Green Acres Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality of two of four sampled residents (Resident 3 and Resident 226) when: 1. Resident 3's suprapubic catheter (a tube that drains urine from your bladder by being inserted through a small incision made in your lower abdomen, just above your pubic bone) urinary bag (urine drainage bag to collect urine) was observed without a urinary catheter bag cover. 2. Resident 226 who was hard of hearing (HOH) and spoke a foreign language that the facility staffs could not understand, and the resident could not understand the common language in the facility was not accurately assessed and provided the proper means of communicating with the staffs and residents. These deficient practices violated the resident's rights to maintain privacy, enhanced…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement its policy and procedure on Advance Directive (AD, a legal document indicating resident preference on end-of-life treatment decisions) by failing to ensure the Advance Directive was offered and explained and the signed AD was in the chart for two of four sampled residents (Residents 14 and 39). This deficient practice has the potential to omit the residents ' medical decisions if they become incapacitated (unable to make decision for self) leading to unnecessary or unwanted treatments due to lack of clear instructions regarding their end-of-life care. Findings: 1. A review of Resident 14's admission Record indicated that the facility admitted Resident 14 on 11/15/2024 with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and schizophrenia (a mental illness characterized by disturbances in thought). A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During a review of Resident 226 ' s admission Record indicated Resident 226 was admitted to the facility on [DATE], with diagnoses that included Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control, dementia (a progressive state of decline in mental abilities), Unspecified abnormalities of Gait and Mobility (changes to the way a person walks or moves due to injuries, medical conditions, or other reasons.) During a review of Resident 226 ' s Minimum Data Set (MDS - a resident assessment tool) dated 10/1/24, indicated Resident 226 was severely cognitively impaired (a condition that makes it very difficult for a person to think, learn, and remember). The MDS also indicated Resident 226 had moderate difficulty in hearing. During a review of Resident's 226's Care Plan dated 1/10/25, indicated Resident 226 was at risk of having needs unmet related to difficulty in communication secondary to hard of hearing and spoke a foreign language. 1. Resident will be able to relate 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident received proper assistive devices to maintain hearing abilities for one of 3 sampled residents (Resident 226) who was not assisted by the facility in arranging a referral for audiologist (a physician specialized in hearing loss) consult. This deficient practice resulted in a delay of services and Resident 226 not being able to hear adequately while communicating with staffs. Findings: During an observation on 2/4/25 at 8:33 AM, Resident 226 was observed alert, lying in bed, with a raised voice speaking to a laboratory staff, who also had to raise volume for Resident 226 to hear the resident. Resident 226 also pulled out pieces of paper and requested to communicate in writing. During an interview on 2/4/25 at 9:31 AM, Resident 226 stated she has hard of hearing (HOH), has no device, to assist her with the difficulty hearing whatever the staffs say to her. During a concurrent observation and interview on 2/5/25 at 9:15 AM…

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 three sampled residents (Resident 3) received appropriate treatment and services to prevent urinary tract infection (UTI-when bacteria gets into your urine and travels up to your bladder), in accordance with the facility's policy and procedures (P&P) on Infection Prevention and Control Program. 1. On 2/4/2025, Resident 3 was observed while sitting on his wheelchair, Resident 3's suprapubic catheter (a tube that drains urine from your bladder by being inserted through a small incision made in your lower abdomen, just above your pubic bone) drainage bag (urine drainage bag to collect urine) was hanging on the wheelchair ' s left arm rest (positioned higher than Resident 3's bladder). 2. On 2/5/2025, Resident 3 was observed with the suprapubic catheter tubing wrapped around his left leg while sitting on his wheelchair. This deficient practice had the potential for Resident 3 to have recurrent urinary tract infection and…

