River Walk Care Center

Based on observation, interview, and record review, the facility failed to ensure:1. Expired food was disposed of;2. Food was labeled and dated in the refrigerator and freezer once opened;3. Frozen food items were stored properly and;4. Steam table was kept free of debris.These failures had the potential for residents to consume expired food items and the potential for food borne illness.Findings:During a concurrent observation and interview on 10/27/25 at 9:07 a.m. with Dietary Supervisor (DS), in the dry food storage room, there was a package of 12 hamburger buns on the shelf labeled with the date 10/15/25 (12 days earlier). DS stated the hamburger buns should have been used within five to seven days from the date on the label. During a concurrent observation and interview on 10/27/25 at 9:10 a.m. with DS, in the walk-in refrigerator, there were nine bowls of apple crisp, 11 containers of vanilla pudding, 13 plastic containers of mixed fruit and 11 containers of chocolate pudding on trays that contained no label. There was a plastic food storage container that was labeled lunch…

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 notify the physician when one of two sampled residents (Resident 1) had blue discoloration to his left foot. This failure resulted in the facility being unaware of Resident 1's nondisplaced (bone fragments are in their original position) fracture (break in the bone) proximal (closer to the center) aspect proximal phalanx (toe bone) left first digit and a delay in care.Findings:During a review of the Progress Notes (PN) dated 8/11/25 at 10:26 p.m. (documented by Licensed Vocational Nurse (LVN) 3), the PN indicated, Resident is being monitored for s/s (signs and symptoms) of edema (swelling that occurs when fluid builds up in the body's tissues) to BLEs (bilateral lower extremities), will encourage resident to elevate legs. Denies pain and discomfort at this time. Resident has bluish discoloration noted on left foot.During a review of the PN dated 8/12/25 at 12:03 p.m. (documented by LVN 2), the PN indicated, Resident has bluish discoloration noted on left foot.During a review of the PN dated 8/12/25 at 8:26 p.m. (documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow Physicians Order (PO) for one of three sampled residents (Resident 1) when a follow up wound clinic appointment was not scheduled. This failure had the potential for Resident 1's wound to worsen. Findings: During a review of Resident 1's Discharge Activity Instructions ([NAME]), dated 4/29/25, the [NAME] indicted, Follow up at [clinic name] Wound Healing Clinic to resume grafix (skin graft) and wound vac (machine used for wound healing) therapy. During an interview on 5/28/25 at 1:30 p.m. with Wound Nurse (WN), WN stated Resident 1 was admitted on [DATE] from the hospital with multiple wounds including unstageable (depth and stage cannot be determined) to right buttocks and stage 3 (full-thickness loss of skin. Dead and black tissue may be visible) to left buttock and sacrum. WN stated she was not aware of Resident 1 having a follow up order at the wound clinic. During a concurrent interview and record review on 5/28/25 at 1:39 p.m. with…

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

Based on interview and record review, the facility failed to follow its policy and procedure for a change of condition for one of three sampled residents (Resident 1) when a S (Situation) B (Background) A (Appearance) R (Review and Notify) (SBAR-document used to notify the physician of a change of condition) was not completed, and Resident 1 was not monitored for a change of condition when experiencing a dislocated hip. This failure had the potential for staff to be unaware of Resident 1's worsening condition and the potential for a delay in care. Findings: During a review of Resident 1's Progress Notes (PN) dated 1/27/25 at 1:58 p.m., the PN indicated, Xray results received. The prosthetic (artificial body part) head is dislocated (joint that is no longer in proper alignment) superior (above another structure) to the acetabular cup (a prosthetic implant used in total hip replacement surgery to replace the natural acetabulum). No evidence of acute fracture or dislocation. [Physician name] made aware. New orders: Refer to [Physician name] . During a review of Resident 1's PN dated…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with a detailed discharge summary. This failure had the potential for Resident 1 to be unaware of how to care for his wounds and the potential for the wounds to worsen. Findings: During a review of Resident 1's Order Summary Report (OSR-physicians orders) dated 12/1/24, the OSR indicated, L (left) back of heel diabetic ulcer (open sores or wounds on the feet of people with diabetes [high blood sugar]) 1.3 cm (centimeters-a unit of measurement) x 1.1 cm cleanse with wound cleaner, pay [sic] dry and swab with betadine.start date 8/21/24.unstageable pressure injury (pressure ulcer [injury to skin and underlying tissue resulting from prolonged pressure on the skin] where the depth and extent of the tissue damage cannot be determined) to L inner heel cleanse with wound cleaner and swab with betadine.start date 11/19/24.unstageable pressure injury to L medial foot cleanse with wound cleanser and swab with betadine.start date 11/19/24. During a review 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 interview and record review, the facility failed to ensure physician's orders were followed for one of three sampled residents (Resident 1) when: 1. The physician was not notified when blood sugar results were greater than 400; 2. Antibiotics were not administered for osteomyelitis (bone infection). These failures had the potential for Resident 1 to experience adverse side effects such as delayed wound healing and the potential for wounds to worsen. Findings: 1. During a review of Resident 1's Order Summary Report (OSR-physician orders) dated 1/1/25, the OSR indicated, Humulin R (medication used to control high blood sugar).inject as per sliding scale: if 70-200 = 0 (units); 201-250 = 2; 251-300 = 4; 301-350 = 6; 351-400 = 8, subcutaneously (under the skin) three times a day for diabetes mellitus (chronic metabolic disorder characterized by high blood sugar levels, due to a deficiency in insulin production or the body's inability to effectively use insulin) hold if BS (blood sugar) < (less than) 70 or > (greater than) 400. Notify MD. During a review of Resident 1's OSR…

