Gramercy Court

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for one of four sampled resident (Resident 1), when Resident 1 was punched in the face by Resident 2. This failure caused injury to Resident 1's lip.Resident 1 was admitted to the facility early 2024 with diagnosis which included a mental health disorder marked by hallucinations and delusions, anxiety, impulse disorder, and mood disorder.During a review of Resident 1's Order Summary Report [OSR], order date 3/11/24, the OSR indicated, Resident is Incapable Of Understanding Rights, Responsibilities, And Informed Consent.Resident 2 was admitted to the facility mid 2025 with diagnosis which included a mental health disorder marked by hallucinations, delusions and extreme mood swings.During a review of Resident 2's OSR, order date 5/14/25, the OSR indicated, Resident is Incapable Of Understanding Rights, Responsibilities, And Informed Consent.During 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 Based on observations, interviews, and record reviews, the facility failed to protect one of five sampled residents (Resident 1) from abuse when Resident 2 slapped Resident 1 on the left cheek. This failure resulted in Resident 1 experiencing feelings of unsafety, disrespect and physical pain.Findings:Review of Resident 1's admission Records indicated Resident 1 was admitted in Summer of 2024 with diagnoses which included a mental health condition that affected how people think, feel and behave and Type 2 Diabetes. A review of Resident 1's Brief Interview for Mental Status (BIMS), dated 6/2/25, the BIMS indicated Resident 1 had a score of 12 out of 15 which indicated Resident 1 had a moderate cognitive impairment.A review of Resident 1's Interdisciplinary Team (IDT) Note dated 7/14/25 indicated, At approximately 1540 [3:40 p.m.] on 7/13/25, MHW [Mental Health Worker] reported they had heard a slapping sound and saw this resident's [Resident 1] peer strike him on the left side of the face.Resident [Resident 1]…

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 protect the resident's right to be free from abuse for one of three sampled residents (Resident 1) when Resident 2 pushed Resident 1 and hitting Resident 1's head into a wall which resulted in Resident 1 sustaining a skin tear. This failure resulted in Resident 1 not free from abuse by Resident 2. Findings: Review of Resident's 1 admission Record indicated Resident 1 was admitted [DATE] with diagnoses including schizoaffective disorder, bipolar type (a mental illness that is characterized by disturbances in thought and mood swings that range from the lows of depression to elevated periods of emotional highs). Review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 5/14/25, indicated Resident 1 was cognitively intact. Review of facility dcoument titled Health Status Note, for Resident 1 dated 5/18/25, indicated, Resident [1] was assaulted by another resident [2] attempting to break up a fight . 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.

Based on observation, interview, and record review, the facility failed to maintain a safe environment for one of 35 sampled residents (Resident 1), when Resident 1 eloped (left the facility unsupervised without prior authorization) through an unsecured exit gate. This failure decreased the facility's potential to maintain residents' safety and prevent accidents. Findings: A review of an admission record indicated Resident 1 was admitted to the facility in November 2024 with a diagnosis of bipolar schizoaffective disorder (causes mood swings that range from the lows of depression to elevated periods of emotional highs and a mental illness that is characterized by disturbances in thought). A review of Resident 1's Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 2/26/25, indicated Resident 1's Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 14 out of 15 with good memory and judgement. During an interview on 4/21/25 at 1:30 p.m. with…

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

Based on observation, interview, and record review, the facility failed to ensure medications were stored properly for a census of 107, when: 1. Staff stored personal belongings inside Hall C medication room; 2. Expired medications were found in two medication carts; 3. Two multi-dose liquid protein bottles without open dates and an expired inhaler were found in one medication cart; 4. Medication was left at Resident 404's bedside table; and 5. Treatment cart was left unlocked. These failures decreased the facility's potential to safely store medications. Findings: 1. During a concurrent observation and interview on 12/4/24 at 10:42 a.m. with Licensed Nurse 6 (LN 6), Hall C medication room was observed. LN 6 confirmed a lunch box, a water bottle, three jackets and a bag were found inside the medication room and stated these were her belongings and she placed them in the medication room. 2. During a concurrent observation and interview on 12/4/24 at 11:28 a.m. with LN 6, Hall C medication cart-1 was observed. 31 expired and discontinued pills of carvedilol (a medication used to treat…

