Riverside Village Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure professional standards of practice during medication administration and the facility's policy and procedure were implemented, for three of 10 residents observed during medication administration (Residents 48, 55, 31, and 161), when: 1. Resident 48's medication was placed on a shelf next to Resident 55, readily available for use. This failure had the potential for Resident 48's medication be administered to Resident 55; 2. The identification of Resident 31 was not verified prior to administering the medications. This failure had the potential for the medications to be administered to the wrong resident; and 3. Resident 161 was not provided privacy while administering the medications. This failure had the potential to affect Resident 161's psychosocial and mental status. Findings: 1. May 1, 2024, at 7:44 a.m., during a medication pass observation with Licensed Vocational Nurse (LVN) LVN 3, LVN 3 was observed to have 1 open packet of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure sufficient staff were provided to meet the needs of the residents when: 1. For five of 55 residents (Residents 55, 48, 31, 163, and ) complained that staff failed to assist with activities of daily living (ADL- daily care activities) in a timely manner; and 2. The facility did not meet the required minimum of Actual Total CNA Direct Care Service Hours the actual CNA DHPPD of 2.4 hours for the month of March 2025, for 16 out of 31 days reviewed, and for the month of April 2025, for 11 out 30 days reviewed. These deficient practices caused feelings of frustrations and anger, among the residents, and negatively affected the quality of care for the residents. Findings: 1a. On April 29, 2025, at 11:09 a.m., during an interview with Resident 55, Resident 55 stated he was sliding off his bed and used his call light and yelled out for the nurse aound late night of April 24, 2025. Resident 55 stated he yelled out for over 15 to 20 minutes,…

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

Based on observation, interview, and record review, the facility failed to store, prepare, and serve foods under safe and sanitary conditions when the staff placed a four-ounce (unit of measurement) soup ladle directly on the table instead of the clean container in between serving of the soup for the residents, for . This failure had the potential to put the vulnerable residents at risk for foodborne illnesses. Findings: On April 29, 2025, at 12:15 p.m., during the dining room observation, the Certified Restorative Nurse Assistant (CRNA) was observed to use the four-ounce ladle to serve soup into a bowl and then placed the ladle on the tablecloth instead of the clean container. On April 29, 2025, at 12:25 p.m., an interview with the CRNA was conducted. The CRNA stated she placed the ladle on the tablecloth in between serving of the soup to the residents. The CRNA stated she had been trained to place the used soup ladle on the clean tray. The CRNA further stated she should not have placed the ladle on the tablecloth as it might cause cross-contamination and illness in the residents.…

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 infection control practices were implemented when: 1. Two used diapers were found on top of resident cabinet drawer in room [ROOM NUMBER]; 2. One direct care staff was observed wearing long artificial finger nails while providing care to the residents; 3. The Certified Restorative Nursing Assistant (CRNA) did not wear personal protective equipment (PPE- equipment used to protect against infection or illness) when providing care to a resident with an active of Methicillin-Resistant Staphylococcus Aureus (MRSA - a bacteria resistant to many antibiotics [medication used to treat infections]) wound infection; 4. The CRNA did not clean and disinfect (use of chemicals to reduce the number of germs or virus particles on surfaces) the Hoyer lift (mechanical device use for lifting) after resident use; 5. The CRNA did not conduct proper handwashing after providing care to a resident with active infections of MRSA of the wound; and 6. The…

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

Based on observation, interview, and record review, the facility failed to provide a safe, functional and comfortable environment, when the lint trap of dryer 3 was observed damaged and the lint trap was not cleaned. This failure to maintain a functional environment had the potential to compromise resident safety. Findings: On May 2, 2025, at 9:24 a.m., during a concurrent observation and interview with the Laundry Staff (LS). The lint trap located at the bottom of dryer 3 was observed damaged with an opening at the corner towards the middle of the edge of the screen and filled with thick, soft lint that was collected from the clothes. The LS stated lint trap in dryer 3 was damaged and laundry staff still used it. The LS stated the lint trap was not collected since yesterday and was not cleaned by the laundry staff. The LS further stated the lint trap should have been cleaned and the damaged lint trap of dryer number 3 should have not been used because it could result to fire. A review of record titled, DRYER'S LINT TRAP CLEANING LOG, indicated the lint trap was not cleaned at 12…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a comprehensive care plan to address the contractures (shortening and hardening of muscles) of the feet, for one of two residents, (Resident 10). This failure had the potential for Resident 10 not to receive the appropriate interventions tailored to her needs and further worsening of the contractures of the feet. Findings: On April 29, 2025, at 9:37 a.m., during the initial tour of the facility, Resident 10 was observed laying on her bed in her room with both ankles extended in a downward position with no adaptive devices on her feet. Resident 10 was not able to flex both ankles upward. On April 30, 2025, at 9:41 a.m., during an interview with Certified Nursing Assistant (CNA) 2, she stated Resident 10 had the foot drop for a long time already. CNA 2 stated they only put heel pads to protect her from skin breakdown. On May 1, 2025, Resident 10's record was reviewed. Resident 10 was admitted to the facility on [DATE], with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appropriate care and treatment to manage contractures, for one of one resident reviewed for range of motion (ROM-the full movement potential of a joint) (Resident 10). This failure had the potential for Resident 10 to have further worsening of the feet contractures and contribute to pain and discomfort. Findings: On April 30, 2025, at 9:47 a.m., Resident 10 was observed laying on her bed with both feet extended in a downward position. Resident 10 was wearing soft blue foam heel pads to cover the ankles. On April 30, 2025, at 9:41 a.m., during an interview with Certified Nursing Assistant (CNA) 2, she stated Resident 10 had the foot drop for a long time already. CNA 2 stated they only put heel pads to protect her from skin breakdown. On April 30, 2025, at 10:35 a.m., during an interview with Certified Restorative Nursing Assistant (CRNA) 1, CRNA 1 stated she would provide ROM exercises to the residents after she received the order…

