Resident 3 to be inappropriately placed in a nursing home and had the potential to not receive the mental health treatment needed. During a concurrent interview and record review on 10/15/24 at 10:15 a.m. with Minimum Data Set (resident assessment tool) Coordinator (MDSC) 1, Resident 3's PASRR Level 1 Screening, dated 1/15/24 was reviewed. Resident 3's PASRR Level 1 indicated Level 1 Screening: Positive. Section III Serious Mental Disorder: Yes Diagnosis: Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), major depressive disorder…

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 complete and provide two of two newly admitted sampled residents (Resident 51 and Resident 109) and/or their representatives a summary of the baseline care plan (BCP-the minimum healthcare information to care for each resident upon admission) within 48 hours of admission. This failure had the potential for unmet care needs. Findings: 1. During a review of Resident 51's admission Record (AR), the AR indicated, Resident 51 was admitted on [DATE] with diagnoses including acute osteomyelitis (inflammation and swelling in the bones) left ankle and foot, Type 2 diabetes mellitus (DM- chronic condition with persistent high blood sugar levels) with diabetic neuropathy (nerve damage in the legs and feet in people with diabetes) and other skin ulcers. During a review of Resident 51's Operative Report (OR), dated 9/20/24, the OR indicated, Post-Op [after surgery] Diagnosis: Left first toe gangrene [dead tissue caused by an infection or lack of blood flow].…

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 follow their policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, for one of 18 sampled residents (Resident 22). This failure had the potential to not meet Resident 22's physical, psychosocial (related to thought or behavior), and functional needs. Findings: During a review of Resident 22's Order Listing Report (OLR), dated 8/23/24, the OLR indicated, admitted under the care of [Name of Hospice]. During a review of Resident 22's Minimum Data Set (MDS-resident assessment tool), dated 8/23/24, the MDS Section O (Special Treatments, Procedures, and Programs), indicated Resident 22 received hospice care while Resident 22 was in the facility. During a concurrent interview and record review on 10/16/24 at 3:32 p.m. with MDS Consultant (MDSC) 2, Resident 22's Care Plans (CP) were reviewed. MDSC 2 stated there was no End of Life or Hospice CP for Resident 22 and there should have been a CP developed after Resident 22 was admitted to hospice. During a review of the facility's P&P titled, Care Plans,…

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 to one of 11 sampled residents (Resident 5) were administered medications according to physician orders. This failure had the potential for Resident 5 to have adverse medication outcomes. Findings: During a review of Resident 5's Care Plan (CP), dated 8/9/17, the CP indicated Resident 5 had hypertension (High blood pressure). The CP indicated, Interventions/Tasks.Give anti hypertensive [sic] medications as ordered. During a review of Resident 5's CP, dated 11/21/20, the CP indicated, Resident 5 has alteration in comfort related to shoulder and knee pain. The CP indicated, Interventions/Tasks. Administer pain medications as ordered. During a review of Resident 5's Medication Administration Record (MAR), dated 10/2024, the MAR indicated the following: a. AmLODPine Besylate [medication to lower blood pressure] Tablet 5 MG [milligrams] Give 1 tablet by mouth one time a day for HTN [hypertension-high blood pressure] hold if SBP [systolic blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 18 sampled residents (Resident 7) was provided activities of her choice. This failure resulted in Resident 7 not participating in person centered activities. Findings: During a review of Resident 7's admission Record (AR), dated 10/17/24, the AR indicated Resident 7 was admitted to the facility on [DATE] with diagnoses including major depressive disorder (mental disorder that affects how a person feels, thinks, and acts), Alzheimer's Disease (brain disorder that gradually destroys memory and thinking skills, and eventually the ability to perform everyday tasks) and need for assistance with personal care. During a review of Resident 7's Minimum Data Set (MDS - an assessment tool), dated 7/18/24, the MDS section F - Preferences for Customary Routine Activities, indicated, it was very important to Resident 7 to do things with groups of people, do her favorite activities, and go outside to get fresh air when the weather is good.…

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 18 sampled patients (Patient 15) was provided quality care when: 1. A Care Plan (CP) for pain management was not developed. 2. The admission Nursing - Pain Observation and Assessment (NPOA) was incomplete, and reassessment was not done. These failures resulted in Patient 15 experiencing unrelieved pain and a feeling of isolation. Findings: 1. During a review of Patient 15's admission Record (AR), dated 10/16/24, the AR indicated, Patient 15 was admitted to the facility on [DATE] with diagnoses including, hemiplegia (partial or complete paralysis of one side of the body) and hemiparesis (partial paralysis or weakness on one side of the body) following Cerebral Infarction (stroke - disrupted blood flow to the brain) affecting right side, muscle weakness, and need for assistance with personal care. During a review of Patient 15's History and Physical Examination (H&P), dated 8/9/24, the H&P indicated This resident [Patient 15]…

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.