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 promote dignity for one of 30 sampled residents (Resident 27), when Resident 27 was wearing a gown while sitting in a wheelchair with her back and side of body exposed. This failure decreased the facility's potential to maintain residents' dignity and privacy. Findings: A review of Resident 27's admission Record, indicated Resident 27 was admitted to the facility in January 2024 with a diagnosis of left hip fracture. A review of Resident 27's Minimum Data Set (MDS, an assessment tool), dated 10/22/24, indicated Resident 27 had a brief interview for mental status (an assessment tool for cognitive status) scored 12 out of 15 with moderate memory impairment. Resident 27 required substantial to maximal assistance (helper does more than half the effort) with dressing clothes. A review of Resident 27's [Activities of Daily Living] Self-Care Performance Deficit care plan, dated 7/18/24, indicated staff had to promote dignity by ensuring privacy during care . During an observation on 12/3/24 at 9:27 a.m., Resident 27…

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

Based on interview and record review, the facility failed to ensure an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was obtained for the use of psychotherapeutic drug (a medication to control a resident's behavior) for one of 30 sampled residents (Resident 43), when Resident 43 was prescribed three psychotherapeutic drugs without an informed consent. This failure had the potential for Resident 43 to receive unnecessary medications. Findings: A review of Resident 43's admission Record, indicated Resident 43 was admitted to the facility in January 2020 with a diagnosis of anxiety. A review of Resident 43's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 11/13/24, indicated Resident 43 had a brief interview for mental status (an assessment tool for cognitive status) scored 15 out of 15 with intact cognition. A review of Resident 43's Order Summary Report, dated 12/4/24, indicated orders for buspirone (an anti-anxiety medication) 20 milligrams…

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 self-medication administration assessment was completed for one of 30 sampled residents (Resident 43), when Resident 43's medications were accessible and left stored on top of bedside table. This failure increased Resident 43's potential to unsafely self-administer medications. Findings: A review of Resident 43's admission Record, indicated Resident 43 was admitted to the facility in January 2020 with a diagnosis of anxiety. A review of Resident 43's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 11/13/24, indicated Resident 43 had a brief interview for mental status (an assessment tool for cognitive status) scored 15 out of 15 with intact memory. During a concurrent observation and interview on 12/2/24 at 9:32 a.m. with Resident 43 inside her room, Resident 43 had a plastic container filled with multiple anti-fungal, anti-itching, and antibiotic creams in packets and tubes placed at bedside table. Resident 43 stated the nurse and certified nursing assistant gave her 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 a discharge Minimum Data Set (MDS-a federally mandated resident assessment tool) was completed in accordance with the regulatory timeframe required for one of 30 sampled residents (Resident 76), when Resident 76's discharge assessment was not submitted within 14 calendar days of discharge. This failure decreased the facility's potential to complete residents' assessments in a timely manner. Findings: A review of Resident 76's admission Record, indicated he was admitted to the facility on [DATE] and discharged to the hospital on 7/15/24. During a concurrent interview and record review on 12/4/24 at 10 a.m. with the Business Office Consultant (BOC), the facility's census of July 2024 was reviewed. BOC confirmed Resident 76 was admitted in the first week of July and was discharged 13 days after admission. During a concurrent interview and record review on 12/4/24 at 10:20 a.m. with the MDS Coordinator (MDSC), Resident 76's Progress Notes and MDS…