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

Based on interview and record review, the facility failed to implement its policy and procedure on behavioral health services by failing to provide one of two sampled residents (Resident 9) a referal to psychiatrist (a physician specialized in mental and behavioral health) consultation evaluation for aggressive behavior towards the staff and residents to attain the resident's highest practicable physical, mental, and psychosocial well-being. This deficient practice had the potential to worsen the mental health symptoms of the resident, increase risk of relapse, decrease quality of life, and increase the likelihood of needing more intensive interventions like hospitalization in the future. Findings: A review of Resident 9's admission Record indicated that the facility initially admitted Resident 9 on 2/27/2012 and readmitted the resident on 1/14/2025 with diagnoses that included schizophrenia (a mental illness characterized by disturbances in thought and false belief of reality). A review of Resident 9's Minimum Data Set (MDS - a resident assessment tool), dated 1/17/2025, indicated…

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

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five (5) percent (%) during medication pass by committing four (4) medication errors on one of six sampled residents (Resident 15) during medication observation with 29 medication opportunity that resulted to a 13.79% medication error rate. This deficient practice had the potential to result in adverse reaction) undesired effect of a drug or other type of treatment) to the medications that could jeopardize the safety of the residents that could lead to serious harm, injury, or death. Findings: A review of Resident 15's admission Record indicated that the facility initially admitted Resident 15 on 4/3/2024 and readmitted the resident on 10/9/2024 with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and schizophrenia (a mental illness characterized by disturbances in thought). A review of Resident 15's Minimum Data Set (MDS - a 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 implement its policy and procedure on how to properly and safely store medications and biologicals by failing to separately store Hydrogen Peroxide Topical Solution (an external [outside the body] medication with mild antiseptic used on the skin to prevent infection of minor cuts, scrapes, and burns) on the same shelf with oral (medications given by mouth) medications such as stool softeners and vitamins. This deficient practice had the potential to cause medication errors and expose residents to adverse reactions (an undesired harmful effect) that could lead to serious harm or death. Findings: During an inspection of the facility's East Wing medication storage room with licensed vocational nurse (LVN) 3 on 2/6/2025 at 10:05 AM, a bottle of Hydrogen Peroxide Topical Solution, an external (applied outside the body) medication used on the skin to prevent infection of minor cuts, scrapes, and burns, was observed on the same shelf where oral medications were kept. During a concurrent interview with LVN 3, LVN 3…

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 system in preventing, controlling infections and communicable diseases were in place, when one of two sampled residents (Resident 3) according to the facility's Infection Prevention and Control Program. Resident 3 who was on an enhance barrier precaution (EBP) (taking extra steps to prevent the spread of serious infections, like using gowns and gloves) due to a suprapubic catheter (a tube that drains urine from your bladder by being inserted through a small incision made in your lower abdomen, just above your pubic bone) was observed receiving high contact care (fixing Resident 3 ' s suprapubic catheter tubing and urine drainage bag) from Licensed Vocational Nurse (LVN) 1 and Certified Nurse Assistant (CNA) 1). LVN 1 and CNA 1 failed to use an isolation gown as part of their PPE (Personal Protective Equipment) and proceeded to the Nurses Station without performing hand hygiene (a way of cleaning the hands, which can prevent 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 observations, interviews, and record review the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills as staff were not following the manufacturer ' s guidelines when checking the concentration of the dish machine chlorine (a chemical used for disinfection) solution. This failure had a potential to result to potential cross-contamination (a transfer of bacteria from one object to another), ineffective dish machine, and unsanitized dishes that could lead to food borne illness (an illness caused by contaminated food and beverages) in 82 of 82 medically compromised residents who received food and ice from the kitchen. Findings: During an interview with the Diet Aide (DA) 1 on 2/8/2024 at 12:27 PM, DA 1 stated he washed trays and pitchers in a low temperature dish machine in Facililty 2 ' s kitchen. DA 1 stated he checked the dish machine temperatures for wash and rinse and the wash temperature should be at 140 degrees Fahrenheit (°F, unit of measurement) and rinse temperature should be at 135°F. DA 1 stated he also checked 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 the correct texture for puree and soft mechanical diets when: a. Five (5) of 5 residents on soft mechanical diet did not receive ground sausage links and sausage was dry. b. Six (6) of 6 residents on puree diet received oatmeal that was not pureed in texture and consistency. This deficient practice had the potential to cause difficulty in eating, chewing, and swallowing causing a decrease food intake resulting to weight loss. Findings: During an observation of tray line (assembly area for resident ' s food) breakfast service in Facility 2 ' s kitchen on 2/7/2024 at 7:22 AM, the oatmeal for puree diet had lumps, oatmeal residue and was not pureed in consistency. During a test tray (a sample tray to evaluate taste, appearance and palatability of food) of puree diet (a diet with smooth pudding like consistency food) with Dietary Supervisor 1 (DS 1) and Registered Dietitian 1 (RD 1) on 2/7/2024 at 7:42 AM, the puree diet tray included puree waffles covered with thick brown syrup, puree sausage with thick…