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 therapeutic menu was followed for one of three sampled residents (Resident 1). This failure resulted in Resident 1 being served the incorrect dessert. Findings: During a review of Resident 1's Order Summary Report (OSR-physician orders) dated 4/1/25, the OSR indicated, CCHO (consistent carbohydrate diet for diabetes [condition where the body either doesn't produce enough insulin or can't effectively use the insulin it does produce, leading to high blood sugar levels])/NAS (no added salt) diet. During a review of the Cooks Spreadsheet (CS) dated 4/22/25, the CS indicated, the CCHO diet was to be served vanilla mousse no chocolate chips. During a concurrent observation and interview on 4/22/25 at 12:30 p.m. with Certified Nursing Assistant (CNA) 1, in Resident 1's room, Resident 1's lunch tray was sitting on the over bed table. The lunch tray contained vanilla mousse pudding with chocolate chips. CNA 1 stated Resident 1 was provided pudding with chocolate chips. During an interview on 4/30/25 at 3:16…

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 physician orders were followed for one of three sampled residents (Resident 1) when treatments were not done as ordered. This failure had the potential for Resident 1's wounds to worsen. Findings: During a review of Resident 1's Treatment Administration Record (TAR) dated 9/2024, the TAR indicated, Cleanse right side of abdomen with wound cleanser pat dry and leave open to air one time a day for abrasion start date 9/13/24.cleanse with Dakin's (antiseptic solution), pat dry, apply dakins soaked gauze and cover with abd (abdominal) pad, and enforce with tape one time a day for abd post surgical old scar tissue open area start date 9/10/24.L (left) heel diabetic blister cleanse with wound cleanser, pat dry and swab with betadine.one time a day start date 9/13/24.R (right) heel diabetic blister.cleanse with wound cleanser, pat dry and swab with betadine one time a day start date 9/13/24.sacrum shearing.cleanse with wound cleanser pat dry and apply calmoseptine (medication) one time a day for shearing start date…

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 professional standard of care for one of two sampled residents (Resident 1) when blood glucose (sugar) test (measures the sugar level in the blood) was not checked timely as ordered by the physician. This failure had the potential for Resident 1 to have adverse health outcomes. Findings: During a concurrent observation and interview on 3/12/25 at 11:05 a.m. with Resident 1, Resident 1 was in her room, sitting in a wheelchair. Resident 1 stated her blood sugar was checked four times a day, before each meal and at bedtime. Resident 1 stated Registered Nurse (RN) does not check her blood sugar before dinner. Resident 1 stated, [RN] checks it [blood sugar level] either while I'm already eating or after I'm done eating and by that time it [sugar level] is high and he gives me more insulin (lowers blood sugar level). During a review of Resident 1's Quarterly Minimum Data Set (MDS - a standardized, comprehensive assessment tool) dated 12/30/24, indicated, Resident 1 had a BIMS (Brief Interview for Mental…