The facility failed to follow its policy and procedure (P&P) titled Repositioning for one of one Residents (Resident 22). This failure had the potential for Resident 22 to develop pressure ulcers. Findings: During a review of Resident 22's CP, dated 10/7/20, the CP indicated, [Resident 22] has potential for pressure ulcer development r/t Alzheimer's [a disease that destroys memory and other mental functions].Interventions/Tasks. [Resident 22] requires monitoring/reminding/assistance to turn/reposition at least every 2 hours, more often as needed as requested. During a review of Resident 22's MDS Section GG, dated 8/23/24, the MDS GG indicated Resident 22 is dependent and unable to roll left or right on her own. During a concurrent interview and record review on 10/17/24 at 3:03 p.m. with RNC 2, Resident 22's TR, dated 8/2024 was reviewed. The TR indicated, on the following dates Resident 22 was not repositioned and turned during day shift: 8/1, 8/18, and 8/26. The TR indicated, on the following dates Resident 22 was not reposition and turned during night shift: 8/1, 8/2, 8/7, 8/8,…

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 an appropriate diet texture (consistency of food or the size of food pieces) was provided to one of 15 sampled residents (Resident 16). This failure had the potential to cause Resident 16 to choke on her food or have an adverse outcome. Findings: During a review of Resident 16's admission Record (AR), dated 6/8/22, the AR indicated, Resident 16 had a diagnosis of dysphasia (difficulty swallowing) and feeding difficulties. During a concurrent observation and interview on 10/14/24 at 12:44 p.m. with FM 1 in Resident 16's room, Resident 16 was served lunch which included a regular textured meatball sandwich on a hoagie bun. Resident 16 was missing most of her top teeth. FM1 stated Resident 16 she does not wear her top dentures anymore because family was afraid she would swallow them. FM 1 stated, [Resident 16] pockets [holds food in her cheeks] her food and will hold on to big pieces. FM 1 stated Resident 16's food never comes chopped up and is always a regular texture. During a review of Resident 16'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 ensure one of two sampled residents (Resident 17) had complete pre-dialysis and post dialysis communication assessments. This failure had the potential for Resident 17 to have a change of condition that was not communicated and could result in negative health outcomes. Findings: During a review of Resident 17's admission Record (AR), dated 10/17/24, the AR indicated Resident 17 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD - kidneys can no longer function properly) and dependence on renal dialysis (treatment that removes excess water and toxins from the blood when kidneys no longer function). During a review of Resident 17's Order Entry (OE), dated 8/20/24, the OE indicated, Dialysis Orders, Dialysis Center: [identification number] Days and time of treatment: M [Monday] - W [Wednesday] - F [Friday]. During a concurrent interview and record review on 10/17/24 at 10:13 a.m. with Director of Staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled, Bed Safety and Bed Rails, for one of 18 sampled residents (Resident 55) when: 1. The bed rail and entrapment risk observation/assessment (BEAR) was inaccurate and incomplete. 2. The Interdisciplinary Team (IDT - team of health care professionals) was not involved in the review of use of bed rails. 3. There was no physician's order for continuous use of bilateral (right and left) bed rails. 4. There was no Care Plan (CP) for use of bilateral bed rails. This failure resulted in Resident 55's IDT had the potential to put Resident 51's safety and health at risk. Findings: 1. During a review of Resident 55's admission Record (AR), dated 10/17/24, the AR indicated Resident 55 was admitted to the facility on [DATE] with diagnoses including encephalopathy (general term for a brain disorder), muscle weakness, dysphasia (condition that affects a person's ability to understand and speak). During an…

