Bridgewood Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide services according to professional standards of quality for one of 16 sampled residents, Resident 33, when the Director of Nursing (DON) removed, and did not measure the length of Resident 33's Peripherally Inserted Central Catheter (PICC, thin, and long plastic tube that goes into a vein in your arm and ends in a large vein close to your heart) before throwing it in the trash can. This deficient practice had the potential risk of not removing the full length of the catheter and causing infection. Findings: A review of Resident 33's Clinical Record indicated Resident 33 was admitted to the facility in April 2025 with diagnoses that included infection and inflammatory reaction due to internal left knee prosthesis (artificial implants) and Methicillin Resistant Staphylococcus Aerus (MRSA, a serious, potentially fatal, bacterial infection [diseases that can affect your skin, lungs, brain, blood and other parts of your body]). A…

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

Based on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for one of 46 residents (Resident 25) when: Resident 25's haloperidol (medication used to treat nervous, emotional, and mental conditions) was not available to administer in the dose prescribed by the doctor. This failure had the potential for medication error and disruption of the resident's treatment plan. Findings: During an observation of medication administration on 6/3/25 at 7:41 a.m., Licensed Nurse 4 (LN 4) was observed to prepare Resident 25's morning medications which included haloperidol 5 mg (milligram, unit of measure). Reconciliation of the observed medication administration for Resident 25's current Physician Orders, dated 6/2/25, indicated, haloperidol oral tablet 5 mg. Give 0.5 tablet by mouth one time a day for schizophrenia (a chronic mental and brain disorder) . (0.5 tab =2.5 mg). During an interview on 6/3/25 at 7:41 a.m., with LN 4, LN 4 stated, I cannot administer resident's medication without clarifying it. There is a discrepancy with the…

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

Based on interview and record review, the facility failed to ensure the availability and timely administration of medications for four of 15 sampled residents (Residents 2, 3, 7, and 9) when: 1. Resident 2 did not receive a dose of Venlafaxine (A drug used to treat depression and certain anxiety disorders) and two doses of Clonazepam (a medication used to treat anxiety), 2. Resident 3 did not receive four doses of Clozapine (a medication that treats mental health conditions like schizophrenia - a mental illness that is characterized by disturbances in thought), 3. Resident 7 did not receive four doses of Haloperidol Decanoate injection (Haldol, medication used to treat schizophrenia), and 4. Resident 9 did not receive nine doses of Clozapine and three doses of Austedo (a medication used to treat movement disorders). These failures had the potential to negatively affect the residents' mental health and stability. Findings: 1. Resident 2 was admitted to the facility in October of 2024 with diagnoses that included paranoid schizophrenia, bipolar disorder, major depressive disorder. 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 the care plan to prevent falls was implemented for one resident (Resident 1) for a census of 47. This failure increased Resident 1's risk of falling, which could result in injury. Findings: A review of the clinical record indicated Resident 1 was admitted [DATE] with diagnoses including conversion disorder (a mental health condition where psychological stress is expressed as physical symptoms) with decreased coordination or balance and episodes of involuntary muscle contractions and spasms. A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 3/13/25, indicated Resident 1 had moderate cognitive impairment with BIMS (Brief Interview for Mental Status- an assessment used to screen and identify memory, orientation, and status of the resident) score of 10 out of 15. Resident 1's functional abilities indicated she had impairment on both lower extremities and used a wheelchair for mobility…

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

Based on interview and record review, the facility failed to develop a specific care plan for weight loss and pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for one resident (Resident 1) out three sampled residents, that included measurable objectives and timeframes. This failure had the potential to compromise the nutritional and health status for Resident 1. Findings: Resident 1 was admitted to the facility in early 2024 with diagnoses which included sepsis (a life-threatening blood infection), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hypertensive heart (high blood pressure) and chronic kidney disease. A review of Resident 1's Interdisciplinary team (IDT) note dated 9/23/24, indicated there was a weight change of 5.7%. A review of Resident 1's Order Summary Report (OSR), dated 9/12/24, indicated, Sacrococcyx, stage 4 PU (pressure ulcer)-cleanse with NS/Vashe (normal saline moistened gauze), pat dry. Apply scant medihoney and cal alginate, lightly pack with…