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 maintain a safe, functional, and sanitary condition to ensure safe and sanitary food preparation and storage practices in Facility 1 ' s kitchen by failing to: 1. Ensure Facility 1 ' s Kitchen was maintained to prevent the subfloor from being completely rotten, and tile from disrepair due to having an old rotten floor, the dishwasher left rusted, and the wooden entrance door frames throughout the kitchen worn out and deteriorating as reported by the local Health Department on 12/14/2023. As a result, Facility 1 was required to start construction renovation to their kitchen on 1/29/2024. The facility did not develop plan on how to maintain food safety for the residents during a construction of the kitchen to ensure the food products being transported from the facility were kept dry and covered to prevent contamination and stored in sanitary condition. 2. Ensure not to store dry food in the dry storage area or store perishable foods (foods…

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 safe environment for 11 out of 81 residents (Residents 12, 15, 20, 28, 30, 39, 42, 47, 63, 69 and 71), who were assessed at being at risk for falling, staff and visitors by failing to: 1. Ensure that the facility's roof was free from cracks, holes and other damage that allowed water from rain to penetrate through and drip into the space between the roof and ceiling. 2. Ensure that the ceiling structure inside the building did not become damaged from rainwater leaking in through holes, cracks, and other damage to the roof. 3. Maintain the ceiling structure free from moisture, water damage, active leaking, and degradation due to rainwater penetrating through cracks, holes, or other damaged areas of the roof. 4. Provide documented evidence that the facility routinely performs scheduled maintenance service to all areas in the facility that included the roof inspections. These deficient practices resulted in an outburst of 5 water…

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 call lights to call for assistance from 2/6/2024 to 2/9/2024 for five (Resident 15, 39, 68, 69, and 78) out of six residents who experienced a temporary room change due to ceiling leaks, in accordance with their care plans. This failure had the potential to prevent Resident 15, 39, 68, 69, and 78 from asking assistance especially during emergency situations, and not receiving necessary care and services, which could negatively affect the residents ' physical comfort and psychosocial well-being. Cross reference F921 Findings: 1. During a review of Resident 15 ' s admission Record, the facility admitted Resident 15 on 2/14/2022 with diagnoses including muscle wasting and atrophy (thinning or loss of muscle tissue), abnormalities of gait (manner of walking) and mobility (ability to move), anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one ' s daily…