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

Based on interview, and record review, the facility failed to employ a full time Director of Nursing (DON) for a facility licensed for 62-beds. This failure resulted in lack of oversight on the total operation of nursing services and provision of quality of care. Findings: During entrance conference on 10/14/24 at 9:15 a.m. with Administrator, Administrator stated, The facility does not have a director of nursing. During a concurrent interview and record review on 10/15/24 at 2:30 p.m. with Director of Staff Development (DSD), the facility Payroll Based Journal (PBJ) dated 9/5/24 and 9/17/24 was reviewed. DSD stated there was no DON for over a year now, and she was assigned to calculate the nursing staffing hours and submit the report to PBJ. DSD stated there was no DON to review the nursing staffing hours for accuracy. DSD stated the Administrator or Registered Nurse Consultant (RNC) 1 did not provide oversight and recheck the reports submitted. During an interview on 10/17/24 at 8:15 a.m. with Infection Preventionist (IP), IP stated the facility did not have a DON to provide her…

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

Based on observation, interview, and record review, the facility failed to ensure one of three medication carts did not contain expired medication. This failure had the potential for a medication with reduced effectiveness to be administered to a resident. Findings: During a concurrent observation and interview on 10/16/24 at 10:18 a.m. with Licensed Vocational Nurse (LVN) 4 at Medication Cart 3 (MC3), an Advair Diskus Inhaler [medication used to treat difficulty breathing] was labeled with a discard date of 10/8/24. LVN 4 stated the inhaler should have been discarded by 10/8/24. LVN 4 stated it is the responsibility of the nurse who is assigned to the medication cart to check the expiration dates and dispose of any expired medications or supplies. During a review of the facility's policy and procedure (P&P) titled, Medication Storage, dated 2019, the P&P indicated, N. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication…

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

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was five percent or less when two medication errors were observed out of 25 medication administration opportunities, which resulted in a medication error rate of 8%. These failures had the potential for residents to not receive the therapeutic effects of the medication. Findings: 1, During a concurrent observation and interview on 10/16/24 at 11:12 a.m. with Licensed Vocational Nurse (LVN) 4 outside of Resident 109's room, LVN 4 prepared Resident 109's medication for administration. LVN 4 took Resident 109's blood sugar and the blood sugar was 236 (normal range 60-99 mg/dl [milligram per deciliter]). LVN 4 stated Resident 109 had a insulin sliding scale (amount of insulin given is based on blood sugar level) order for insulin to be administered before all meals. LVN 4 stated Resident 109's blood sugar was 236 therefore he would receive four units of Humalog insulin. LVN 4 stated Resident 109 also was to receive six units of Humalog insulin before all meals. LVN 4 administered…

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

Based on observation, interview, and record review, the facility failed to ensure one of 10 sampled residents (Resident 109) was free from a significant medication error. This failure had the potential for Resident 109 to adverse health outcomes. Findings: During a concurrent observation and interview on 10/16/24 at 11:12 a.m. with Licensed Vocational Nurse (LVN) 4 outside of Resident 109's room, LVN 4 prepared Resident 109's medication for administration. LVN 4 took Resident 109's blood sugar and the blood sugar was 236 (normal range 60-99 mg/dl [milligram per deciliter]). LVN 4 stated Resident 109 had a insulin sliding scale (amount of insulin given is based on blood sugar level) order for insulin to be administered before all meals. LVN 4 stated Resident 109's blood sugar was 236 therefore he would receive four units of Humalog insulin. LVN 4 stated Resident 109 also was to receive six units of Humalog insulin before all meals. LVN 4 administered 10 Units of Humalog insulin to Resident 109. During a concurrent interview and record review on 10/17/24 at 8:15 a.m. with LVN 4,…

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 two of three kitchen staff (Dietary Service Supervisor [DSS] and Kitchen [NAME] [KC])followed their policy and procedures (P&P) titled, DRESS CODE FOR WOMEN AND MEN, This failure had the potential for food contamination. Findings: During an observation on 10/14/24 at 9:03 a.m. in the kitchen, DSS and KC had a beard and mustache on their face. DSS and KC wore a beard restraint (net used to cover facial hair) which left their mustaches exposed. During an interview on 10/14/24 at 9:36 a.m. with DSS, DSS stated mustaches were okay to have exposed if the mustache was trimmed. During a review of the facility's policy and procedures (P&P) titled, DRESS CODE FOR WOMEN AND MEN, dated 2018, the P&P indicated, PURPOSE: Appropriate dress in the Food & Nutrition Department Personal hygiene and appropriate dress are a very important part of the total appearance of the Food & Nutrition Service Department. Appearance is very important in maintaining a high standard of food service.PROPER DRESS.Men.8. Beards 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 ensure intake and output was monitored for one of four sampled residents (Resident 1) when Resident 1 was on a fluid restriction. This failure resulted in the facility being unaware of Resident 1 ' s fluid intake and output. Findings: During a review of Resident 1 ' s Order Summary Report (OSR), dated 9/9/24, the OSR indicated, Admission.6/27/24.Resident has fluid restriction of 1.8 liters (unit of measurement)/24 hrs (hours).Order date.6/27/24. During an interview on 9/17/24 at 11:55 with Registered Nurse (RN), RN stated when a resident was on a fluid restriction, their intake and output should be monitored daily. During a concurrent interview and record review on 9/17/24 at 3:17 p.m. with Director of Staff Development (DSD), Resident 1 ' s clinical record was reviewed. DSD was unable to provide any intake and output monitoring documentation for Resident 1. DSD stated, Resident 1 ' s intake and output was only monitored during the first 30 days after admission, and it should have been ongoing due to the fluid restriction.…