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

Based on interview and record review, the facility failed to implement policies and procedures (P&P) for the prohibition and prevention of abuse for a census of 48 residents when two out of five sampled facility staff (Certified Nurse Assistant [CNA] 1 and CNA 2) were actively working in the facility without an initial background check (a formal process that verifies an upcoming employee's personal and professional information such as identity, work history, criminal record, and any other relevant information) done. This failure placed all the residents in the facility at risk for possible serious physical and/or psychosocial harm and decreased the facility' ability to protect residents from exposure to an employee with a criminal history of abuse, neglect, and/or exploitation. Findings: During an interview on 9/3/24 at 1:12 p.m. with CNA 1, CNA 1 stated she has been working as a CNA (provides vital support to both residents and nurses which includes assisting, transporting, bathing, and feeding patients, stocking medical supplies, and logging patient information) in 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 a safe, clean, comfortable and homelike environment was provided for seven of 18 sampled residents (Resident 9, Resident 18, Resident 153, Resident 253, Resident 254, Resident 255, and Resident 256), when a cabinet and closet drawers were in disrepair, with chipped paint, and the walls were empty and bare inside the residents' rooms. This failure had the potential to result in the residents not attaining their highest practicable level of well-being. Findings: Resident 9 was admitted in late 2011 and readmitted in early 2022 with diagnoses which included stroke and weakness. During a review of Resident 9's Minimum Data Set (MDS, an assessment tool), dated 6/19/24, the MDS indicated Resident 9 had mild memory impairment and required extensive assistance with activities of daily living (ADLs). During a concurrent observation and interview on 7/9/24 at 8:35 a.m. in Resident 9's room, the cabinet drawers and closet doors 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 interview and record review, the facility failed to develop and implement comprehensive, documented care plans for four of 18 sampled residents (Resident 18, Resident 15, Resident 204, and Resident 19), when: 1. Resident 18 had no documented care plan for the isolation precautions; 2. Resident 15 had no documented care plan for skin integrity; 3. Resident 204 had no documented care plan for the use of dentures; and 4. Resident 19 had no documented care plan for medication combined with other medications. These failures had the potential to put the residents at risk for unmet needs and as well as the potential to negatively impact their highest practicable level of well-being. Findings: 1. Resident 18 was admitted to the facility in early 2024 with diagnoses which included chronic lung disease and pneumonia (lung infection). During a review of Resident 18's Minimum Data Set (MDS, an assessment tool), dated 4/21/24, the MDS indicated Resident 18 had no memory impairment and required extensive assistance with activities of daily living (bathing, dressing, toileting). During a…

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

Based on observation, interview and record review, the facility failed to implement their policy and procedure (P&P) for the accurate accountability of controlled medications (medications with a high potential for abuse and addiction) when controlled drug count records (a record used to reconcile inventory of controlled medications in the medication cart by the outgoing and incoming nurse during a shift change) were not routinely signed by the outgoing and incoming nursing shifts, and ensure controlled substance medications were accurately accounted for on the medication administration record (MAR) and Controlled Drug Record (CDR) for two of three randomly selected residents (Residents 6 and 45). These failures resulted in the facility not having accurate accountability of controlled medications, and the potential for abuse or misuse of these medications. Findings: During a concurrent interview and record review on 7/8/24 at 1:54 p.m. with Licensed Nurse 3 (LN 3), the controlled drug sign-in/sign-out sheets, dated April 2024 to July 2024, for Medication Cart B were reviewed. 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 ensure multi-dose medications were dated with an open and discard date to ensure they were not used beyond the discard date, prescription medications were appropriately labeled with a pharmacy label or name to correctly identify which resident they were for, medications with different routes of administration were stored in accordance with facility policy and procedures (P&P), and expired medications were not available for resident use. The deficient practices had the potential for residents to receive medications with unsafe and reduced potency from being used past their discard date, incorrect medications from inadequate labeling, medications given incorrectly through the wrong route of administration. Findings: During a concurrent observation and interview on 7/8/24 at 8:27 a.m. with Licensed Nurse 2 (LN 2) in Medication Storage room [ROOM NUMBER], the following was identified: 1 box hemorrhoidal (medication to treat swollen 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 provide alternatives to the meal entree that were of similar nutritive value. This had the potential of leading to protein/calorie malnutrition for the 44 residents eating facility prepared meals. Findings: During a concurrent observation and interview on 7/8/24 at 10:34 a.m., in the hallway outside the kitchen, Dietary Supervisor 1 (DS 1) showed the alternatives that residents can choose if they did not desire the menu meal. Included on the list was a grilled cheese sandwich. DS 1 explained that when ordered 2.5 hours prior to the meal, she would cross off the entrée and write in the desired item onto the meal ticket. During an observation of the lunch meal plating on 7/9/24 at 12:21 p.m., DS 1 stated that the dialysis lunch bags contained shelf stable items such as fruit cups, but when the nurse came to collect the bag for the resident, staff would add a sandwich such as peanut butter and jelly. During an interview on 7/10/24 at 11:18 a.m. with the Registered Dietitian (RD), the RD explained that she had…