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

Based on interview and record review, the facility failed to develop a care plan for one of 30 sampled residents (Resident 254), when Resident 254 did not have a care plan for hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care facility). This failure decreased the facility's potential to meet Resident 254's hospice care needs. Findings: A review of Resident 254's admission Record, indicated Resident 254 was admitted to the facility in November 2024 with multiple diagnoses including frequent falls, malnutrition (less than minimum foods or nutrients essential for health), and palliative care (a medical care helps people with serious illnesses live with comfort and dignity). During a concurrent interview and record review on 12/5/24 at 9:47 a.m. with Licensed Nurse 1 (LN 1), Resident 254's care plans were reviewed. LN 1 confirmed no hospice care plan had been developed for Resident 254. During a concurrent interview and record review on 12/5/24 at 10:25 a.m. with the Director of Nursing (DON), Resident 254'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.

Based on observation, interview, and record review, the facility failed to provide services according to professional standards of quality for three of 30 sampled residents (Resident 254, Resident 255, and Resident 257), when: 1. Resident 254's physician order to admit to hospice care (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) was not transcribed to the order summary record (OSR); 2. Resident 255's physician's order of heparin sodium (a medication used to prevent blood clots in blood channels in the body) was incorrectly recorded in OSR; and 3. Resident 257 was not given metformin hydrochloride (metformin HCl-a medicine to treat high blood sugars) as prescribed by the physician. These failures increased the residents' potential to have unmet health needs. Findings: 1. A review of Resident 254's admission Record, indicated Resident 254 was admitted to the facility in November 2024 with multiple diagnoses including frequent falls, malnutrition (less than minimum foods or nutrients essential for health),…

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.

2. A review of an admission record, indicated Resident 30 was admitted to the facility in June 2020 with a diagnosis of dementia (a progressive state of decline in mental abilities) with agitation. A review of Resident 30's Order Summary Report, indicated an order dated 2/17/24 for lorazepam one mg to be given every four hours as needed (PRN), with no stop date. A review of Resident 30's Medication Administration Record, indicated the PRN order for lorazepam was administered from 2/17/24 to 7/23/24. During a concurrent interview and record review on 12/4/24 at 11:02 a.m. with the Director of Nursing (DON) and ADON, Resident 30's Medication Regimen Review for February 2024 and progress notes were reviewed. Both DON and ADON confirmed that the doctor's order did not include a rationale/reason to continue Resident 30's order for lorazepam from February 2024 to July 2024. During an interview on 12/5/24 at 1 p.m. with the DON, DON confirmed Resident 30's lorazepam PRN order did not have a stop date and was given more than 14 days. DON stated a doctor's note with a rationale should have…