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 develop a Care Plan (CP) for one of three sampled residents (Resident 1) after a fall. This failure had the potential for Resident 1 to experience further falls. Findings: During a review of Resident 1 ' s S [Situation] B [Background] A [Appearance] R [Review and Notify] (SBAR), dated 12/6/23, the SBAR indicated, During morning med (medication) pass in a well lit room resident was found on floor and reported that she slipped off her bed. During a review of Resident 1 ' s Progress Notes (PN), dated 12/7/23 at 3:08 p.m., the PN indicated, 12/6/23 at approximately 1150 resident was found on floor sitting next to her bed.Current Intervention(s): Non skid socks on at all times. During a concurrent interview and record review on 12/12/23 at 2:48 p.m., with Registered Nurse (RN) 1, Resident 1 ' s CP's were reviewed. There was no CP developed after Resident 1 ' s fall. RN 1 stated, the CP should have been completed after the fall. During a review of the facility ' s policy and procedure (P&P) titled Falls and Fall Risk, Managing…

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

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) was properly secured during transportation when: 1. Seatbelt was loosely fastened unto Resident 1's wheelchair. 2. Footrest (a removable footplate where the feet are placed to avoid injury and maintain balance) was missing from Resident 1's wheelchair. These failures resulted in Resident 1 falling out of wheelchair, sustaining skin tear to right wrist and abrasion (scrape) to right shin. Findings: 1. During an interview on 11/13/23 at 12:45 p.m. with Licensed Vocational Nurse (LVN), LVN stated Resident 1 was taken to a doctor's appointment on 10/20/23, using the facility van. LVN stated on the way to the appointment, Resident 1's seat belt was placed too loose causing Resident 1 to slid out of the wheelchair and landing on his knees. During a concurrent observation and interview on 11/13/23 at 1:06 p.m. in Resident 1's room, Resident 1 stated during the car ride to the doctor's appointment on 10/20/23, the transport driver had to immediately hit the break on…

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

Based on interview and record review, the facility failed to ensure Computed Tomography (CT-diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce images of the inside of the body) results for one of three sampled residents (Resident 1) were received. This failure resulted in the facility being unaware of Resident 1's CT results. Findings: During a review of Resident 1 ' s Order Details (OD), dated 6/23/23, the OD indicated, Appointment: CT Scan R) [right] hip. During a review of Resident 1 ' s [Hospital 1] Imaging Report (IR), dated 6/26/23, the IR indicated, CT right hip.Acute appearing impacted left subcapital (femoral neck-thigh bone) hip fracture.Consider MRI [magnetic resonance imaging-a type of scan that uses strong magnetic fields and radio waves to produce detailed images of the inside of the body] left hip without contrast follow-up for confirmation as clinically warranted. During an interview with Licensed Vocational Nurse (LVN) 1, on 7/11/23, at 11:32 a.m., LVN 1 stated, Resident 1 had a CT of the right hip done on 6/26/23. LVN…