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

Based on observation, interview and record review, the facility failed to ensure that dietary staff provided the correct portions when plating the consistent carbohydrate diet. This had the potential of leading to poor blood sugar control for the 11 residents (Residents 9, 13, 18, 28, 30, 33, 41, 153, 253, 255, and 453) eating the controlled carbohydrate diet (CCHO). Findings: During an observation of the lunch meal plating on 7/9/24 at 11:50 a.m., [NAME] 1 (Ck 1) was setting up the steamtable for the meal service. The meal included polenta which was noted to have two scoops, one with a grey handle (1/2 cup) and one with a green handle (1/3 cup). During an observation of the meal plating on 7/9/24 starting at 12:00 p.m., the residents receiving a CCHO diet were given polenta using the green handle scoop. Review of the facility provided Cook's spreadsheet for the Summer Menus, Week 2 Tuesday indicated that the CCHO diet was to receive a #16 scoop which was equal to ¼ of a cup. During this same meal plating, those on the CCHO diet were observed to receive a half portion of chocolate…

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 food in accordance with professional standards of food safety in order to prevent the outbreak of foodborne illness when: 1) Opened food items were not protected and sealed after opening; 2) Food labeling process was not followed when drinks on a tray in the refrigerator were not labeled and dated, and almond extract did not have a readable use-by date; 3) Unclean food service items, including a food processor bowl, were found with brown build-up, along with a cutting board which was noted to have food residue on the cutting surface; 4) Paint on the kitchen walls, sink backsplash, and ceilings were found to be chipped, stained, and covered with glue-like build-up; 5) Two packages of lunch meat were not thawed per standards when they were observed in a steam table container filled with static (non-running) water in the cook's sink; 6) Two alcohol sanitizer containers were accessible by dietary staff in the kitchen; 7) Dishwashing was not done according to standards when two steam…

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 infection control guidelines and practices for a census of 44 when: 1. Transmission based precautions were not followed for contact/droplet infection for Resident 18; 2. Bandage scissors were not cleaned during wound care treatment for Resident 13; 3. There were no Enhanced Barrier Precautions (EBP, involves use of gown and gloves during high contact resident care designed to reduce transmission of Multi Drug Resistant Organisms [MDRO, bacteria resistant to antibiotics]) in place for Resident 2's wound care and indwelling catheter; 4. There was no EBP in place for Resident 19; 5. Resident 453's isolation trashcan was not covered; and 6. A toothbrush, balled up paper towels were found on the floor, and a commode with white spots over the seat were found in an adjoining resident bathroom. These failures increased the risk for transmission of infections. Findings: 1. Resident 18 was admitted to the facility in early 2024 with diagnoses which included chronic lung disease and pneumonia (lung infection).…

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 review and revise the comprehensive care plan for one of 18 sampled residents (Resident 153), when the fall risk care plan was not updated after a fall incident. This failure had the potential to result in further falls and injuries. Findings: Resident 153 was admitted to the facility in late 2023 with diagnoses which included stroke, difficulty walking, muscle weakness, and expressive language disorder. During a review of Resident 153's Nursing Care Plan (NCP) dated 2/2/24, the NCP indicated, [Resident 153] is at risk for falls and/or injuries related to falls .poor safety awareness . During a review of Resident 153's Minimum Data Set (MDS, an assessment tool) dated 5/6/24, the MDS indicated Resident 153 had moderate memory impairment, had a history of falls, non-English speaker, and needed extensive assistance with activities of daily living (ADLs). During a review of Resident 153's Nursing Progress Notes (NPN), dated 7/6/24, the NPN indicated, Fall Risk .Disoriented x3 at all times .1-2 falls in past 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.