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

Based on observation, interview, and record review, the facility failed to ensure medication administration competency assessment was completed for one of two licensed nurses (Registered Nurse-RN). This failure had the potential for medication errors and unmet care needs. Findings: During a review of RN's employee file, RN was hired on 12/30/24. There was no medication administration competency assessment noted in RN's employee file. During an interview on 3/12/25 at 2:07 p.m. with RN, RN stated he had been working at the facility for approximately three months and had not been assessed for medication administration competency. During a concurrent interview and record review on 3/18/25 at 12:25 p.m. with Director of Nurses (DON), DON reviewed RN's employee file and confirmed medication administration competency for RN was not completed. DON stated it was the facility practice for medication administration assessment to be completed upon hire. During a review of the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, dated 2022, the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide supervision for one of two sampled residents (Resident 1) with a diagnosis of dementia (a progressive state of decline in mental abilities), is a high risk for elopement and had a history of elopement. This failure resulted in Resident 1 eloping from the facility without staff being aware and potential for harm. Findings: During a review of Resident 1's admission Record (AR), undated, the AR indicated Resident 1 was admitted on [DATE]. During a review of Resident 1's Progress Note (PN), dated 11/2/24, at 5:46 p.m. the PN indicated, Another resident [Resident 2] stated that resident [Resident 1] walked out the front door and turned right, and left the facility. Staff member ended up finding resident walking on the sidewalk and brought him back to the facility via car. Resident 1's Elopement Evaluation dated 5/1/24, 7/19/24, and 10/11/24 indicated Resident 1 was a high risk for elopement. Resident 1's quarterly Minimum Data Set (MDS…

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

Based on interview, and record review, the facility failed to follow the facility's policy and procedure (P&P) titled, Advanced Directives, when 26 of 30 sampled residents (Resident 292, Resident 63, Resident 341, Resident 49, Resident 17, Resident 50, Resident 32, Resident 61, Resident 46, Resident 52, Resident 2, Resident 12, Resident 5, Resident 4, Resident 65, Resident 15, Resident 85, Resident 60, Resident 56, Resident 35, Resident 31, Resident 23, Resident 57, Resident 69, Resident 78, and Resident 39) did not have an Advance Directive, including the right to accept or refuse medical or surgical treatment, in the residents' medical record. This failure had the potential for the facility to provide treatment and services against multiple residents wishes. Findings: During an interview on 10/15/24 at 12:51 p.m. with admission Coordinator, (AC), AC stated, it was very important for Resident 341 to have Advance Directive. AC stated, the Advanced Directive allowed the facility to know the resident's wishes. During an interview on 10/15/24 at 4:17 p.m. with Resident 292, 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 follow their policy and procedure (P&P) titled, Laundry and Bedding, Soiled, when one of eight sampled residents (Resident 60) was observed with brown stains on the bed linen. This failure had the potential for Resident 60 to be exposed to infectious disease. During a concurrent observation and interview on 10/14/24 at 10:34 a.m. with Family Member (FM) 2 in Resident 60's room, an unoccupied bed had multiple brown spots on the bed linen. FM 2 stated the bed linen has been dirty for 2 days. FM 2 stated she did not want to sit in a room with dirty bed linen. During a concurrent observation and interview on 10/14/24 at 10:40 a.m. with House Keeping (HK) 1 in Resident 60's room, HK 1 confirmed there were dried brown colored spots on the bed linen. HK 1 stated dirty bed linen should be changed. HK 1 stated it was the responsibility of the Certified Nursing Assistant (CNA) to change the bed linen. During a concurrent observation and interview on 10/14/24 at 10:46 a.m. with CNA 6, in Resident 60's room, CNA 6 stated…

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 procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, when oral care was not provided for one of eight sampled residents (Resident 51). This failure had the potential to result in oral discomfort or infections and dental cavities. Findings: During a review of Resident 51's Minimum Data Set (MDS- a federally mandated resident assessment tool), the MDS indicated Resident 51 had a diagnosis of a stroke (brain attack when blood flow to the brain is disrupted causing brain cell death) with hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), was fed via a gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and was dependent (required another person to perfom task) for oral hygiene. During a review of Resident 51's Order Care Summary (OCS), dated 10/16/24, the OCS indicated, Enteral Feed Order every shift Ensure Oral Care is…