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 follow its policy and procedure (P&P) titled Advance Directives (a document indicating a person's wishes for end-of-life care) when staff did not facilitate formulation of Advance Directives for 7 of 33 sampled residents (Resident 1, Resident 22, Resident 26, Resident 35, Resident 41, Resident 43, and Resident 45). This failure had the potential for staff to be unaware of the medical treatment to be provided to resident, when they no longer able to make decisions in the event of an emergency. Findings: During an interview on 11/3/22, at 9:13 AM, with Admissions Coordinator (AC), AC stated, When they (residents) come in with family (on admission), we ask if they have an advance directive. If they do, we get a copy. If not, then we refer to social services to get one going. AC stated, no specific form is signed by the resident or family member indicating if they have an advance directive or wish to formulate one. AC stated, there should be documentation in PCC (Point, Click, Care- electronic medical record) notes. 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: 1. Follow its policy and procedure (P&P) for administering medications through an enteral tube (GT- Gastrostomy tube, surgically placed through the abdominal wall to the stomach) by gravity flow for one of 33 sampled residents (Resident 2). This failure had the potential for Resident 2 to experience aspiration pneumonia (occurs when food or liquid is breathed into the airways or lungs). 2. Follow physician's orders for administration of oxygen (a colorless, odorless reactive gas, a life-supporting component of the air) for one of 33 sampled residents (Resident 14). This had the potential to result in unmet care needs and adversely affect resident's health. Findings: 1. During an observation on 11/4/22, at 8:54 AM, outside Resident 2's room, Licensed Vocational Nurse (LVN ) 2 was observed preparing Resident 2's medication administration . LVN 2 crushed each of the following tablets with a pill crusher and placed separately in a 30 milliliter (ml - unit of measure) medication cup: Magnesium Oxide (dietary…

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

Based on observation, interview, and record review, the facility failed to provide care and services to maintain good oral hygiene for one of 33 sampled residents (Resident 2). This failure resulted in Resident 2's having poor oral hygiene with presence of cracked dry lips and can lead to dental and gum disease. Findings: During a concurrent observation and interview on 11/1/22, at 11 AM, with Certified Nursing Assistant (CNA) 2, inside Resident 2's room, Resident 2 was observed in bed with dry cracked lips. CNA 2 stated, Residents with G-tubes (GT- Gastrostomy tube, surgically placed through the abdominal wall to the stomach) should be provided with oral care every two hours by swabbing with a green sponge soaked with Listerine (mouthwash) to prevent cracked dry lips. During a concurrent observation and interview on 11/1/22, at 11:10 AM, with Licensed Vocational Nurse (LVN) 1, Resident 2 was in bed with dry cracked lips. LVN 1 stated, He [Resident 2] should not have dry cracked lips and oral care should be done every shift; otherwise, he [Resident 2] may have something accumulating…

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 clearly document in the clinical record for one of 33 sampled residents (Resident 35's) wishes in the event of cardio-pulmonary arrest (heart stops, no breathing). This had the potential for staff not knowing if they should perform cardio-pulmonary resuscitation (CPR, when trained staff give chest compressions and rescue breathing) to Resident 35. Findings: During a review of the facility Policy and Procedure (P&P) titled, Emergency Procedure - Cardiopulmonary Resuscitation, dated 2/18, the P&P indicated, If an individual. is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR . shall initiate CPR unless: a. it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR . exists for that individual. During a review of Resident 35's Physician's Orders for Life-Sustaining Treatment (POLST), dated [DATE], the POLST indicated, Do Not Attempt Resuscitation/DNR. During a review of Resident 35'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 provide appropriate activities based on interest and preferences for one of 33 sampled residents (Resident 34). This failure had the potential to negatively impact Resident 34's psycosocial well-being. Findings: During a concurrent observation and interview on 11/1/22, at 2 PM, with Resident 34, inside Resident 34's room, Resident 34 was observed in bed scratching his arms and rubbing his back against his bed. Resident 34 stated, I cannot get out of bed because the nurses complained that it was a hassle to bring in the machine [Hoyer lift patient lift used by caregivers to safely transfer patients from one place to another] to help lift me out from the bed to the chair. During an interview on 11/3/22, at 3:30 PM, with Activity Assistant (AA), AA stated, Resident 34 came down to activities for Bible study every Wednesday at 2 PM, but not anymore. During a review of Resident 34's Minimum Data Set (MDS assessment- screening tool), Section F-Activity Preferences, dated 3/27/22, MDS indicated, the following: Doing…

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 facilitate an audiology consult for one of 33 sampled residents (Resident 160). This failure resulted in a delay in the provision of assisstive hearing devices which hindered Resident 160's ability to communicate effectively. Findings: During a concurrent observation and interview on 11/1/22, at 10:15 AM, with Resident 160, Resident 160 was observed in bed and had difficulty hearing. Resident 160 stated, I cannot hear you. I don't have a hearing aid. When asked if he (Resident 160) would like a hearing aid, Resident 160 stated, Yes. During a concurrent interview and record review, on 11/4/22, at 11:30 AM, with Social Service Director (SSD), Resident 160's Social Service Notes (SSN) dated 9/2/22 were reviewed. The SSN indicated, Resident 160 observed to be a little hard of hearing. SSN, dated 9/15/22, indicated, no ancillary service concern at this time for Resident 160. SSD confirmed, Resident 160 was hard of hearing at the time of assessment. During a review of the facility's policy and procedure (P&P)…