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with acceptable professional standards of quality for one of eight sampled residents (Resident 45) when nursing staff failed to verify the contents of a probiotic (a supplement to support and promote gut health) administered to Resident 45. This failure resulted in Resident 45 receiving the incorrect probiotic and the potential for worsening of their clinical condition or complications related to gut health such as diarrhea, nausea and vomiting. Findings: During a medication pass observation on 7/8/24 at 12:15 a.m. with Licensed Nurse 3 (LN 3), LN 3 was observed preparing ten medications for Resident 45, including lactobacillus with pectin (a probiotic used to maintain or promote gut health) 200 million cells per capsule, 2 capsules. A review of Resident 45's medical record indicated a physician's order, dated 5/23/24, for saccharomyces boulardii (a probiotic), 1 capsule three times a day for supplement. During a concurrent interview and record review on 7/8/24 at 1:45…

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 that the facility provided care and services consistent with professional standards for one of 18 sampled residents (Resident 15) when a pressure ulcer/injury (PU/PI, localized damage to the skin and/or underlying tissue from prolonged pressure on the skin) was found on his right heel. This failure resulted in Resident 15 developing an unstageable pressure ulcer (full thickness skin and tissue loss) to his right heel. Findings: Resident 15 was admitted to the facility in mid-2023 with diagnoses which included diabetes (uncontrolled blood sugar), chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), dependence on renal dialysis, acute kidney failure (a disorder of the kidneys when they cannot filter waste products from the blood). A review of Resident 15's clinical record did not include the following documents: a care plan with interventions for a skin assessment, repositioning, monitoring, offloading, heel protectors and/or hygiene/shower. During 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 residents maintained acceptable parameters of nutritional status when two of 5 sampled residents (Residents 16 and Resident 33) lost 20 pounds or more over 6 months, without an identified cause and food preferences were not obtained. These failures had the potential to negatively affect Resident 16's and Resident 33's overall health by leading to malnutrition and muscle wasting. Findings: Resident 33 was admitted to the facility in early 2023 with diagnoses of mild cognitive impairment, anemia (low levels of healthy red blood cells to carry oxygen throughout your body), essential hypertension (high blood pressure), type 2 diabetes mellitus without complications (disease that affects the body's ability to regulate blood sugar levels), and muscle weakness. A review of Resident 33's Face Sheet (FS), dated 7/10/24, indicated Resident 33's primary language was Spanish. Review of Resident 33's weight history includes the following: 1/1/24=111 pounds 4/1/24=99 pounds 7/2/24=87 pounds Resident 33 was noted 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 one of 18 sampled residents (Resident 10) was free of a significant medication error when he received Advair Diskus (generic name fluticasone/salmeterol, a medication to treat asthma) 42 times (doses) past the expiration date. This deficient practice had the potential for ineffective use of the Advair Diskus, resulting in breathing complications and worsening of Resident 10's clinical condition. Findings: Resident 10 was admitted to the facility in [DATE] with diagnoses which included asthma. A review of Resident 10's medical record indicated a physician's order for fluticasone/salmeterol 250/50 micrograms (mcg, a unit of measurement)/puff, 1 inhalation orally every 12 hours related to unspecified asthma, dated [DATE]. During a concurrent record review and inspection of Medication Cart B on [DATE] at 10:03 a.m. alongside Licensed Nurse 3 LN 3, a Advair Diskus inhaler labeled opened on [DATE] was identified. The manufacturer'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 and record review, the facility failed to puree zucchini by methods that conserved nutritive value and flavor. This had the potential of leading to poor intake and malnutrition for the four residents (Resident 5, Resident 33, Resident 49, and Resident 153) eating pureed meals. Findings: During an observation on 7/9/24 at 11:03 a.m., [NAME] 1 (Ck 1) pureed the hot foods for the lunch meal service. CK 1 removed 10 quarter pieces of zucchini from the oven and placed the zucchini into the processor bowl. She next added an unmeasured amount of melted butter to the bowl and proceeded to blend the mixture. When processing stopped, the mixture was found to be too thin and runny. Ck 1 proceeded to add an unmeasured (approximately ¼ cup) amount of thickener to the bowl and turned the food processor back on to blend. When Ck1 stopped the processor, she was happy with the consistency and placed the zucchini into a steam table pan and put it into the oven. Review of facility provided Pureed Vegetables Recipe (Healthcare Menus Direct, LLC.) indicated the following ingredients…