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 a resident was free from unnecessary medications for one of five residents reviewed for unnecessary medications (Resident 19) when: 1.Quetiapine (medication used to treat mental illness characterized by disordered thinking, hallucination) was administered without implementing resident-centered non pharmacological interventions prior to administration of the medication; and 2. There was no attempt for gradual dose reduction (GDR - process of slowly and systematically decreasing the dosage of a medication, particularly psychotic medication) with the use of quetiapine. These failures had the potential to result in ineffective behavior management for Resident 19 which increased the potential for unidentified risks associated with the use of medication such as sedation, respiratory depression, and memory loss. Findings: On May 1, 2025, at 12:40 a.m., during a concurrent observation and interview with a Certified Nursing Assistant (CNA)…

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, for one of one resident reviewed for dental (Resident 22), a dental consultation was provided for the resident. This failure had the potential to result in Resident 23 not receiving the dental services needed to maintain her highest practicable level of well-being. Findings: On April 29, 2025, at 4:07 p.m., Resident 22 was observed missing some upper and lower teeth. In a concurrent interview with Resident 22, he stated he could chew well, I don't have postiza (denture- artificial teeth), and had not seen the dentist. On May 1, 2025, Resident 22's record was reviewed. Resident 22 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty in swallowing). A review of Resident 22's Order Summary, included the following physician's order: - Dental Health Services as needed, date ordered July 3, 2021; and - .Dysphagia Mechanical Soft Texture (texture of food to make them easier to chew and swallow) .,…

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 resident's information was protected from unauthorized use, for one of five residents observed during medication administration (Resident 161), when the electronic health record of Resident 161 was left open and unattended by the licensed nurse. This failure had the potential for Resident 161's record to be disclosed to other people not authorized in the provision of care and treatment. Findings: On May 1, 2025, 08:06 a.m., during a medication pass observation with Licensed Vocational Nurse (LVN) 3, LVN 3 was observed to leave the computer open and unattended with Resident 161's resident information viewable to persons not directly related to the resident's care. Resident 161's record was reviewed. Resident 161's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included fracture (break) of left femur (thigh bone), difficulty walking, diabetes (too much sugar in the blood), and…

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

Based on observation, interview, and record review, the facility failed to ensure heater equipment in the resident's room was maintained in a safe operating condition, for one of 55 residents (Resident 52), when one baseboard heater cover was observed open, detached and laying on the floor. This failure had the potential to cause a fire and hazardous environment for the residents, staff and visitors. Findings: 1. On April 29, 2025, at 2:30 p.m., during a concurrent observation and interview with Resident 52 inside her room, Resident 52 was observed sitting in a wheelchair looking at the baseboard heater below the window panel. The baseboard heater cover was observed open and detached and laying on the floor. Resident 52 stated her she could feel the warm breeze directly coming from the baseboard heater. Resident 52 stated she could not pass directly because she was afraid that she might burn from the heater. On April 29, 2025, at 2:43 p.m., an interview was conducted with the Maintenance Supervisor (MS). The MS stated the baseboard heater cover was damaged and was detached from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to safeguard residents ' privacy and confidentiality, for two of two residents (Residents 1 and 2), when the residents were filmed by a staff member and posted on to social media without the residents or resident representative's consent. The deficient practice had the potential to affect the resident psychosocial well being. Findings: On April 1, 2025, at 9 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding resident's rights. 1. On April 1, 2025, at 11:05 a.m., a concurrent observation and interview with Resident 1 was conducted. Resident 1 was observed alert and was sitting in a wheelchair in the activity room. Resident 1 stated she did not dance anymore and pointed to the wheelchair. Resident 1 further stated she had bad memory and did not remember dancing with the Social Service Director (SSD) or gave permission to post her video on social media. On April 1, 2025, a review of Resident 1's record…