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 maintain comfortable and safe room temperature levels between 71 to 81-degree Fahrenheit (° F, unit of measurement) in the resident's rooms as required by the Federal regulation for five out of 17 residents (Resident 40, 49, 12, 47, and 30). This deficient practice resulted in the resident's increased level of discomfort and the potential to result in loss of body heat that could negatively impact the resident's quality of life. Findings: 1. During a review of Resident 40's admission Record indicated the facility originally admitted Resident 40 on 6/2/2015 and readmitted her on 7/27/2020 with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and hypertension (high blood pressure). During a review of Resident 40's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/11/2023, indicated Resident 40 had intact memory and cognition (ability 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to report allegations of abuse (intentional causing of harm or injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental suffering; includes verbal, sexual, physical, and mental abuse) to the facility ' s abuse coordinator between two residents (Resident 43 and Resident 51) out of a census of 81 residents on 2/8/2024 in accordance with the facility ' s policy on Abuse Allegation Reporting. This failure had the potential to under report alleged cases of abuse, which could lead to a failure to investigate alleged abuse in a timely manner. Findings: During a review of Resident 51 ' s admission Record, the facility admitted Resident 51 on 11/10/2023 with diagnoses including muscle wasting and atrophy (thinning or loss of muscle tissue), abnormalities of gait (manner of walking) and mobility (ability to move), dementia (decline in mental ability severe enough to interfere with daily life), 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 accurately assess range of motion [ROM, full movement potential of a joint (where two bones meet)] for two of six sampled residents (Resident 4 and 24) with limited ROM. 1. For Resident 24, the facility failed to include any assessment of Resident 24 ' s actual ROM in both arms and both legs for a quarterly Joint Mobility Screen (brief assessment of a resident's range of motion in both arms and both legs), dated 2/6/2024, which included a conclusion statement that indicated Resident 24 did not have any decline in ROM. This failure resulted in the inaccurate assessment and transmission of Resident 24 ' s Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool) assessment, dated 1/25/2024, for ROM limitations. 2. For Resident 4, the MDS, dated [DATE], indicated Resident 4 did not have any functional ROM limitations in both arms. The OT Evaluation, dated 5/29/2023, indicated Resident 4 had contractures in both arms 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 maintain range of motion [ROM, full movement potential of a joint (where two bones meet)] and mobility for three (Resident 15, Resident 62, and Resident 24) of six sampled residents with positioning and mobility (ability to move) concerns. 1. For Resident 15 and 62, the facility failed to use a front-wheeled walker (FWW, an assistive device with two front wheels used for stability when walking) in accordance with the Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) recommendations and physician orders. The facility also failed to specify the distance for Resident 15 and 62 to walk to maintain their mobility after discharge from PT services. 2. For Resident 24, the facility failed to apply splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) to both knees in accordance with the PT…

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 apply bed brakes and repair wheelchair brakes for one (Resident 15) of six sampled residents with positioning and mobility (ability to move) concerns. This failure had the potential to cause Resident 15, who was assessed as a high risk for fall, to fall from both the bed and the wheelchair, placing Resident 15 at increased risk for physical injury. Findings: During a review of Resident 15 ' s admission Record, the facility admitted Resident 15 on 2/14/2022 with diagnoses including muscle wasting and atrophy (thinning or loss of muscle tissue), abnormalities of gait (manner of walking) and mobility, anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one ' s daily activities), and schizophrenia (mental disorder characterized by abnormal social behavior). During a review of Resident 15 ' s Fall Risk Assessment, dated 9/6/2023, the Fall Risk Assessment indicated Resident 15 was at high risk for falls. During a review of Resident 15 ' s care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) and target behaviors (behaviors related to a diagnoses of mental illness) of restlessness and aggression related to the use of lorazepam (a medication used to treat mental illness) between 2/6/24 and 2/8/24 in one of five sampled residents (Resident 62.) This deficient practice of failing to monitor for adverse effects and target behaviors increased the risk Resident 62 could have experienced adverse effects related to her psychotropic medication (medications that affect brain activities associated with mental processes and behavior) therapy possibly leading to impairment or decline in her mental or physical condition or functional or psychosocial status. Findings: A review of Resident 62 ' s admission Record (a document containing a resident ' s demographic and diagnostic information), dated 2/8/24, indicated Resident 62 was initially admitted to the facility…

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 that medication error rate was less than five percent (%). Three medication errors out of 29 total opportunities contributed to an overall medication error rate of 10.34 % affecting two of nine residents observed for medication administration (Residents 11 and 483). The medication errors noted were as follows: Omitted or late administration of vitamin C (a vitamin supplement) 500 milligrams (mg - a unit of measure for mass) for Resident 11. Omitted or late administration of zinc sulfate (a vitamin supplement) 220 mg for Resident 11. Attempted administration of one dose of expired insulin aspart (a medication used to treat high blood sugar) prior to surveyor intervention for Resident 483. The deficient practice of failing to administer medications in accordance with the physician ' s orders and professional standards of practice increased the risk that Residents 11 and 483 may have experienced medical complications possibly…