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 maintain one of the reach-in freezers. This had the potential of leading to food-borne illness for the 44 residents eating facility prepared meals. Findings: During the initial kitchen tour on 7/8/24 at 9:10 a.m. with Dietary Supervisor 1 (DS 1) two reach-in freezers were observed on the wall leading the outside door. The freezer closet to the outside door was stuffed with roughly 75% meat products and 25% frozen desserts. During a concurrent interview with DS 1, she stated that the freezer usually contained meat products but that one of the freezers was not working and they had to move those items into this freezer. During this same observation on 7/8/24 at 9:16 a.m., the freezer next to it had a temperature of 38 degrees Fahrenheit (F). This freezer contained 3 frozen apple pies, a frozen peach pie, and a box of donuts. During a concurrent interview with the DS 1, she stated that this was the freezer that was not working and would be fixed today or tomorrow. During a visit to the kitchen on 7/9/24 at 10:56 a.m., the DS 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow proper infection prevention and control practices for two of three sampled residents (Resident 1, and Resident 2) when: 1. Oxygen tubing was not labeled, 2. Urinal ½ full of a yellow amber colored fluid was found sitting on top of the bedside table. 3. The floor has multiple white shiny pieces of food laying on the floor next to the bed. 4. Urinal was mislabeled. During an initial tour on 6/12/24 at 12:35 p.m., an observation of room [ROOM NUMBER] with three residents, Resident 2's bedside table had a urinal with yellow amber colored fluid in it, multiple white shiny pieces of food on the floor next to the bed. Resident 1 has a mislabeled urinal on his bedside table and his oxygen tubing was not labeled. During a concurrent observation and interview on 6/12/24 at 12:40 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated, That trash on the floor we don't even know what that is. I think it's an eggshell . CNA also confirmed…

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 1) was free from abuse when Resident 2 struck him in the face and head. This failure had the potential to result in serious physical injury for Resident 1. Findings: A review of Resident 1's admission record indicated he was admitted in 5/23 with diagnoses including hemiplegia and hemiparesis (paralysis and weakness) following a cerebral infarction (stroke) affecting the left non-dominant side. A Minimum Data Set (MDS, an assessment tool), dated 2/16/24, indicated Resident 1 had moderate cognitive impairment. A review of Resident 1's clinical record included the following documents: A nursing progress note, dated 4/5/24 and written by the Director of Nursing (DON), indicated a certified nursing assistant (CNA) had heard scuffling coming from Resident 1 and Resident 2's room around 6 a.m. that morning and upon entering the room saw Resident 2 hitting Resident 1 in the face and head. The note 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 ensure infection prevention and control program guidelines and practices were maintained for a census of 44, when: 1. Licensed Nurse 6 (LN 6) did not sanitize hands and changed gloves during wound dressing change for Resident 3; 2. Unlabeled and undated opened humidifiers found at the bedside of Resident 153; 3. Outdated humidifier was used for Resident 155; 4. Used coffee mugs and office equipment were found on top of a folding table in the dining room; 5. Nursing staff did not perform hand hygiene during direct resident care in an isolation room; and 6. Infection Preventionist (IP) verbalized no knowledge of infection control and prevention. These failures had the potential to result in transmission and spread of infection for a vulnerable population. Findings: 1. Resident 3 was admitted in early 2022 with diagnoses which included leg paralysis, pressure ulcer of the sacral region, and depression. During a review of Resident 3's Minimum Data Set (MDS, an assessment tool), dated 5/10/23, the MDS indicated…

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

Based on observation, interview and record review, the facility failed to provide a comfortable and dignified atmosphere for dining for a facility census of 44 residents, when residents waited for their meals while the other residents were eating. This failure resulted in the residents' frustration and anger when residents were not all served meals at the same time. Findings: During a dining observation on 6/26/23, beginning at 12:33 p.m. in the residents' dining room, 10 residents were present, some with meals and others without meals. There were five tables with two residents sitting together at each table in the dining room. Three of the tables with two residents had their meals served. During an interview on 6/26/23, at 12:40 p.m., with Resident 152, Resident 152 stated she had been waiting ten minutes for lunch that usually comes at 12:00 p.m. Resident 152 stated she was frustrated and did not want to wait. During a concurrent observation and interview on 6/26/23, at 12:49 p.m., with Restorative Nursing Aide 1 (RNA 1), it was observed two tables with four residents still had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the residents' needs were accommodated for four of 22 sampled residents (Resident 27, Resident 32, and Resident 154), when: 1. Call light was broken and no call bell was provided to Resident 27, Resident 32 and Resident 154. These failures had the potential to result in the residents not attaining their highest practicable physical and psychosocial well-being. Findings: During an observation on 6/26/23, at 9:15 a.m., the call light outside Resident 27, Resident 32 and Resident 154's rooms flashed continuously. During a review of the facility binder labeled, Maintenance Log, on 6/26/23, the maintenance log did not indicate any entry reporting a problem with the call light system 1.a. Resident 27 was admitted in early 2023 with diagnoses which included left ankle fracture, left ankle and foot pain, muscle weakness, and depression. During a review of Resident 27's Minimum Data Set (MDS, an assessment tool), dated 4/22/23, the MDS…