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, Enteral Feedings - Safety Precautions, for one of four sampled residents (Resident 51) when: 1. Enteral nutrition feeding bottle was not labeled. This failure had the potential for old, spoiled, or expired nutritional feedings to be administered to Resident 51. 2. Enteral tubing was disconnected from gastrostomy (G-tube - a surgical inserted tube that provides direct access into the stomach) site a three-way-valve. The three-way-valve was not closed, and stomach contents were leaking onto Resident 51's abdomen and clothing. This failure had the potential for Resident 51's skin to develop sores. Findings: During a review of Resident 51's Minimum Data Set (MDS- resident assessment tool), the MDS indicated Resident 51 had a diagnosis of a stroke (brain attack when blood flow to the brain is disrupted causing brain cell death) with hemiplegia (total paralysis of the arm, leg, and trunk on 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 implement pharmacy recommendations for one of 19 sampled residents (Resident 341) after multiple falls. This failure had the potential for staff to be unaware of Resident 341 experiencing adverse consequences from medication and Resident 341 to experience subsequent falls. Findings: During a review of Resident 341's Interim Medication Regimen Review (IMRR), dated 5/11/2024, the IMRR indicated, Type of Review: Change of Condition.Fall.Recommendation.BMP (basic metabolic panel-a common blood test that can be used to screen for, diagnosis[sic], or monitor health conditions).TSH (thyroid-stimulating hormone-blood test that measures the amount of TSH in the blood).BP (blood pressure).HR (Heart Rate).Check orthostatic BPS (blood pressure taken when standing up from a sitting or lying position) Q (every) Shift X (times) 3 days. Notify MD if resident experiences orthostasis (drop in blood pressure when standing). During a review of Resident 341's IMRR, dated 7/12/2024, the IMRR indicated, Type of Review: Change of…

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

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, for providing services for maintaining independence in activities of daily living (ADLs - routine tasks/activities such as eating, bathing, dressing) for one of three sampled residents (Resident 52) when Resident 52 did not have an adaptive device to enable her to drink water independently. This failure resulted in Resident 52 to be dependent upon facility staff. Findings: During a concurrent observation and interview on 10/14/24 at 9:30 a.m. with Resident 52, Resident 52's water cup was on the bedside table out of Resident 52's reach. Resident 52 had contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) in both hands. Resident 52 stated she was not able to reach her water. Resident 52 stated when she can reach her water cup, it was very difficult to drink without spilling the water. During a concurrent observation and interview on 10/15/24 at 8:15 a.m. with Resident 52, 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 ensure staff were in-serviced on the elopement binder. This failure had the potential for staff to be unaware of residents that were at risk for elopement. Findings: During a review of the Elopement Binder (EB), the EB indicated, Resident 40, Resident 69, Resident 74, Resident 75, Resident 76, and Resident 294 were high risk for elopement. During a review of the facility's ETP Attendance Roster (ETPAR), dated 2/8/24, the ETPAR indicated, Course Title(s): Elopement Risk/Charge Nurse responsibilities. There were 19 staff that attended the in-service. During an interview on 10/14/24 at 3:35 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was unaware of the residents that were at risk for elopement. During an interview on 10/14/24 at 3:44 p.m. with CNA 2, CNA 2 stated the residents at risk for elopement always had a staff with them and all the residents at the facility were elopement risk. During an interview on 10/14/24 at 4:16 p.m. with Administrator, Administrator stated there was an elopement binder located…