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 weekly and alternate menus to three of 30 sampled residents (Resident 204, Resident 24, and Resident 38). This failure decreased the facility's potential to meet the residents' nutritional and cultural preferences. Findings: A review of Resident 204's admission Record, indicated she was admitted to the facility in November 2024 with diagnoses including disorder of electrolyte and fluid imbalance. A review of Resident 204's Minimum Data Set (MDS, a federally mandated resident assessment tool), indicated her brief interview of mental status score was 13 out of 15 with intact cognition. During a concurrent observation and interview on 12/2/24 at 9:40 a.m., Resident 204 was up in her wheelchair with breakfast tray not touched. Resident 204 stated breakfast was always the same, she was unable to know what it was until been served, and there was no menu provided by the kitchen or dietician so she could choose her own food preference. A review of an admission record indicated, Resident 24 was admitted to 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 ensure one of 30 sampled residents (Resident 46) was provided with necessary adaptive equipment (special eating equipment) for meals as ordered. This failure decreased the facility's potential to meet the resident's nutritional needs. Findings: A review of an admission record indicated Resident 46 was admitted to the facility in July 2020 with a diagnosis of type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 46's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 10/4/24, indicated a brief interview of mental status score of three out of 15 with memory problems. During an observation on 12/2/24 at 12:25 p.m., inside Resident 46's room, a lunch tray was given to her. The food consisted of chopped meat, chopped vegetables, and mashed potato. All food was served in one plate. Resident 46 was observed transferring food to a cup before eating then stated it was easier for her to eat in a smaller dish. 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 properly store food in accordance with professional standards for food safety for a census of 107, when: 1. Two expired food products were stored in the spice shelf; 2. One box of expired food was stored in the dry storage area; 3. A 12 pack box of expired lactose free drink was stored in the walk-in refrigerator; and 4. Undated food products were stored in the walk-in refrigerator and dry storage area. These failures increased the potential for food-borne illnesses among the residents. Findings: 1. During a concurrent observation and interview on 12/2/24 at 8:30 a.m. with the Dietary Supervisor (DS) during the initial kitchen tour, two spice bottles were found on the spice shelf past their use by date. The powdered ginger had a use by date of 11/2023 and the ground nutmeg had a use by date of 11/4/23. DS confirmed both bottles were expired. 2. During a concurrent observation and interview on 12/2/24 at 8:30 a.m. with DS during the initial kitchen tour, a box of expired dried beans was stored in the dry…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pain management consistent with professional standards of practice for one of two sampled residents (Resident 1), when the facility did not administer Resident 1's pain medication for several hours upon admission and pain was not assessed in a timely manner for effectiveness of the pain medications. This failure resulted in Resident 1 experiencing uncontrolled pain and suffering for prolonged periods of time, which had the potential to negatively impact his daily activities, rest and sleep. Findings: A review of Resident 1's admission Record, indicated the facility admitted the resident at the end of 2023. Resident 1's multiple diagnoses included cellulitis of left leg (infection affecting the skin and tissue, characterized by pain, swelling, redness, and tenderness), chronic pain syndrome, osteoarthritis of both hips (a progressive disorder of the joints, caused by a gradual loss of cartilage), and osteonecrosis (a chronic condition that…

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 complete and report the results of an investigation of a Resident-to-Resident altercation to the State Survey Agency within 5 working days of the incident for two of three sampled Residents, (Resident 1 and Resident 2). This failure to complete the report investigation had the potential for residents to be subjected to further incidents of abuse. Findings: A review of Resident 1 ' s admission Record, indicated, Resident 1 was admitted to the facility in December 2021, with diagnosis that included schizophrenia (a mental illness that is characterized by disturbances in thought), disorder of psychological development (physical or mental impairment) and major depressive disorder. A review of Resident 1 ' s Brief Interview for Mental Status (BIMS), Resident 1 scored 15 which indicated he had no impairment in cognition. A review of Resident 2 ' s admission Record, indicated, Resident 2 was admitted to the facility in March 2024, with diagnoses that included Alzheimer ' s Disease (a disease characterized by a progressive decline…

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 respect and dignity for one of four sampled residents (Resident 1), when staff did not keep an accurate inventory of Resident 1's property. This failure resulted in the unrecovered loss of Resident 1's personal mobile phone while Resident 1 was residing in the facility. Findings: During a review of Resident 1's admission Record, the admission Record, indicated Resident was admitted in late 2024. A review of Resident 1's Order Summary Report, indicated Resident 1 had multiple diagnoses including multiple fracture of ribs. During an interview on 10/16/24 at 4:44 p.m. with Resident 1's wife, Resident 1's wife stated, Resident 1 was admitted to the facility with his mobile phone in his possession. Resident 1's wife further stated she was able to speak to Resident 1 on his mobile phone while he was residing in the facility. Resident 1's wife further stated Resident 1 was discharged from the facility without his mobile phone and was unable to find his mobile phone after discharge. Resident 1's wife 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 implement the cardiopulmonary resuscitation (CPR, an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) policy for one of three sampled residents (Resident 1), when two certified nursing assistants (CNA 1 and CNA 2) provided CPR to Resident 1 without maintaining a current CPR certification. This failure decreased the facility's potential to provide low quality CPR for residents during emergencies. Findings: A review of Resident 1's admission Record, dated [DATE], indicated Resident 1 was re-admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a chronic mental illness that combines symptoms of schizophrenia and a mood disorder), drug abuse, and diabetes (body's inability to properly regulate blood sugar levels). A review of Resident 1's admission Data Collection and Baseline Care Plan Tool, dated [DATE], indicated Resident 1's Code Status: Attempt Resuscitation - Full…