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

Based on observation, interview and record review, the facility failed to ensure a safe, clean, comfortable and a homelike environment was provided for three of 22 sampled residents (Resident 22 and Resident 153), when: 1. The immediate environment was empty and walls were bare in Resident 22's room; and 2. A dirty commode was found at Resident 153's bedside; These failures had the potential to result in the residents not attaining their highest practicable well-being. Findings: 1. Resident 22 was admitted in early 2020 and readmitted in late 2022 with diagnoses which included inability to communicate following a stroke, difficulty swallowing, reduced mobility, anxiety, and depression. During a review of Resident 22's Minimum Data Set (MDS, an assessment tool), dated 5/28/23, the MDS indicated Resident 22 had severe memory impairment and required extensive assistance with activities of daily living (ADLs). During an observation on 6/27/23, at 9:41 a.m., Resident 22 was found lying in bed, awake, alert and verbally non-responsive. Resident 22's bedside table and night stand 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 observation, interview, and record review, the facility failed to ensure the instructions needed for effective person-centered care were provided for four of 22 sampled residents (Resident 151, Resident 152, Resident 153 and Resident 155), when the Baseline Care Plan (BCP) was not completed and no copy given to the resident nor the responsible party (RP). This failure had the potential to result in the lack of communication among staff, inadequate care for the resident, and leaving the resident and the RP with no information summarizing the goals, medications, treatments, diet, and discharge plans. Findings: 1. Resident 151 was admitted in the middle of 2023 with diagnoses which included right leg fracture, right hip pain, and heart failure. During a review of Resident 151's BCP, dated 6/21/23, the BCP indicated Resident 151's primary language was Russian, communicated easily with staff, understood the staff, and did not need interpreter to communicate with a doctor or health care worker. There were no…

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 communication needs were met for two of 22 sampled residents (Resident 151 and Resident 37), when there was no communication board or device accessible to the staff to communicate with the residents. This failure had the potential to result in not meeting the residents' highest practicable well-being. Findings: 1. Resident 151 was admitted in the middle of 2023 with diagnoses which included right leg fracture, right hip pain, and heart failure. During a concurrent observation and interview on 6/26/23, at 9:11 a.m., Resident 151 was in bed, alert and awake, verbal and responsive speaking her native language. When asked how she was doing, Resident 151 stated, No English. During a concurrent observation and interview on 6/26/23, at 9:14 a.m., with License Nurse 3 (LN 3), LN 3 verified there was no communication board at the bedside, and stated, I don't know how they talk to [Resident 151] .I don't see any communication binder 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 provide an environment free from potential accident hazard for two of 22 sampled residents (Resident 11 and Resident 34), when water coming out from the bathroom sink faucets was too hot to touch. This failure had the potential to result in accidents and burns for Resident 11 and Resident 34. Findings: 1. Resident 11 was admitted in early 2019 and re-admitted in early 2023 with diagnoses which included memory impairment, muscle weakness and infection. During a review of Resident 11's Minimum Data Set (MDS, an assessment tool), the MDS indicated Resident 11 had moderate memory impairment. During a review of Resident 11's Nursing Care Plan (NCP), dated 1/13/23, the NCP indicated the resident had a skin integrity problem. During an observation on 6/26/23, at 9:10 a.m., Resident 11 walked into the bathroom and stated, The water here gets hot sometimes .the water could get really hot. I go to the bathroom and wash my hands and I feel the 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.

Based on observation, interview, and record review, the facility failed to ensure pharmacy services were provided to meet the needs of each resident in a census of 44, when: 1. There was an absence of accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction), when random controlled medication audits for three out of three residents (Resident 17, 30 and 37) did not reconcile; and 2. An efficient system was not in place to accurately document and secure emergency medications (e-Kit). These failures had the potential to allow for abuse or misuse of these medications and the potential for emergency medications to be unavailable when needed. Findings: During a review of Resident 17, Resident 30, and Resident 37's MARs (Medication Administration Record)s, medications that were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but were not documented accurately on the (MAR) to indicate they were given to the residents. 1. Resident 17 had a physician's…