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 oral care after meals was provided, for one of three sampled residents (Resident 3). This failure had the potential to cause serious health issues and could affect the residents psychosocial well being. Findings: On April 1, 2025, at 9 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding quality of care. On April 1, 2025, a review of Resident 3's record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included major depressive disease (a persistent feeling of hopelessness, sadness and loss of interest), dementia (a mental disease that interferes with daily functioning), encephalopathy (condition where brain function is impaired), sepsis (infection damages the body ' s tissues and organ) and muscle wasting. A review of Resident 3's History and Physical, dated March 2, 2025, indicated the resident did not have the capacity to understand and make decisions. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure appropriate staff assistance was provided during transfer according to the plan of care, for one of five residents (Resident A). This failure resulted to Resident A to experience physical pain and had the potential for the residents to sustain injury. Findings: On December 17, 2024, at 9:45 a.m., an unannounced visit was conducted at the facility to investigate a complaint of quality of care and a facility reported allegation of abuse. On December 17, 2024, at 11:40 a.m., an interview and concurrent record review was conducted with the Rehabilitation Program Manager (RPM). The RPM stated Resident A had weakness and flaccid (no strength) on the left side. The RPM stated Resident A required moderate to maximum assistance with transfers, and the recommendation was to have two person assist with all transfers, and a mechanical lift being the safest option. The RPM stated Resident A had left sided pain since her stroke, her left arm and leg were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one of three residents' (Resident 1) medication (Hydralazine-used to treat high blood pressure) was administered in accordance with the physician order. The medication was not held for systolic blood pressure (SBP-force of blood pumped out of the heart) below 110 per order. This failure had the potential for Resident 1 to have low blood pressure requiring medical attention. Findings: On November 18, 2024, at 9:15 a.m., an unannounced visit was conducted to investigate a complaint on quality-of-care issue. On November 18, 2024, Resident 1 ' s record was reviewed. The record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included fusion of spine in lumbar (lower back) region, spinal stenosis (spaces inside the bones of the spine get too small), end stage renal disease (permanent condition that occurs when the kidneys stop functioning), dependence on renal dialysis (treatment that removes waste and excess fluid…

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 the transfer was appropriate and necessary for one out of three sampled residents (Resident 1), when Resident 1 was transferred to the general acute care hospital (GACH) without documented justification on how needs could not be met at the facility. This failure has the potential to negatively affect resident's needs due to unnecessary transfer. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including fracture (a break or a crack in a bone) of unspecified parts of lumbosacral spine (lower part of the spine) and pelvis (the bones between the lower abdomen and upper thighs). A review of Resident 1's Notice of Transfer/ Discharge Form, dated, September 6, 2024, indicated, .The transfer or discharge is necessary for your welfare and your needs cannot be met in the facility . A review of Resident 1 ' s Interact Transfer Form V5, dated September 6, 2024, indicated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a comfortable environment, for five of 13 sampled residents (Residents 4, 5, 6, 7, and 8) when the airconditioning (AC) unit was not working and the resident's room temperatures exceeded 81degrees Fahrenheit. In addition, the facility failed to report an unusual occurrence of disruption of services when the facility's airconditioning unit was not working. These failures resulted in discomfort for Residents 4, 5, 6, 7, and 8 and had the potential to for the residents to experience dehydration (loss of body fluids), heat stress (condition where the body is under stress from overheating), and heat stroke (when the body cannot control its temperature); Findings: On August 6, 2024, at 9:55 a.m., during the initial tour, standing narrow fans were moving from side to side both in the hallways and in the resident's rooms. Large and small stationary fans were observed placed in the resident rooms and in the hallways. On August 6, 2024, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two (Resident A and Resident B) of three sampled residents was assessed properly for bladder and bowel continence. This failure resulted in Resident A and Resident B not being identified, assessed and provided appropriate treatment and services to improve or restore as much bladder and bowel function as possible. Findings: On July 5, 2024, at 12:30 p.m., an unannounced visit to the facility was conducted to investigate a complaint for quality of care. 1. On July 5, 2024, a review of Resident A's medical record indicated Resident A was admitted to the facility on [DATE], with diagnoses which included intracerebral hemorrhage (bleeding inside the brain) and epileptic syndrome (a group of symptoms causing seizures). Resident A's Minimum Data Set (MDS - a resident assessment tool), dated June 2, 2024, indicated Resident A was always continent (ability to control) for urinary and bowel function continence. Resident A's Documentation Survey Report,…

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 3. An admission Record indicated the facility admitted Resident #16 on 03/09/2024. Resident #16's Physician Orders for Life-Sustaining Treatment (POLST), prepared on 03/09/2024, revealed in the event the resident was found with no pulse and not breathing, the resident elected Do Not Attempt Resuscitation/DNR (Allow Natural Death). The POLST reflected this information was discussed with the resident, and the resident had No Advance Directive; however, the section of the form for the physician, nurse practitioner, or physician assistant signature was not signed. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/15/2024, revealed the MDS reflected that Resident #16 had a POLST form in their chart that was signed by a physician, nurse practitioner, or physician assistant. The MDS further indicated that the section of the POLST addressing advance directives was discussed with the resident's legally recognized decision maker and was not completed, as opposed to reflecting the resident…