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 provide adequate monitoring and supervision for one of three sampled residents (Resident 1), when Resident 1 eloped (departed health facility unsupervised and undetected) during a group outdoor walking activity. This failure had the potential to increase Resident 1's risks for experiencing harm while away from the facility unsupervised. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to facility in late 2023 under conservatorship (when a judge appoints another person, a conservator, to manage the affairs and care for another adult), with diagnoses that included bipolar type schizoaffective disorder (illness that can cause hallucinations, delusions, and dramatic moods swings), diabetes (a chronic condition that affects the way the body processes blood sugar), and need for assistance with personal care. A review of Resident 1's Minimum Data Set (MDS: an assessment tool), dated 6/7/24, indicated resident could walk independently and did not use an elopement alarm (device that would alert…

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

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from abuse when he was struck in the face by Resident 2. This failure resulted in Resident 1 sustaining a swollen eye, severe headache and vomiting requiring hospitalization. Findings: A review of Resident 1's (Res 1) admission record indicated he was admitted in May 2024 with diagnosis of schizophrenia (mental illness that affects a person's thoughts, feelings, and behaviors). A review of Resident 2's (Res 2) admission record indicated he was admitted in May 2024 with diagnoses including schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder). A review of Res 1's progress notes, dated 7/7/24 and written by the Licensed Nurse (LN), indicated Res 1 was struck in the face multiple times by Res 2 which resulted in a swollen eye, severe headache, and vomiting. A review of Res 2's progress note, dated 7/7/24 and written by the LN, indicated Res 2 admitted that he struck Res 1. During an interview on 7/17/24 at 9:34…

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 provide safe pharmaceutical services for one of four sampled residents (Resident 1) when the Licensed Nurse left Resident 1's brimonidine eye drops (medication to treat vision loss by lowering pressure) in his room unsupervised. This failure had the potential for abuse or misuse of the medication and the potential for not meeting the resident's therapeutic needs or worsening of their medical conditions. Findings: Resident 1 was admitted to the facility July 2023 with multiple diagnoses which included need for assistance with personal care, primary open-angle glaucoma (eye disease that can cause vision loss) and insomnia due to other mental disorder. A review of Minimum Data Set (MDS, an assessment tool), dated 2/27/24, indicated a BIMS (Brief Interview of Mental Status, a cognitive assessment) of 9, meaning Resident 1 had moderately impaired cognition. During an interview on 4/3/24, at 11:17 a.m., with the Licensed Nurse (LN), the LN stated during the morning medication pass on 2/29/24, she had left Resident 1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain safe smoking practices for 17 residents (Resident 42; 196; 27, 78, 29, 72, 80, 2, 90, 82, 49, 75, 54, 74, 58, 73, and 71) for a census of 93 when: 1. Resident 42 and Resident 196 were in possession of cigarettes and a lighter and were smoking independently prior to the completion of a smoking assessment; 2. Resident 27 smoked without supervision, did not wear a smoking apron, and possessed cigarettes and a lighter; and, 3. Residents 78, 29, 72, 80, 2, 90, 82, 49, 75, 54, 74, 58, 73, and 71 smoked without using a smoking apron per signed consent/policy. These failures had the potential to jeopardize the residents' safety. Findings: 1. A review of Resident 42's admission record indicated she was admitted in 12/23 with diagnoses including tobacco use. A Minimum Data Set (MDS, an assessment tool), dated 1/30/24, indicated Resident 42 had no memory impairment. A review of Resident 42's clinical record included the following documents:…