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 prepare food by methods that conserved flavor and appearance. Pureed sausage was served with sweet syrup, puree waffle was drenched with syrup and oatmeal had lumps. This deficient practice placed 6 of 92 facility residents at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Findings: During an observation of trayline (a place for resident ' s tray assembly) breakfast service in Facility 2 ' s kitchen on 2/7/2024 at 7:19 AM, puree diet trays received puree waffle that was drenched with syrup and puree sausage links had syrup. A review of Facility 1 ' s menu titled Winter Menus, dated 2/7/2024, indicated Pureed diet included the following food: Orange juice 4 ounces (oz, a unit of measurement) Puree oatmeal ¾ cup (c., a unit of measurement) Puree sausage #24 scoop (1.35 oz) Puree waffle ½ c Margarine 1 teaspoon (tsp, unit of measurement) Syrup 1 oz Milk 1 c During a test tray (a sample tray to evaluate taste, appearance, and palatability of food) of puree diet (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 lunch at the facility ' s established mealtime on 2/6/2024 and served lunch to residents in the facility ' s East Wing at least 30 minutes late. This deficient practice caused three of 10 sampled residents (Resident 12, 62 and 68) for dining observation to feel hungry and agitated. Findings: 1. During a review of Resident 62 ' s admission Record, the facility admitted Resident 62 on 8/1/2023 with diagnoses including muscle wasting and atrophy (thinning or loss of muscle tissue), abnormalities of gait (manner of walking) and mobility (ability to move), dementia (decline in mental ability severe enough to interfere with daily life), cerebral infarction (brain damage due to a loss of oxygen to the area), and legal blindness. During a review of Resident 62 ' s Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 11/10/2023, the MDS indicated Resident 62 had severely impaired cognition (ability to think,…

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 accurately reflect the amount of time the facility provided Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) services on 2/7/2024 to three of six sampled residents (Resident 62, 15, and 26) with positioning and mobility (ability to move) concerns. This failure resulted in the inaccurate records for the provision of RNA services to Residents 62, 15, and 26. Findings: 1. During a review of Resident 62 ' s admission Record, the facility admitted Resident 62 on 8/1/2023 with diagnoses including muscle wasting and atrophy (thinning or loss of muscle tissue), abnormalities of gait (manner of walking) and mobility, dementia (decline in mental ability severe enough to interfere with daily life), cerebral infarction (brain damage due to a loss of oxygen to the area), and legal blindness. During a review of Resident 62 ' s physician orders, dated 10/1/2023, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure three of three sampled residents (Residents 24, 49, 68) were competent in understanding the terms of the facility ' s binding arbitration agreement (an agreement that allows parties to resolve disputes and lawsuits privately rather than going to the court). This failure had the potential for Resident 24, 49, 68 to not understand their rights for a binding arbitration agreement. Findings: During a review of Resident 24 ' s History and Physical (H&P), dated 10/20/2023, the H&P indicated Resident 24 does not have the capacity (the ability to make a rational decision based upon all relevant facts and considerations) to understand and make decisions. During a review of Resident 24 ' s Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 10/22/2023, the MDS indicated Resident 24 was admitted on [DATE] with the following diagnoses, but not limited to, major depressive disorder (mental health illness causes 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 implement, monitor, and evaluate identified Quality Assurance and Performance Improvement Program (QAPI, a program that is focused on action plan to correct identified quality deficiencies (a deviation in performance resulting in an actual or potential undesirable outcome, or an opportunity for improvement) relating to building maintenance and safety. The facility failed to: 1. Documented evidence the QAPI program implemented a plan to maintain the kitchen in good working condition and ensure the safe renovation of the kitchen, including a plan for providing meals to residents while the kitchen is closed. 2. Document evidence that the QAPI program implemented a plan to ensure the maintenance of the buildings roofing were maintained to prevent leaks and protect residents from a hazardous situation. These deficient practices resulted in leaking of the roof into 3 facility rooms and a hallway resulting in eleven residents (Residents 12, 15, 20, 28, 30,…