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

Based on interview, record review, and facility policy review, the facility failed to provide advance directive information to 1 (Resident #57) of 5 residents reviewed for advance directives. Findings included: A facility policy titled, Advance Directives, revised in 12/2016, indicated, Advance Directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 2. Written information will include a description of the facility's policies to implement advance directives and applicable state law. An admission Record revealed the facility admitted Resident #57 on 04/20/2024. Resident #57's Physician Orders for Life-Sustaining Treatment (POLST), prepared on 04/20/2024, revealed the section addressing advance directives was not completed. Resident #57's Consents form, dated 04/20/2024, revealed the Advance Directives section…

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

Based on observation, interview, and facility policy review, the facility failed to ensure privacy was provided during resident care for 1 (Resident #46) 1 resident reviewed for privacy. Findings included: A facility policy titled, Dignity, revised in 02/2021, indicated, 11. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. An admission Record revealed the facility admitted Resident #46 on 02/29/2024. According to the admission Record, the resident had a medical history that included diagnoses of quadriplegia and muscle wasting and atrophy. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/04/2024, revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had a functional limitation in range of motion on both sides of their upper and lower extremities, was dependent on staff for toileting hygiene, and was always incontinent of urine and…

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

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a care plan was developed to address smoking for 1 (Resident #32) of 1 sampled resident reviewed for smoking and failed to ensure the care plan reflected the level of assistance required with activities of daily living (ADLs) for 1 (Resident #46) of 2 sampled residents reviewed for ADLs. Findings included: An undated facility policy titled, Goals and Objectives, Care Plans, indicated, 3. Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment and: a. Are resident oriented; b. Are behaviorally stated; c. Are measurable; and d. Contain timetables to meet the resident's needs in accordance with the comprehensive assessment. 4. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved. 1. An admission Record indicated the facility admitted Resident #32 on 04/22/2024. Resident #32'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, record review, and facility policy review, the facility failed to ensure staff provided assistance with activities of daily living (ADLs) for 2 (Resident #44 and Resident #46) of 2 residents reviewed for ADLs. Findings included: A facility policy titled, Activities of Daily Living (ADLs), Supporting, revised in 03/2018, indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The policy further indicated, 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care). 1. An admission Record revealed the facility admitted Resident #44 on 12/26/2023. According to the admission Record, the resident had a medical history that included diagnoses of transient cerebral ischemic attack (a brief stroke-like…

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 Establish and maintain safe resident smoking practices, per the facility's Policy & Procedure (P&P) Smoking Policy-Resident, as two residents (Residents1&2) were observed smoking on the patio, without staff supervision. This failure could have resulted in injuries to Residents1&2, while smoking without staff supervision. Findings: On October 27, 2023, at 11:15 a.m., an unannounced revisit was conducted at the facility for a Quality-of-Care issue. On October 27, 2023, an interview was conducted with the Director of Nursing (DON), who indicated, Smoking Patio hours are at designated times. Residents can go out on patio at anytime but must be monitored by staff when smoking. DON further stated, the activities staff are responsible to hand out the smoking paraphenalia (Cigarettes & lighters), and monitor the smoke breaks, then staff collect the cigarettes and lighters until the next smoke break. On October 27, 2023, at 11:45 a.m., a concurrent…