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 safely store medications for a census of 93 when emergency kits (E-kits) were stored beyond their expiration date and were not replaced in a timely manner. These failure decreased the facility's potential to safely administer medications during emergency situations. Findings During a concurrent observation and interview on 1/30/24 at 1:23 pm with Director of Nursing (DON) at Medication Storage room [ROOM NUMBER], an Antibiotic E-kit had been opened with multiple E-kit logs, dated from the months of September 2023, October 2023, November 2023, December 2023 and January 2024. DON confirmed that the E-kit had been opened and should have been replaced by pharmacy within 72 hours. During a concurrent observation, record review and interview on 1/30/24 at 1:59 p.m. with Licensed Nurse 3 (LN 3) at Medication Storage room [ROOM NUMBER], four E-kits were observed sealed with a blue plastic tie: -Injectable E-kit 1 of 2 was an E-kit log with 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 observation, interview, and record review, the facility failed to ensure medications were labeled and dated correctly for a census of 93. This failure decreased the facility's potential to safely store medications. Findings During a concurrent interview and observation at 1/30/24 at 12:18 p.m. with Licensed Nurse 6 (LN 6) at Medication Cart 1, the following medications were observed: - an unused and unopened multi-dose insulin (a medication to lower blood sugar) vial found with an open date of 1/29/24; and, - a used multi-dose insulin bottle found with an open date of 1/28/24 and a discard date written as 42 days; LN 6 stated that the unopened insulin vial should be in the fridge if it isn't in current use and the discard date should be in 28 days, not 42 days. During a concurrent interview and observation at 1/30/24 at 1:34 p.m., with LN 7 at Medication Cart 2: - a used Fluticasone Propionate/ Salmeterol DISKUS inhalation Powder (a multi-dose inhaler) 500 micrograms (mcg, a unit of measure)/50 mcg was found with no open date or discard date; - a used multi-dose bottle of…

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

Based on observation, interview and record review, the facility failed to store food in a sanitary manner for a census of 93 when: 1. A snack was stored past its use by date; 2. Several food items were opened and not dated with their open date in the walk-in refrigerator and reach-in freezers; 3. The double ovens were observed with burnt, blackened debris on their bottoms; 4. Food items were opened, undated and did not include use by dates in the dry storage area; 5. The ice machine's interior was dirty; and, 6. The floor beneath the ice machine had areas of blackened debris along the bottom of the wall and between the tiles. These failures had the potential to result in foodborne illnesses. Findings: 1. In a concurrent observation and interview, on 1/29/24 beginning at 7:40 a.m., a small plastic bin on a refrigerator shelf contained a slice of buttered white toast in a plastic bag. The label on the bag indicated it had been prepared on 1/25/24. The Assistant Dietary Manager (DMA) stated prepared snacks were good for two days and confirmed the toast was past its use by date 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 protect residents' health information for a census of 93 when tray tickets were disposed of in the trash. This failure decreased the facility's potential to protect residents' personal health information. Findings: In a concurrent observation and interview, on 1/31/24 at 8:50 a.m., Dietary Aide 1 (DA 1) was at the dirty dish area scraping resident trays and stacking dishes for washing. DA 1 was discarding resident meal tickets in the regular trash with food and stated he normally threw the returned meal tickets into the trash. In an interview, on 1/31/24 at 9:05 a.m., the Dietary Manager (DM) stated any returned meal tickets were thrown in the trash. The DM confirmed residents' names and diet orders were on the tickets and agreed it was a Health Insurance Portability and Accountability Act (HIPAA), a law which protects all individually identifiable health information) issue if they were going into the regular trash. A review of the facility's policy titled, Protected Health Information (PHI), Management and…