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

Based on observation and interview, the facility failed to disinfect shared equipments for four sampled residents (Resident 52, 57, 15, and 26) out of of 15 residents observed for medication administration and position and mobility (ability to move) concerns. 1. Two (Residents 52 and 57) of nine residents observed for medication administration, the facility failed to disinfect the blood pressure cuff (material placed around a person ' s arm and then inflated to measure blood pressure) before and after use. 2. Two of six residents (Resident 15 and 26) observed for positioning and mobility concerns, the facility failed to disinfect a vinyl (type of nonporous material) gait belt (assistive device placed around a person ' s waist to assist with safe transferring between surfaces or while walking) before and after resident use. These failures had the potential to spread of infection throughout the facility. Findings: 1. During an observation of medication administration with the Licensed Vocational Nurse (LVN) 1 in the [NAME] Wing Nursing Station on 2/7/23 at 8:18 AM, LVN 1 was observed…

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 assist one of two sampled resident ' s representative (Resident 49) in formulating an Advance Directives (AD-a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor). This deficient practice had the potential to cause conflict with Resident 49's wishes regarding health care treatment especially in an event of emergency. Findings: During a review of Resident 49 ' s admission Record indicated the facility admitted Resident 49 on 8/26/23 with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and hypertension (high blood pressure). During a review of Resident 49 ' s History and Physical (H&P), dated 8/28/23, indicated Resident 49 does not have the capacity to understand and make decisions. During a review of Resident 49 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/4/23, indicated Resident 49 had intact…

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: Create a comprehensive care plan for the use of lorazepam (a medication used to treat mental illness) to treat behaviors of restlessness and aggression in one of five sampled residents (Resident 62). Create a comprehensive care plan for the use of lorazepam to treat behaviors of increased agitation, yelling, and screaming toward other and staff in accordance with the facility policy for one of five sampled residents (Resident 70). This deficient practice of failing to create comprehensive, resident-specific care plans related to the use of psychotropic medications (medications that affect brain activities associated with mental processes and behavior) increased the risk that Resident 62 and 70 ' s use of psychotropic medications would not be periodically reevaluated as intended. This increased the risk that Residents 62 and 70 may have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise care plans for one of 35 sampled residents (Resident 51). This failure had the potential to affect Resident 51 ' s provision of care and services while residing in the facility. Findings: During a review of Resident 51 ' s admission Record, the facility admitted Resident 51 on 11/10/2023, with diagnoses including muscle wasting and atrophy (thinning or loss of muscle tissue), abnormalities of gait (manner of walking) and mobility (ability to move), dementia (decline in mental ability severe enough to interfere with daily life), and cerebral infarction (brain damage due to a loss of oxygen to the area). During a review of Resident 51 ' s care plan for self-care deficit (difficulty performing self-care tasks like bathing, dressing, grooming), revised on 11/27/2023, the care plan interventions included for the facility to provide Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint…