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

Based on observation, interview and record review, the facility failed to ensure Resident 1 was free from significant medication errors on October 27, 2023, as Licensed Vocational Nurse 1 (LVN1) did not follow the facility's Policy & Procedure (P&P), Administering Medications, as she left Resident 1's medications in his hand, and exited resident's room, before witnessing Resident 1 take his medications. This failure resulted in Resident 1 missing his 8:00 a.m. dose of medications, including Metocarbonal and Cyclobenzaprine (Muscle relaxers, used to relieve muscle spasms). Findings: On October 27, 2023, at 11:15 a.m., an unannounced Quality-of-Care issue was conducted. During an observation on October 27, 2023, at 11:55 a.m., of Resident 1 in his bedroom, resident was observed lying flat in bed, reaching to the right of his bed, for 2 orange-colored pills on his bedside table; An empty medication cup and several pills were observed on Resident 1's mattress next to him, and one pill observed on resident's shoulder. Resident 1 was further observed moving his mouth, making inaudible…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two residents, (Resident 2)'s call light was within reach. This failure had the potential for Resident 1 to have unmet needs. On October 30, 2023, at 3:05 p.m., observed Resident 2 in her room, sitting in a wheelchair on the right side of her bed. Resident 2's call light was wrapped around the upper right siderail and was dangling onto the floor, outside of Resident 2's reach. On October 30, 2023, at 3:05 p.m., an interview was conducted with Resident 2. Resident 2 asked if she could be assisted to the restroom and back to bed. Resident 2 was asked if she knew where her call light was located, Resident 2 stated no . Resident 2 was asked if she could reach her call light, Resident 2 answered no . On October 30, 2023, at 3:06 p.m., an interview was conducted with the Medical Records Director, (MRD). The MRD stated the Resident 2's call light was not within reach. On October 30, 2023, at 4:14 p.m., an interview was conducted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide medication and treatment to address one of three residents' (Resident 1)'s multiple episodes of diarrhea when: 1. Loperamide HCL (medication for diarrhea) was not provided every four hours in accordance with the physician order; and 2. Docusate sodium tablet (medication for constipation) was administered on four occasions when Resident 1 was having loose stools. Findings: On August 8, 2023, at 2:56 p.m., an unannounced visit to the facility was conducted to investigate quality care issue. A review of Resident 1's medical records indicated she was admitted to the facility on [DATE], and discharged on May 13, 2022, with diagnoses which included dehydration, (a harmful loss of the amount of water in the body), constipation, (difficulty in emptying the bowel leading to hard feces), stroke, and chronic kidney disease, (the gradual loss of kidney's ability to filter wastes and excess fluids from the blood). A review of Resident 1's History and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure one of the three sampled residents (Resident 1) was free from unnecessary medication when Docusate Sodium Tablet (medication used for constipation and or a stool softener) was given on four occasions when Resident 1 was having multiple episodes of diarrhea. This failure had the potential for Resident 1 to suffer prolonged diarrhea. Findings: On August 8, 2023, at 2:56 p.m., an unannounced visit to the facility was conducted to investigate quality care issue. A review of Resident 1's medical records indicated she was admitted to the facility on [DATE], and discharged on May 13, 2022, with diagnoses which included dehydration, (a harmful loss of the amount of water in the body), constipation, (difficulty in emptying the bowel leading to hard feces), stroke, and chronic kidney disease, (the gradual loss of kidney's ability to filter wastes and excess fluids from the blood). A review of Resident 1's History and Physical dated indicated she had the…

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

Based on observation, interview, and record review, for four (Resident 1, 2, 3, and 4) of six residents, the facility failed to ensure necessary care and services were completed as scheduled on June 12, 2023, when the Restorative Nursing Assistant (RNA) failed to conduct Restorative Nursing Therapy (RNT) as ordered. As a result, the facility failed to promote the resident's abilities in the performance of their activity of daily living when the RNA failed to conduct the RNTs as ordered on June 12, 2023. Findings: On June 29, 2023, at 11:00 a.m., an unannounced visit was conducted to investigate an allegation RNT services were not provided as ordered. On June 29, 2023, at 11:45 a.m., the facility's June 2023 staffing schedule was reviewed with the Administrator (ADM). The record indicated RNA 1 was marked R (Request Off) on June 12, 2023. ADM stated RNA 1 worked on the floor as a Certified Nursing Assistant (CNA) coverage that day. On June 29, 2023, the Staffing Schedule and Signature Sheet , dated June 12, 2023, was reviewed. The record indicated RNA 1 did not work as an RNA but…

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 observations, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. Several various size of metal sheet pans were stacked and stored wet; 2. The ice machine was not cleaned and sanitized properly; 3. Thawing meats were in the reach-in refrigerator without label of pull out and used by dates; 4. The microwave in the kitchenette had significant amount of food debris and sauce stings; and 5. The facial hair of Dietary Aide (DA) 2 was not covered. These failures had the potential to cause foodborne illnesses in a medically vulnerable population of 55 out of total census of 58 residents who received food from the kitchen. Findings: 1. During the initial tour in the kitchen, an observation and concurrent interview with the Dietary Supervisor (DS) on June 21, 2021, at 9:39 a.m. was conducted. Three of one-quarter (1/4) size metal pans and two of full sheet size metal pans were observed stacked wet and stored in the clean storage rack. The DS confirmed the metal pans were…

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

Based on observation and interview, facility failed to provide a clean environment for the residents and visitors, when two of two garbage disposal bins located outside, by the kitchen, were overflowing and were not securely covered with dumpster lids. In addition, trash was found on the floor next to the garbage disposal bins. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility. Findings: On June 21, 21, at 9:06 a.m., two of two dumpsters located outside, near the facility kitchen, were observed with the lids not securely covering the dumpsters. There was significant amount of bags of trash, overflowing on top of the two dumpsters. There were trash found on the floor next to the dumpsters. A concurrent interview was conducted with the Dietary Supervisor (DS). The DS stated the trash should not be overflowing and the dumpster lids should to be tightly closed. She stated waste management picked up trash daily except Sundays, and the two dumpsters are shared with the assisted…

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 result of the most recent survey of the facility was posted and readily accessible to resident, family members, and representatives of the residents. This failure had the potential for residents and family members not to be aware of the survey findings which could affect the decision to stay in the facility. Findings: On June 22, 2021, at 10:40 a.m., during the confidential Resident Council meeting multiple residents stated the survey results were not visible and accessible to read. On June 23, 2021, at 8:13 a.m., the Director of Nursing (DON) was asked where the survey results were kept. The DON was observed looking for the result in the front lobby. The DON verified that the result of the recent survey was kept inside the desk of the receptionist. She stated the survey result should be posted and readily accessible to residents, their family members or representatives to read. A review of the facility policy and procedure titled, Resident Rights, dated December 2016, indicated, .Federal and state…