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 treat one of three sampled residents (Resident 1) with dignity and respect when Certified Nursing Assistant (CNA 1) used foul language and shooed (make someone go away) Resident 1 away with her hands. This failure resulted in Resident 1 becoming agitated (to feel bothered or worried) and violated Resident 1 ' s rights. Findings: During an interview on 10/3/24 at 10:15 a.m. with Social Service Designee (DSD) and Director of Nurses (DON), SSD stated on 9/28/24 during night shift, two staff (CNA 2 and CNA 3) witnessed CNA 1 using foul language towards Resident 1. DON stated using foul language towards any resident was not acceptable. During a concurrent observation and interview on 10/3/24 at 10:53 a.m. in the dining room, Resident 1 was sitting in a table by himself. Resident 1 was verbal but was unable to answer any questions appropriately. During a review of Resident 1 ' s admission Record (AR), undated, the AR indicated, Resident 1 had 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 wound treatments were completed for three of three sampled residents (Resident 1, Resident 2, and Resident 3). This failure had the potential for the residents' wounds to worsen. Findings: 1. During a review of Resident 1's Order Summary Report (OSR), dated 9/20/23, the OSR indicated, Flagyl [antibiotic] Oral Tablet.apply to right hip topically every day shift for Stage IV (full thickness skin loss with extensive destruction, exposed bone, tendon, or muscle).Start Date 8/31/23. During a review of Resident 1's Treatment Administration Record (TAR), dated 9/2023, the TAR indicated, Flagyl [antibiotic] Oral Tablet.apply to right hip topically every day shift for Stage IV. There were missing signatures indicating the treatment was not done on 9/9, 9/10, and 9/15. 2. During a review of Resident 2's OSR, dated 9/1/23, the OSR indicated, Cleanse Stage II (shallow open ulcer with a red or pink wound bed) to coccyx (tailbone) with NS, pat dry, apply medihoney (used to decrease bacterial growth in a wound), and cover with…

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

Based on observation, interview, and record review, the facility failed to monitor the temperature in the dry food storage room. This failure had the potential to decrease quality and palatability in the food items being stored. Findings: During a concurrent observation and interview on 10/17/22, at 12:20 PM, with Dietary Supervisor (DS), in the dry food storage room, no thermometer was found. DS stated, the thermometer in the dry storage room broke a while ago and we have not replaced it, which we should have. DS stated, they had not kept a temperature log for the dry storage room. During a review of the facility's policy and procedure (P&P) titled, Storage and Food Supplies, dated 2020, the P&P indicated, The storeroom should be well-lighted, well -ventilated, cool, dry, and clean at all times. Thermometers should be placed in all storage areas and checked frequently. Recommended temperature is 50-85º F. If dry food storage goes over 85º F take corrective action.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain a safe and homelike environment when: 1. Eight of 39 sampled residents (Resident 24, Resident 53, Resident 30, Resident 32, Resident 43, Resident 22, Resident 67, and Resident 74) had holes in the ceiling and dark brown/black stained ceiling tiles in their rooms. This failure resulted in Resident 24, Resident 53, Resident 30, Resident 32, Resident 43, Resident 22, Resident 67, and Resident 74 not having a home like environment and had the potential to adversely affect the health and safety of the residents residing in the facility. 2. The baseboard along the wall of the head of one of one resident's (Resident 33) bed was broken. This failure resulted Resident 33 not having a home like environment and the potential for exposure to vermin infestation. 3. Comfortable sound levels were not ensured during the evening shift for five of six confidential residents and Resident 35 when staff used loud, vulgar, and profane language. This…

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 five of five sampled residents (Resident 6, Resident 23, Resident 3, Resident 39 and Resident 51) were free from verbal abuse, when Resident 6 and Resident 23 repeatedly yelled/screamed at each other. This failure resulted in Resident 6, Resident 23, Resident 3, Resident 39, and Resident 51 experiencing mental distress and discomfort, including weeping. Findings: During an observation on 10/17/22, at 3:56 PM, outside of Resident 6 and Resident 23's shared room, voices yelling shut up was heard through the closed door. During an observation on 10/18/22, at 8:36 AM, inside Resident 6 and Resident 23's shared room, two residents could be heard screaming. Resident 6 (in the B bed) was screaming at Resident 23 (in the C bed), You have the face of a bitch, just kill yourself! You are a bastard! Resident 23 replied to Resident 6, Stop bothering me! Resident 6 then said, Shut up, your ugly face bothers you! During this exchange, uniformed staff were observed walking past room without intervening. 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 follow standard practices of care when: 1. Physician was not informed of one of one sampled resident's (Resident 23) ongoing and increased behaviors related to schizophrenia (a mental disorder)], which resulted in a discontinuation of Zyprexa [a psychotropic medication used to treat mental disorders]. This failure resulted in the unmet care needs for Resident 23's ongoing psychological conditions. 2. Staff did not follow physician orders to change Lopez valve (a device which allows the administration of medications and feeding through a gastrostomy tube (G-Tube, a feeding tube inserted through the stomach) for one of one sampled G-Tube residents (Resident 33). 3. Staff did not follow physician orders to clean G-tube site as ordered for one of one sampled G-Tube residents (Resident 33). 4. Staff did not follow physician orders to apply Compression Stockings (specialized hosiery designed to help prevent the occurrence of edema/swelling) daily for one of one sampled residents (Resident 71) with edema. 5. Staff did not ensure…