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 refer and provide podiatry (treatment of the feet) service for two of 33 sampled residents (Resident 2 and Resident 160). This failure resulted on not meeting the care needs of Resident 2 and 160. Findings: During an concurrent observation and interview on 11/1/22, at 10:30 AM, with Resident 160, inside Resident 160's room, Resident 160 was observed with long and crooked toenails. Resident 160 stated, Yes, both were too long and my son have to get something to clip it. During a concurrent observation and interview on 11/1/22, at 11 AM, with Certified Nursing Assistant (CNA) 1, inside Resident 160's room, Resident 160 was observed in bed with long and crooked toenails. CNA 1 confirmed the findings and stated, His toenails were long, and it should not be that way. During a concurrent observation and interview on 11/4/22, at 9:30 AM, with the Director of Nursing (DON), inside Resident 2's room, Resident 2 was observed in bed with long toenails. DON confirmed, Resident 2's toenails were long. Policy and procedure was requested…

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 nursing competency assessments for 2 of 5 sampled staff (LVN 7 and CNA 8) were completed. This failure had the potential for unqualified nursing staff to provide the health care needs of Residents. Findings: During a concurrent interview and record review, on 11/4/22, at 11:42 AM, with Director of Staff Development (DSD), five personnel file's (for the year 2020, 2021) were reviewed. The personnel files indicated, there were no assessments of the level of competencies for Licensed Vocational Nurse (LVN) 7 and Certified Nursing Assistant (CNA) 8. DSD stated, she could not locate the competency/assessments in the personnel file. DSD confirmed the findings and stated the competency assessments should be done annually. DSD stated, there was no documentation that annual in-service training on abuse prevention and reporting was conducted for LVN 7 and CNA 8. The facility was not able to provide a copy of policy and procedures for nursing competencies.

Based on interview and record review, the facility failed to conduct a performance review at least once a year for one of five sampled Certified Nursing Assistant (CNA) 8. This failure had the potential for CNA 8 to not provide the appropriate care to residents. Findings: During a concurrent interview and record review, on 11/4/22, at 11:42 AM, with Director of Staff Development (DSD), CNA's 8 personnel file for the year 2020, 2021 were reviewed. It was noted there were no annual performance review for CNA 8 in 2021. DSD confirmed the findings and stated she could not locate the annual performance review in the personnel file. She also stated there was no documentation on annual in-service training in abuse prevention and reporting was conducted for CNA 8. The facility was not able to provide a copy of the policy and procedures for nursing competencies.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) to provide necessary behavioral health services for one of 33 residents (Resident 45). This failure had the potential to result in Resident 45's inability to attain the highest practicable physical, mental, and psychosocial well-being. Findings: During a review of Resident 45's admission Record (AR), dated 11/22, the AR indicated, Resident 45 was [AGE] years old and had the following diagnoses: End Stage Renal Disease, Dependence on Renal Dialysis (a procedure used to remove fluid and waste products from the blood), Cirrhosis of Liver (late stage of scarring of the liver), Diabetes Mellitus (body's inability to regulate sugar in the bloodstream), Hypertension (high blood pressure), Anxiety Disorder (a disorder causing one to feel nervous, restless, tense, have a sense of impending danger or panic, trouble sleeping, trouble concentrating, feeling weak or tired, and/or avoiding things that trigger…

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

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent (%) when three medication errors occurred out of 30 opportunities during gastrostomy tube (GT- surgically placed tube through the abdominal wall and into the stomach) medication pass for one of five sampled residents (Resident 2). The medication error rate was 10%. This failure had the potential to cause serious harm and injury to resident for not receiving the full dosage of medications ordered by the physician. Findings: During a concurrent observation and interview on 11/4/22, at 8:54 AM, outside Resident 2's room, Licensed Vocational Nurse (LVN) 2 was observed preparing medication administration for Resident 2 when: a. LVN 2 crushed each of the following tablets with a pill crusher and placed separately in a 30 milliliter (ml - unit of measure) medication cup: Magnesium Oxide (dietary supplement) 500 milligrams (mg-unit of measure) tablet, Metformin (anti-diabetic medication) 850 mg tablet, Cholecalciferol (dietary supplement) 1000 International…

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.