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 have more than one staff to provide Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) services out of 12 residents who were supposed to receive RNA services on 2/7/2024. RNA 1 was unable to provide RNA services to three (Resident 6, 24, and 61) of 12 residents on 2/7/2024, because RNA 1 was assigned to supervise multiple residents out in the facility ' s patio on 2/7/2024. On 2/8/2024, RNA 1 was assigned as a Certified Nurse Assistant assigned to perform resident care and was not able to provide RNA services to the 12 residents requiring RNA. On 2/9/2024, the facility failed to provide RNA services to the 12 residents requiring RNA because RNA 1 did not report to work. This failure had the potential for the residents with physician orders for RNA to experience a decline in range of motion [ROM, full movement potential of a joint (where two bones meet)] and mobility (ability to move). Findings: During a review of the facility ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure the physician responded to a recommendation from November 2023 to justify prolonged use of pantoprazole (a medication used to reduce stomach acid) in one of five sampled residents (Resident 62). This deficient practice of failing to ensure the physician evaluated and responded to medication irregularities (potential issues with a resident ' s medication regimen) identified by the faciliity ' s consultant pharmacist during the Medication Regimen Review (MRR – a monthly report from the consultant pharmacist identifying any medication irregularities in a resident ' s current medication regimen) increased the risk that Resident 62 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to medication therapy possibly leading to decline in mental or physical condition or psychosocial status. Findings: A review of Resident 62 ' s admission Record (a document containing a resident demographic 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 five sampled residents (Resident 70) was free of unnecessary medications. Resident 70 was ordered for psychotropic medications (medications that affect the mind and behavior) with an inadequate indication of use for Seroquel (a medication used to treat mental illness) to treat psychosis (a mental disorder characterized by a disconnection from reality) without adequate indication for use and the resident's manifestations of behavior of constant worrying was not monitored. This deficient practice had the potential to place Resident 70 at risk for unrecognized adverse reactions associated with the use of psychotropic drug. Findings: A review of Resident 70's admission Record indicated Resident 70 was admitted on [DATE] with diagnoses that included anxiety disorder (a mental condition characterized by intense, excessive, and persistent worry and fear about everyday situations), dementia (a medical condition characterized by a decline in 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 ensure residents were free from significant medication errors by attempting to administer one dose of expired insulin (a medication used to treat high blood sugar) prior to surveyor intervention for one of nine residents observed for medication administration (Resident 483.) This deficient practice of failing to administer medications in accordance with professional standards of practice increased the risk that Resident 483 may have experienced medical complications from ineffective insulin possibly resulting in hospitalization. Cross-referenced F759 Findings: A review of Resident 483 ' s admission Record (a document containing a resident ' s demographic and diagnostic information, dated [DATE], indicated he was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (a medical condition characterized by the body ' s inability to regulate blood sugar levels.) A review of Resident 483 ' s Order Summary 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 Based on observation, interview, and record review the facility failed to: Ensure unopened insulin (a medication used to control high blood sugar) was stored in the refrigerator per the manufacturer ' s requirements affecting Resident 483 in one out of two medication carts (East Wing Medication Cart). Remove expired insulin (a medication used to treat high blood sugar) from the medication cart affecting Resident 483 in one out of two inspected medication carts (East Wing Medication Cart). These deficient practices of failing to store medications per the manufacturers ' requirements and remove expired medications from the medication carts increased the risk that Resident 483 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death. Findings: A review of Resident 483 ' s admission Record (a document containing a resident ' s demographic and diagnostic information, dated 2/9/24, indicated he was…

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

Based on observation, interview, and record review, the facility failed to ensure one of one seated leg bicycles in the Rehabilitation Room was functioning properly, including during use for one of 13 residents (Resident 43) receiving Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) services. Findings: During a review of Resident 43 ' s admission Record, the facility admitted Resident 43 on 1/17/2024 with diagnoses including Parkinson ' s disease (brain disorder that causes unintended or uncontrollable movements and difficulty with balance and coordination), encephalopathy (disease that affects the brain, causing changes in its function), muscle wasting and atrophy (thinning or loss of muscle tissue), abnormalities of gait (manner of walking) and mobility (ability to move), and anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one ' s daily activities). During a review of Resident 43 ' s PT Evaluation and Plan of Treatment, dated 1/18/2024,…

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 three sampled residents (Resident 1) was free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) in accordance the facility's policy and procedure titled Procedure for Prevention of Resident abuse and mistreatment by failing to ensure: 1. Resident 2 with diagnosis of schizoaffective disorder (mental health condition characterized by hallucinations [false perceptions of sensory experiences] or delusions [a false belief or judgment about external reality]), manifested by believing other people are against him and causing outburst of anger was monitored and supervised to prevent Resident 2 from entering Resident 1's room who was watching TV and pounded on Resident 1's head without a staff to stop Resident 2 from entering Resident 1's room. 2. Resident 2's clinical history from the GACH (General Acute Care Hospital)…

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 accurately assess and provide the necessary behavioral health care and services for one of three sampled residents (Resident 2) with diagnosis of schizoaffective disorder (a chronic and severe mental disorder that affects how a person thinks, feels, behaves and experience psychosis [behavioral symptoms that affect the mind, and loss of contact with reality]) manifested by history of increase agitation, aggressive behavior toward staff, and paranoid delusion (profound fear and loss of the ability to tell what's real and what's not real) believing other people are against him causing outburst of anger as indicated in the facility's policy and procedure by failing to: 1. The Licensed Vocational Nurse (LVN) did not appropriately assess and monitor Resident 2's aggressive behaviors. 2. Administer Ativan (medication used to relieved anxiety [fear of the unknown]) and Haldol (a medication used to control mood and behavior) as ordered by 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.