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 accurately complete the annual Pre-admission Screening Assessment and Resident Review (PASARR-federal requirement to help ensure that individuals are not incorrectly placed in nursing homes or long term care instead of a psychiatric setting) for one out of one sampled residents (Resident 23). This failure had the potential for Resident 23 to be placed in an inappropriate setting and not receive required services. Findings: During a concurrent interview and record review, on 10/20/22, at 10:35 AM, with Minimum Data Set Coordinator (MDSC), Resident 23's PASARR assessment, dated 5/23/22, was reviewed. The PASARR for Resident 23 indicated she did not have a diagnosed mental disorder such as schizophrenia (a serious mental disorder, characterized by seeing or hearing things that are not there, and disorganized thinking). MDSC stated, she was aware Resident 23's diagnosis of schizophrenia. The MDSC stated, she completed the PASARR, and it was incorrect by not documenting Resident 23's schizophrenia diagnosis.

Based on observation, interview, and record review, the facility failed to ensure a baseline care plan was developed and implemented for one of one edentulous [no natural teeth] residents (Resident 41). This failure had the potential for Resident 41 to have unmet care needs. Findings: During a concurrent observation and interview on 10/18/22, at 9:05 AM, with Family Member (FM) 3, in Resident 41's room, Resident 41 was observed with no upper and lower teeth. FM 3 stated, Her [Resident 41] dentures are at home. She doesn't want to wear them. They may be loose. During a concurrent interview and record review on 10/19/22, at 9:15 AM, with Infection Preventionist (IP/LVN), Resident 41's plan of care were reviewed. IP/LVN was unable to find a plan of care initiated and developed to address Resident 41 lack of teeth and dentures. During a review of the facilities policy and procedure (P&P) titled, Dental Services, dated 6/1/22, the P&P indicated, Policy Explanation and Compliance Guidelines. 1. The dental needs of each resident are identified through. MDS [Minimum Data Set an assessment…

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

Based on observation, interview, and record review, the facility failed to ensure two of 39 sampled residents (Resident 23 and Resident 71) had comprehensive care plans developed and implemented for their person-centered care. This failure resulted in Resident 23 and Resident 71 not having their needs met. Findings: During an observation on 10/17/22, at 1:34 PM, in Resident 71's room, Resident 71's legs were swollen from the knees down and had a shiny appearance. Resident 71 was noted sitting in a recliner with the footrest down, wearing sandals, with no compression stockings [specialized hosiery designed to help prevent the occurrence of edema/swelling] on. During a review of Resident 71's physician order (PO), dated 9/30/22, the PO indicated, Resident 71 had an order for compression stockings to be applied daily to BLE (Bilateral Lower Extremities) for Edema in the morning and remove per schedule. During a review of Resident 71's Comprehensive Care Plans, Resident 71's Comprehensive Care Plans did not include a care plan for Resident 71's bilateral lower extremity edema or…

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 hearing aids or other devices to maintain resident's communication abilities for one of one sampled residents identified of being hard of hearing (Resident 71). This failure resulted in Resident 71 not being able to communicate effectively. Findings: During an observation on 10/17/22, at 3:34 PM, in Resident 71's room, Resident 71 was very hard of hearing and only understood if spoken to loudly, directly into her ears. No hearing aids were seen. During a concurrent interview and record review on 10/19/22, at 2:55 PM, with Social Services Manager (SSM), Resident 71's Physician's Order (PO) dated 9/30/22 was reviewed. The PO indicated, on 8/30/22, a hearing aid consult was ordered. SSM stated, the hearing consult didn't happen due to other more critical things going on with the Resident 71 and the facility decided to wait on the consultation. SSM stated, FM 2 was informed Resident 71's hearing consult was put on hold. SSM unable to provide documentation of a completed hearing aid consultation for…