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

Based on interview and record review, the facility failed to ensure the arbitration agreement for three of 24 sampled residents (Resident 1, Resident 34, and Resident 36) specifically provides for the selection of a neutral arbitrator and convenient venue. This failure decreased the facility's potential to provide residents a neutral and fair arbitration process. Findings: A review of resident admission records indicated Resident 1 and Resident 34 were admitted to the facility in September 2023, and Resident 36 was admitted to the facility in February 2022. During a concurrent interview and record review on 1/31/24 at 2:31 p.m. with Admissions Director (AD), Resident 1's, Resident 34's, and Resident 36's Resident-Facility Arbitration Agreement, dated 8/15/23, 10/6/23, and 9/29/23 consecutively were reviewed. AD confirmed each of the three residents' signed arbitration agreements did not provide for the selection of a neutral arbitrator and convenient venue. During an interview on 1/31/24 at 4:01 p.m. with Administrator (ADM), ADM stated AD should have provided residents 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) accurately reflected one of 24 sampled residents' (Resident 47) status when Resident 47's pressure ulcer was not documented. This failure had the potential for inadequate wound care management. Findings: A review of Resident 47's admission record indicated she was admitted fall of 2021 with diagnoses including paraplegia (inability to voluntarily move the lower parts of the body) and Methicillin Resistant Staphylococcus Aureus (MRSA, an infection that is resistant to some antibiotics) in the wound. A Brief Interview of Mental Status (BIMS, an assessment tool), dated 11/7/2023, revealed no problems with cognition. Resident 47 had the capacity to understand and participate in the plan of care and health care decisions. A document titled Surgical Consult, dated 2/2/2023, signed by the wound doctor indicated a consultation and evaluation of two stage 4 pressure ulcers (skin injury that has full…

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

Based on observation, interview, and record review the facility failed to follow their Baseline Care Planning (BCP, identifies the resident's care needs immediately upon admission) policy and procedure for one of 24 sampled residents (Resident 296) when Resident 296 was not provided a written summary of the baseline care plan. This failure had the potential to limit communication concerning the resident's goals, medications, diet, and therapy. Findings: A review of Resident 296's admission record indicated she was admitted in 1/2024 with diagnoses including type 2 diabetes (a chronic disease that occurs when blood sugar is too high) and obstructive sleep apnea (a disorder in which a person frequently stops breathing during sleep due to an upper airway obstruction). Resident 296 was capable of understanding rights, responsibilities, informed consent, and was able to make her own healthcare decisions. A review of Resident 296's clinical record revealed a BCP, dated 1/26/24, was developed by a nursing staff. In an interview on 1/30/24, at 10:40 a.m., with Resident 296, Resident 296…

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 services according to professional standards of quality for three of 24 sampled residents (Resident 42, Resident 36, and Resident 296 ) when: 1. Resident 42 was not given a medication as ordered by the physician; 2. Oxygen was administered to Resident 36 without a humidifier as indicated in physician's orders; and 3. Resident 296 administered own insulin injection without a physician order. These failures increased the residents' potential to have unmet health needs. Findings: 1. A review of Resident 42's admission record indicated she was admitted in 12/23 with diagnoses including sepsis (a life-threatening response by the body to infection). A Minimum Data Set (MDS, an assessment tool), dated 1/30/24, indicated Resident 42 had no memory impairment. A review of Resident 42's clinical record included the following documents: An Order Audit Report, dated 1/30/24, indicated a physician's order on 12/20/23 for cefazolin sodium (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 observation, interview and record review, the facility failed to provide respiratory care for one of 24 sampled residents (Resident 296) when a Continuous Positive Airway Pressure (CPAP, a machine that uses mild air pressure to keep breathing airways open during sleep) machine had not been applied at bedtime as ordered by the physician. This failure had the potential to negatively impact Resident 296's respirations during sleep. Findings: A review of Resident 296's admission record indicated she was admitted in 1/2024 with diagnoses including obstructive sleep apnea (a disorder in which a person frequently stops breathing during sleep due to an upper airway obstruction) and type 2 diabetes (a chronic disease that occurs when blood sugar is too high). Resident 296 was capable of understanding rights, responsibilities, informed consent and was able to make own healthcare decisions. A physician order dated 1/26/2024 indicated Resident 296 must wear a CPAP machine at bedtime. During a concurrent observation and interview on 1/29/24 at 10:48 a.m., inside Resident 296's room,…