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 an Advance Directive (AD-written instruction documentation related to the provision of health care when the resident/individual is no longer able to make decisions) was discussed with the resident and or resident representative upon admission to the facility, for four of 12 residents reviewed (Residents 9, 62, 69, and 120). In addition, the AD was not available in the medical record. This failure had the potential for the residents to not receive their preplanned treatment and services in the event they were incapacitated and or unable to speak for themselves. Findings: 1. A review of Resident 9's record indicated he was admitted to the facility on [DATE], with diagnoses which included surgery of the digestive system. A review of Resident 9's Physician orders for Life-Sustaining Treatment (POLST) section D, did not indicate any information related to the resident's advance directives. 2. A review of Resident 62's record indicated the resident…

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

Based on interview and record review, the facility failed to ensure two food service personnel were able to safely and effectively carry out the functions of the food and nutrition services when: 1. One Dietary Aides (DA 1)and one [NAME] (Cook 1) were unable to demonstrate and verbalized the process of manual dishwashing by using three-compartment sink; and 2. One [NAME] (Cook 1) was unable to verbalize the proper cool down procedure of cooked meat. These failures had the potential to place 55 out of 58 highly susceptible residents who received food from the kitchen at risk for food-borne illness. Findings: 1. During an interview on June 21, 2021, at 9:52 a.m., DA 1 verbalized and demonstrated the process of manual dishwashing with the three-compartment sink. DA 1 stated the three-compartment sink is usually used in case the dishwashing machine was not functioning. DA 1 stated first step was to scrape off the food into the trash can, put the dishes to wash bin with a detergent, rinse the dishes in the rinse bin, and then immersed the dishes into the sanitizing solution. DA 1 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 ensure the menu for the therapeutic diet during lunch meal on June 21 and June 22, 2021, was followed, when: 1. One resident (Resident 53) on NAS (no added salt, diet with no salt packet), CCHO diet (consistent carbohydrate- used in the treatment for diabetes) received regular sugar packet instead of diet sugar packet as indicated on the menu; and 2. Two residents (Residents 45 and 172) on NAS, CCHO, Renal (used in treatment for chronic kidney disease or end stage kidney disease) received ice-cream as dessert instead of half a cup of diet pineapple as indicated on the menu. These failures had the potential to result in compromising the medical and nutrition status of those three residents. Findings: 1. During a dining observation of lunch meal on June 21, 2021, at 12:56 p.m., Resident 53, who was on NAS, CCHO diet received regular sugar packet on her meal tray. A concurrent review of the undated facility document titled, Summer Menus, Week 3 Monday, showed that CCHO diet should receive diet sugar packet.…

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 failure to implement a policy and procedure on Foods Brought by Family/Visitors that included provisions on facility providing education and information about safe food handling practices to residents, family and visitors, and provisions on facility providing training to all facility personnel regarding safe food handling practices who involved in preparing, handling, serving or assisting the resident with meals or snacks. This failure had the potential to cause foodborne illnesses in a medically vulnerable population of 55 out of 58 residents who could consume food and receive food from family or visitors. Findings: During an interview on June 24, 2021, at 8:59 a.m., Certified Nurse Assistant (CNA) 8 stated food from family and visitors for residents were kept in the designated refrigerator. However, she was not sure how many days the food could be kept in the refrigerator. CNA 8 stated she had not been trained on safe food handling practices or reheating procedures. She also stated she was not aware that there was a policy 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure for two of two residents reviewed for dignity (Residents 69 and 223), were treated with respect and dignity that promotes maintenance or enhancement of their quality of life; when: 1. Resident 69 was not assisted to get up from bed before breakfast as requested; and 2. Resident 223 was not dressed in his preferred clothes. These failures had the potential to result in decline in residents' self-worth and self-esteem. Findings: 1. On June 22, 2021, at 10:54 a.m., Resident 69 was interviewed with the family member (FM). The FM stated that during the visit, the resident (Resident 69) complained that he was still in bed, and was upset. The FM stated the resident wanted to get up from bed at 7:30 a.m., and had mentioned the request to the staff. However, the resident was not assisted in getting up until 11:30 a.m. On June 24, 2021, at 10:22 a.m., during an interview with Resident 69, who was still in bed, the resident stated he did not…