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 alternative means of communication for one of one sampled non-English speaking residents (Resident 41). This failure resulted in Resident 41 unable to communicate her needs and had the potential for unmet care needs. Findings: During a concurrent observation and interview on 10/17/22, at 1:10 PM, with Infection Preventionist/Licensed Vocational Nurse (IP/LVN), in Resident 41's room, Resident 41 was lying in bed, awake, and verbally responsive. IP/LVN stated, She [Resident 41] doesn't speak English. She's from [Name of country]. IP/LVN stated, Resident 41 should have a communication card at bedside. IP/LVN was unable to find a communication card at Resident 41's bedside. During a review of the facility's policy and procedure (P&P) titled, Communicating with Persons with Limited English Proficiency, dated 6/1/22, the P&P indicated, It is the policy of this facility to take reasonable steps to ensure that persons with Limited English Proficiency (LEP) have meaningful access and an equal opportunity to…

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

Based on an observation, interview, and record review, the facility failed to provide foot care for one of two sampled residents (Resident 53). This failure resulted in Resident 53 having untrimmed toenails which had the potential to result in skin irritation including skin tears/damage and toenail infections. Findings: During a concurrent observation and interview on 10/20/22, at 10:14 AM, in Resident 53's room, with Certified Nursing Assistant (CNA) 4, Resident 53's toenails were noted to extend beyond the nailbed, were thick and curled. CNA 4 stated, Resident 53's toenails were long and needed to be trimmed. During an observation and interview on 10/20/22, at 2:02 PM, in Resident 53's room, with Social Services Manager (SSM), Resident 53's toenails were noted as long, jagged, and sharp with the large toe nail curling under. SSM stated, the toenails could cut Resident 53. During a concurrent interview and record review on 10/20/22, at 1:50 PM, with SSM, Resident 53's clinical record was reviewed. SSM stated, there were no records of podiatry services for Resident 53. SSM stated,…

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 a safe environment for two of two sampled residents (Resident 41 and Resident 54) when: 1. One screener (unlicensed, untrained person, whose function is to screen visitors and staff for symptoms of COVID-19) assisted Resident 41 with a transfer from her bed to her wheelchair. This failure resulted in Resident 41's fall during transfer from her bed to the wheelchair. 2. Licensed nurses did not complete the post fall monitoring and a neuro checks for Resident 54 for multiple unwitnessed falls. This failure had the potential for Resident 54 to have unknown injuries during seven unwitnessed falls and two fractures. Findings : 1. During an interview on 10/18/22, at 12:15 PM, with Family Member (FM) 3, FM 3 stated, [Resident 41] fell the first time she got here while she was in therapy [8/17/22]. She also fell three weeks ago during transfer from bed to wheelchair with one [Certified Nursing Assistant (CNA)]. FM 3 stated, Resident 41 needed two person…

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

Based on observation, interview and record review, the facility failed to develop and implement a plan of care for one of one sampled resident's (Resident 23) prosthetic (artificial device to replace a missing body part) eye. This failure resulted in the staff being unaware of the plan of care for Resident 23's missing eye. Findings: During an interview on 10/19/22, at 6:52 PM, with Family Member (FM) 1, FM 1 asked about the resident's prosthetic eye. FM 1 stated, when she last visited, Resident 23 was not wearing the prosthetic eye. During a concurrent observation and interview on 10/20/22, at 2:02 PM, with Social Services Manager (SSM), in Resident 23's room, Resident 23 was noted not wearing the prosthetic eye. SSM stated, Resident 23 used to have a prosthetic eye,But I haven't seen it in a long time. During a concurrent interview and record review on 10/24/22, at 10:26 AM, with the Assistant Director of Nursing (ADON), the ADON stated, she could not find a care plan that addressed the prosthetic eye. The ADON stated, she could not find a physician's order that addressed the 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.