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

Based on observation, interview and record review, the facility's consultant pharmacist (CP) failed to identify drug-related issues on one of 22 sampled residents (Resident 31), and act upon the CP's monthly medication regimen reviews (MRR) for all residents from January 2023 to June 2023. These failures had the potential for unsafe medication use for all residents in the facility. Findings: A review of Resident 31's admission record indicated he was admitted to the facility on in early 2023 with diagnoses which included unspecified mood disorder, unspecified anxiety disorder and vascular dementia. A review of Resident 31's medical record indicated a physician's order dated 4/24/23 for olanzapine (an antipsychotic) 2.5 milligram (mg, a unit of measurement) 1 tablet at bedtime for mood disorder manifested by angry outburst. During an interview on 6/28/23, at 11:20 a.m., with Licensed Nurse 2 (LN 2), when asked if the indication for Resident 31's olanzapine was appropriate, LN 2 stated, I don't like the diagnosis for this . I think that is just the behavior that is to be monitored.…

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 labeling and storage of drugs and medications were followed for a census of 44, when: 1. Discontinued and expired medications were not removed from stock; 2. Medications were not labeled properly to ensure it was used for the correct resident and medications were not dated with an open date and discard date to ensure that they were not used beyond the discard date; and 3. The medication storage room and the medication refrigerator temperatures were not monitored appropriately. These failures had the potential to result in medications being administered not in accordance with physician's order and residents receiving medications with unsafe or reduced potency (measure of strength). Findings: 1. During an inspection of the Medication Storage Room and Refrigerator on 6/26/23, at 8:32 a.m., with Licensed Nurse 1 (LN 1), LN 1 confirmed there was a bottle of diphenhydramine (a medication used to relieve symptoms of allergy) 25 mg. (milligrams, a unit of measure) in stock that expired 4/23. LN 1 stated that it…

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 food storage and preparation, and maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 44 residents who ate facility prepared meals when: 1. The garbage can located next to the hand washing sink was soiled and the foot pedal to lift lid was broken; 2. One of two refrigerators and two of three freezers did not have thermometers inside the cold storage areas; 3. New margarine cube in refrigerator was partially unwrapped and exposed to the air; 4. Dented can of yams was in the dry storage area; 5. Fifty pound bag of oatmeal in the dry storage area was open; 6. Six loaves of bread had a delivery date of 6/15/23; 7. Bag of frozen turkey cubes had label that had worn off and was unreadable; 8. Tray of juices, milk, and water in refrigerator were not labeled or dated; 9. Two five pound containers of cottage cheese in refrigerator were opened but not labeled with date opened; 10. Kitchen prep sink did not have an air gap; 11. Logs for dishwasher…

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 resident safety for a census of 44, when the facility did not develop an Antibiotic Stewardship Program that included antibiotic use protocols and a system to monitor antibiotic use. This failure had the potential to increase resident mortality, increase adverse drug events and drug interactions, and resident infection with antibiotic-resistant organisms. Findings: During an interview with the Infection Preventionist nurse (IP) on 6/28/23 at 2:30 p.m., the IP indicated she was not able to access facility documents related to Antibiotic Stewardship, nor had she received facility training related to Antibiotic Stewardship. The IP presented a binder with multiple documents that had residents' names and the name of the antibiotic the residents were taking or had taken. The rest of each page was blank with no reason or follow up regarding the resident and antibiotics usage. The IP indicated she did not know why the resident may have been taking the antibiotic, the dose, or if the antibiotics had been discontinued. The IP…

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 monitor residents or staff who had or had not received a Covid-19 vaccine series for a census of 44, when vaccination records were requested but not provided. This failure had the potential to endanger the health and well-being of residents in the facility. Findings: During an interview on 6/26/23, at 2:30 p.m., with the Infection Preventionist (IP) the IP indicated she was not aware of either staff or residents that had received a Covid-19 vaccine, nor was she aware of a process to monitor who had received a Covid-19 vaccine. The IP further indicated she had not seen the policy for monitoring or administering Covid-19 vaccines. The IP further indicated she had not seen the policy for a Covid-19 outbreak. During a review of a facility policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 5/15/23, the P&P indicated, Residents and staff will be offered the COVID-19 vaccine when vaccine supplies are available .residents and staff will be screened .to determine candidacy for the vaccination…