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 the call lights were within reach for three of sixteen residents (Residents 69, 173, and 224). This failure had the potential to result in residents' needs not met. Findings: 1. On June 21, 2021, at 10:59 a.m., Resident 173 was observed in a wheelchair. Resident 173's call light was observed behind the resident on top of the night stand, away from the resident. In a concurrent interview with Resident 173, she stated she did not know where the call light was. Resident 173 stated she would press the call light button when she needed assistance. On June 21, 2021, at 11:04 a.m., Certified Nursing Assistant (CNA) 3 was interviewed. CNA 3 stated Resident 173 used the call light for assistance. CNA 3 stated the resident's call light was not within reach. CNA 3 stated the call light should be close to the resident. Resident 173's record was reviewed. Resident 173 was admitted to the facility on [DATE], with diagnoses which included left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written Skilled Nursing Beneficiary Notice (SNF ABN- a notice to provide information to residents/beneficiaries if they wish to continue receiving skilled services that may not be paid by Medicare and assume financial responsibility) for two of three residents reviewed for SNF ABN (Residents 6 and 25). This failure resulted in not informing Residents 6 and 25 or their responsible party (RP) of the potential liability for payment in non-covered Medicare Part A services in writing. Findings: 1. A review of record indicated Resident 6 was admitted to the facility on [DATE]. The form titled, SNF Beneficiary Protection Notification Review, indicated, Medicare Part A Skilled Services Episode Start Date: 1/19/21 . Last covered day of Part A Services: 3/15/21. There was no documented evidence the resident or resident representative received a written SNF ABN. 2. A review of record indicated Resident 25 was admitted to the facility on [DATE]. The form…

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 the resident or representative was provided information on bed hold (holding or reserving a resident's bed while the resident was absent from the facility during hospitalization or therapeutic leave) opportunity for one of three residents reviewed for closed records (Resident 44). This failure had the potential to result in the family member not to be given the opportunity to ensure facility bed would remain available for Resident 44's return to receive services needed. Findings: A review of Resident 44's record indicated he was admitted to the facility on [DATE], with diagnoses which included urinary tract infection (kidney infection) and cancer of the bladder. A review of the history and physical indicated the resident has the capacity to understand and make decisions. A review of the progress notes, dated June 14, 2021, indicated Resident 44 was transferred to the acute hospital due to blood infection. There was no documented evidence a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care and services for one of two residents reviewed for activities of daily living (ADL- a term used to refer to people's daily self-care activities) (Resident 69), when the physician order for one on one feeding was not followed. This failure had the potential to result in the decline in the resident's ADLs which could lead to a decrease in oral intake and weight loss. Findings: On June 21, 2021, at 12:52 p.m., A staff (Certified Nursing Assistant/CNA) was observed serving tray to Resident 69, and left. Resident 69 was observed eating using his left hand, and there was no staff observed with the resident. Resident 69's record was reviewed. Resident 69 was admitted to the facility on [DATE], with diagnoses which included hemiparesis (weakness of one side of the body), hemiplegia (paralysis of one side of the body), right dominant side and contracture (stiffening or shortening) of the muscle, right hand. The document titled Order…

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 assess and evaluate the episodes of increased in heart rate for one of three residents reviewed for closed records (Resident 70). In addition, the physician was not notified of the resident's change in condition. These failure had the potential to result in worsening of the resident's medical condition. Findings: 1. Resident 70's record was reviewed. Resident 70 was admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure, chronic atrial fibrillation (irregular heart rate), and diabetes mellitus (abnormal blood sugar). Resident 70's progress notes titled, Nurse's Note, indicated the following: - Dated [DATE], at 12:57 p.m., .resident noted to be pale, no chest rise observed. resident assessed; eyes fixed, no pulse palpated, no breath sounds auscultated. unable to obtain vital signs . - Dated [DATE], at 9:50 a.m., .episode of groaning and moaning noted. resident noted to be gurgling, oral secretions suctioned .…

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 the physician's order for range of motion (ROM) exercises for one of seven residents reviewed for limited ROM (Resident 63). This failure had the potential to result in decline in the ROM of Resident 63's right wrist. Findings: On June 21, 2021, at 10:45 a.m., Resident 63 was observed in his room, with a right wrist drop. He stated he had the wrist drop (paralysis of the muscles which normally raise the hand at the wrist and extend the fingers, typically caused by nerve damage) after he got his COVID 19 vaccine injection in February 2021, given in the facility. Resident 63's record was reviewed. Resident 63 was admitted to the facility August 24, 2020, with diagnoses which included, polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body) and diabetes (disease in which the blood glucose, or blood sugar, levels are too high). Resident 63's History and Physical Examination (H & P), dated August 24, 2020, indicated, .Has the capacity to understand and make decisions .…