Based on observation, interview and record review, the facility failed to provide effective pain management for one of one sampled residents (Resident 23). This failure resulted in Resident 23's unmanaged pain, psychological distress, and refusal of care. Findings: During an observation on 10/18/22, at 10:14 AM, Resident 23 was noted to be crying out in pain, stating her right leg hurts bad, I am in a lot of pain. Resident 23's right leg was noted to be contracted (stiffening of the joints) and bent at the knee, with sole of her foot resting against the inner thigh of her upper left leg. During a concurrent observation and interview on 10/19/22, at 7:48 AM, with Resident 23, Resident 23 was noted to be yelling and crying out from down the hall. Upon entering the room, Resident 23 was noted to be crying and cradling her left hand. Resident 23 stated, my left hand is in a lot of pain, I don't know why. Resident 23's left hand was noted with severe contracture, and had a foam hand roll in the palm. Tears were noted to Resident 23's cheeks. Resident 23 rated her pain on a scale between…

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 staff provided non-pharmological interventions for one of one sampled residents (Resident 33) on a psychotropic medication (medication that affects brain activities associated with mental processes and behavior). This failure had the potential for Resident 33 to experience increased risks such as dizziness, severe drowsiness, loss of consciousness and nausea or vomiting associated with the use of Buspirone HCL [hydrochloride] [Buspar - a psychotropic medication used to treat anxiety]. Findings: During a review of Psychiatric F/U (Follow-up) Note (PFUN), dated 6/13/22, the PFUN indicated, Buspirone HCL 15 mg [milligram - a unit of measurement] via GT [gastrostomy tube - a tube inserted through the stomach) Q [every] 12 hours. During a review of Resident 33's Order Summary Report (OSM), dated 9/27/22, the OSM indicated, buspPIRone [sic] 15 mg Give 1 tablet via G-Tube three times a day for anxiety. During a concurrent interview and record review on 10/19/22, at 10:09 AM, with Infection Preventionist/Licensed Vocational…

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 dental follow-up and services were provided to one of one sampled residents (Resident 41) with dentures. This failure resulted in Resident 41 not receiving dental services. Findings: During a concurrent observation and interview on 10/18/22, at 9:05 AM, with Family Member (FM) 3, in Resident 41's room, Resident 41 was observed with no upper and lower teeth (edentulous). FM 3 stated, Resident 41's dentures were at home. FM 3 stated, Resident 41 doesn't like to wear the dentures because they are loose in her mouth. During a concurrent interview and record review on 10/19/22, at 9:15 AM, with Infection Preventionist/Licensed Vocational Nurse (IP/LVN), Resident 41's assessments and documentation were reviewed. IP/LVN stated, Resident 41 was edentulous. IP/LVN was unable to find documentation Resident 41 had a referral to a dentist. During a concurrent interview and record review on 10/19/22, at 9:25 AM, with Social Service Manager (SSM), SSM assessment and progress notes were reviewed. SSM was unable to…

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

Based on interview and record review, the facility failed to ensure an accurate Treatment Administration Record (TAR), for one of one sampled residents (Resident 71). This failure resulted in the incorrect documentation of Resident 71 had compression stockings (specialized hosiery for residents with swollen legs) applied according to the physician order (PO). Findings: During a review of Resident 71's Physician Orders (PO), dated 9/30/22, the PO indicated, Resident 71 had a PO for Compression stockings to be applied daily to BLE [Bilateral Lower Extremities] for Edema (swelling) in the morning and remove per schedule. During a concurrent observation and interview on 10/19/22, at 11:55 AM, with Registered Nurse (RN) 2, and Resident 71, in Resident 71's room, Resident 71's bilateral legs and ankles were swollen and shiny in appearance. RN 2 confirmed Resident 71 was not wearing compression stockings. Resident 71 stated, They've [staff] never put them on me, but if I had some [compression stockings] I would try them, my legs are so big! During a concurrent interview and record review,…

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

Based on observation, interview, and record review, the facility failed to: 1. Label and date irrigation syringes for two of two sampled residents (Resident 80 and Resident 33) with gastrostomy tube (G-tube - a feeding tube inserted through the stomach) feedings. 2. Follow facility policy and procedure (P&P) for hand hygiene for two of two sampled residents (Resident 33 and Resident 67) when exiting or entering resident rooms and between resident care 3. Follow facility policy and procedure (P&P) for hand hygiene for one of one sampled residents (Resident 78) during wound care. These failures had the potential to place residents, staff, and visitors at risk for infection. Findings: 1 a. During a concurrent observation and interview on 10/17/22, at 12:46 PM, with Infection Preventionist/Licensed Vocational Nurse (IP/LVN), in Resident 80's room, Resident 80 was lying in bed, with a G-tube feeding administered with G-tube pump. One irrigation syringe (used to administer G-tube feeding and medications) hung on the G-tube pump pole. The used irrigation syringe was neither labeled nor…

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.