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 compliance and ethics policy for a census of 44, when a medication temperature monitoring log was falsified. This failure had the potential to negatively impact the quality of pharmaceutical products being stored in a the facility. Findings: During a review of the facility's medication refrigerator and room temperature log sheet on 6/26/23, for the month of June 2023, the log sheet indicated the medication refrigerator temperature was documented, 6/12 AM, 6/13 AM, 6/22 PM, and 6/23 PM, and the medication room temperature was documented, 6/10 PM, 6/11 PM, 6/22 PM, and 6/23 PM. The log sheet indicated, Medication Refrigerator Temp. [temperature] and Medication Room Temp. Monitor BID [twice a day]. During a concurrent interview and record review on 6/26/23, at 11:07 a.m., with the Infection Preventionist (IP), the IP stated, Usually, the desk nurse is assigned to monitor the AM and PM temperatures for the medication refrigerator and medication room. Upon review of the log for June 2023, the IP stated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an adequate call light system was provided for three out of 22 sampled residents (Resident 27, Resident 32 and Resident 154), when the call light was not working. This failure had the potential to negatively affect residents' safety by preventing the residents from communicating a request for assistance when needed. Findings: Resident 27 was admitted in early 2023 with diagnoses which included left ankle fracture, left ankle and foot pain, muscle weakness, and depression. During a review of Resident 27's Minimum Data Set (MDS, an assessment tool), dated 4/22/23, the MDS indicated Resident 27 had mild memory impairment and required supervision assistance with activities of daily living. Resident 32 was admitted in late 2022 with diagnoses which included stroke and depression. During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32 had severe memory impairment and required limited to extensive assistance…

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

Based on observation, interview, and record review, the facility failed to ensure professional standards were followed for one of 22 sampled residents (Resident 29), when a lidocaine (an anesthetic used to treat pain) 5% (percent, a unit of measurement) patch was applied to Resident 29's shoulder blade without ensuring all edges of the patch were adhered and the date, time and initials of the nurse applying it were not documented. This failure had the potential for Resident 29 to not achieve adequate pain relief or be exposed to unwanted side effects of the medication due to incorrect timing of administration. Findings: A review of Resident 29's medical record, dated 5/12/23, indicated a physician's order for lidocaine (an anesthetic used to treat pain) 5% (percent, a unit of measurement) patch, apply to upper back topically in the morning for back pain. During a medication pass observation on 6/26/23, at 10:38 a.m., with Licensed Nurse 1 (LN 1), LN 1 applied a lidocaine patch to Resident 29's upper left shoulder. LN 1 smoothed the patch onto the resident's shoulder, but an…

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

Based on interview and record review, the facility failed to identify one of 22 sampled residents (Resident 33) was at nutritional risk when the Dietary Supervisor (DS) and Registered Dietitian (RD) were not notified of Resident 33's meal refusals for five days. This failure had the potential to result in Resident 33 experiencing weight loss and nutritional deficiencies. Findings: Resident 33 was admitted to the facility in early 2023 with diagnoses which included stroke and muscle weakness. During a review of Resident 33's Minimum Data Set (MDS, an assessment tool), dated 4/16/23, the MDS indicated Resident 33 had moderate cognitive impairment, and required supervision for eating. During a review of Resident 33's Registered Dietitian's Nutritional Assessment, dated 4/13/23, the assessment indicated, Resident doesn't state any food likes and dislikes. Per resident he does not eat dinner meals. Will monitor food preferences, meal intake trends and diet tolerance .will also encourage PO [by mouth] and Fluid intake .Current PO intake 50-60% of needs (inadequate). Resident stated he is…

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

Based on observation, interview and record review, the facility failed to ensure one of 22 sampled residents (Resident 31) was free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when Resident 31 received psychotropic medication without adequate indication for use and was not being appropriately monitored. This failure resulted in unnecessary medication for the resident, which had the potential for increased risks and exposure of side effects associated with psychotropic medications such as sedation, memory loss, falls and abnormal involuntary movements. Findings: Resident 31 was admitted to the facility in the Spring of 2023 with multiple diagnoses which included unspecified mood disorder, anxiety disorder, vascular dementia (memory and thought impairment) and heart disease. During a record review of Resident 31's Minimum Data Set (MDS, assessment tool) dated 5/3/23, the MDS indicated Resident 31 had moderately impaired cognition (ability to think and understand), no hallucinations, no delusions…

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 functional and comfortable environment when one of 22 sampled residents (Resident 33) did not have a functioning over-the-bed light. This failure had the potential to cause Resident 33 to not have proper lighting to support his needs. Findings: Resident 33 was admitted to the facility in early 2023 with multiple diagnoses which included stroke and muscle weakness. During a review of Resident 33's Minimum Data Set (MDS, an assessment tool), dated 4/16/23, the MDS indicated Resident 33 had moderate cognitive impairment. During a concurrent observation and interview on 6/27/2,3 at 10:31 a.m., with Resident 33, observed the over the bed light did not turn on when the chain was pulled. Observed the light did turn on when the wall switch by the door was used. Resident 33 indicated he was unable to walk to the switch by the door to turn on the light. Resident stated he wants the light on when he prays. Resident 33's roommate stated the light had not worked for about two weeks. During 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.