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 the care plan for fall was implemented for one of one resident reviewed for falls (Resident 69), when resident's bed was not placed in the lowest position and the call light was not within reach. This failure had the potential for further falls and injuries. Findings: On June 21, 2021, at 2:47 p.m., Resident 69 was observed in bed, the bed was not in the lowest position. Resident 69's call light was observed hanging on the right side of the bed, not within reach of Resident 69. On June 24, 2021, at 10:22 a.m., Resident 69 was in bed. Resident 69's bed was observed not in the lowest position. The call light was not visible, and observed in between the mattress and the side rail. Resident 69's record was reviewed. Resident 69 was admitted to the facility on [DATE], with diagnoses which included hemiparesis (weakness of one side of the body), hemiplegia (paralysis of one side of the body), right dominant side and difficulty in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess the appropriateness and continued use of Foley catheter ( flexible tube that passes through the urethra and into the bladder to drain urine) for one of one resident reviewed for catheter (Resident 223). This failure had the potential to predispose Resident 223 to catheter associated urinary tract infection. Findings: On June 21, 2021, at 11:22 a.m., during interview, Resident 223, who has a Foley catheter, stated the catheter was inserted while at the hospital, due to his fall injury. Resident 223's record was reviewed. Resident 223 was admitted to the facility on [DATE], with diagnoses which included right lower rib fracture (broken bone) and generalized weakness. The document titled HISTORY AND PHYSICAL EXAMINATION, dated June 14, 2021, indicated, .s/p (status post) fall .rib fractures rt (right) 9-12 . The document titled CUSTOM IDT (Interdisciplinary) CARE CONFERENCE FORM, dated June 15, 2021, indicated .s/p fall weakness…

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 services was provided for adequate pain management when referral for pain management was not completed for one of two residents reviewed for pain (Resident 63). This failure had the potential to result in Resident 63's pain not managed appropriately. Findings: On June 21, 2021, at 10:45 a.m., during an interview, Resident 63's stated his knee pain was not controlled. He stated the pain medications he was getting were not effective. A review of Resident 63's record indicated the resident was admitted to the facility on [DATE], with diagnoses which included, polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body) and diabetes (high blood sugar). Resident 63's History and Physical Examination (H & P), dated August 24, 2020, indicated, .Has the capacity to understand and make decisions . Resident 63's Order Summary Report, order date of April 1, 2021, indicated, REFER TO PAIN MANAGEMENT RE: PAIN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the dietary preference for one of three residents reviewed for food preference (Resident 36). This failure had the potential for Resident 36's dietary intake to be inadequate by not making reasonable effort of adjusting resident's food plan and preference. Findings: On June 21, 2021, at 2:30 p.m., Resident 36 was interviewed. She stated that she requested for peanut butter and jelly sandwich for her midnight snacks. However, it was not provided. Resident 36 stated she made several request from the facility staff after dinner. Resident 36 was admitted to the facility on [DATE], with diagnoses which included cellulitis (bacterial infection involving the inner layers of the skin) of Right leg. The history and physical indicated Resident 36 has the capacity to understand and make decision. On June 24, 2021, at 9:59 a.m., the Registered Dietician (RD) was interviewed. She stated that the licensed nurse is supposed to communicate to dietary manager…

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 maintain a complete medical records in accordance to the accepted professional standards and practices, when there was no record of communication between the dialysis center and the facility on one of one resident reviewed for dialysis (Resident 172) on June 16, 2021. This failure had the potential to result in the facility not being aware of any recommendation from the dialysis center for Resident 172, which could affect overall care. Findings: A review of Resident 172's record indicated, that the resident was admitted to the facility June 10, 2021, with diagnoses which included end stage renal disease (ESRD- inability of the kidney to make urine and remove waste from the blood). A review of Resident 172's care plan indicated, Focus .dialysis (process of removing waste from the blood with the use of a machine) .Goal .Resident will adjust and adapt to renal dialysis .Interventions .Check v/s (vital signs- blood pressure, weight) upon return from dialysis .Coordinate resident's care with the dialysis center staff . On June…

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 appropriate infection control practices were implemented when: 1. A staff was observed going inside the room located in the yellow zone (designated for PUI - person under investigation due to unknown COVID-19 status), without donning an isolation gown; and 2. Two staff were observed wearing a surgical mask under the N95 (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles). These failures had the potential to result in transmission of COVID-19 infection between staff and residents. Findings: 1. On June 23, 2021, at 8:27 a.m., the Social Service Assistant (SSA) was observed entering room [ROOM NUMBER] (room on quarantined- in the yellow zone) wearing an N95, face shield, and gloves. The SSA was observed not wearing an isolation gown. On June 23, 2021, at 8:45 a.m., the SSA was interviewed. The SSA stated when inside the yellow room (referring to room under…

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 COVID-19 (illness caused by a virus that can be transmitted person to person) testing was conducted on admission for two of three residents on quarantined (Residents 222 and 224), due to COVID-19. This failure had the potential to result in transmission of COVID-19 to the staff and residents in the facility. Findings: 1. Resident 222's record was reviewed. Resident 222 was admitted to the facility on [DATE], with diagnoses which included pneumonia (infection of the lung). The document Order Summary Report, for the month of June 2021, indicated the following: - DROPLET AND CONTACT ISOLATION X (for) 14 DAYS FOR COVID19 PRECAUTION .Order Date .June 22, 2021. - MAY DO COVID TESTING UPON admission AND RETESTING AS PER FACILITY PROTOCOL .Order date .June 16, 2021. Resident 222's immunization history indicated Resident 222 was vaccinated for COVID-19 on June 15, 2021, with second dose scheduled on July 2021. There was no documentation Resident 222 was…

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