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 food was prepared in a manner to maintain nutritive value for 19 residents receiving a therapeutic diet (foods of altered texure) for a census 93 when foods were prepared approximately 3 hours in advance and held in a 300 degrees Fahrenheit (F, a unit of measurement) oven. This failure had the potential to decrease the nutritive value of the foods being served. Findings: A Diet Order Tally Report, dated 1/31/24, indicated 19 residents received therapeutic diets. In a concurrent observation and interview, on 1/31/24 at 8:41 a.m. the [NAME] (CK) was asked when he prepared the therapeutic diets for lunch and he proceeded to open the oven and stated he had just finished 5 minutes ago. Two ¼ pans of pureed green beans and pureed chopped steak were in the oven along with 1/3 pans of bite-sized green beans, minced and moist green beans, brown rice and minced and moist chopped steak. The CK stated the foods were held in the oven at 300 degrees F until it was closer in time to tray line and then he would turn…

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.

2. A review of Resident 86's admission record indicated he was originally admitted on 12/2023 and readmitted on 1/2024 with diagnoses including type 2 diabetes (a chronic disease that occurs when blood sugar is too high). Makes own health care decisions without memory problems. During a concurrent observation and interview on 1/31/2024, at 7:35 a.m., during breakfast, observed Resident 86's meal tray was served by Certified Nurse Assistant 4 (CNA 4) and confirmed the meal tray consisted of 1 glass of milk, scrambled eggs, a piece of toast and a bowl of oatmeal. A concurrent observation, interview, and record review on 1/31/2024, at 7:40 a.m., with Resident 86, he complained he already requested the kitchen staff not to send oatmeal on his breakfast tray, but the tray still included a bowl of oatmeal. CNA 4 checked Resident 86's meal ticket, verified oatmeal was already written as one of his disliked foods. In a review of Resident 86's meal ticket for breakfast indicated Regular, Heart Healthy with Thin Liquids; Standing Order: 8 oz. whole milk; Dislike: Oatmeal. In an interview, on…

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

Based on observation, interview and record review, the facility failed to ensure trash was properly disposed for a census of 93 when the facility's dumpster lids were left open. This failure had the potential to attract unwanted pests and vermin. Findings: In a concurrent observation and interview, on 1/29/24 at 2:57 p.m., the dumpster located near the side entrance to the facility was observed full of trash with both of its lids left open. The Maintenance Director (MD) confirmed the lids had been left open and should have been closed. A review of the facility's policy titled, Food - Related Garbage and Refuse Disposal, revised 10/17, stipulated, All garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use.

Based on observation, interview, and record review the facility failed to follow infection control practices for one of 24 sampled residents (Resident 47) when the Housekeeper did not apply the required Personal Protective Equipment (PPE, gloves gown and/or goggles/face shield if risk of splash and spray) while cleaning her room. This failure had the potential to spread infection in the facility. Findings: In an observation on 1/29/2024, at 11 a.m., a Housekeeper was observed cleaning inside Resident 47's room, a room on Enhanced Barrier Precaution (EBP, infection control intervention to reduce transmission of resistant organisms) without wearing proper PPE. When asked if she's aware of the sign [EBP] posted outside the said room, Housekeeper quickly apologized and admitted to not wearing the proper PPE which she should have done before entering the room. In an interview on 1/29/2024, at 11:07 a.m., with Licensed Nurse 8 (LN 8), LN 8 confirmed the housekeeper was not wearing the appropriate PPE while cleaning inside Resident 47's room. During an interview on 1/31/2024, at 1 p.m.,…

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

Based on interview and record review, the facility failed to ensure nurse aides received 12 hours of annual in-service which included dementia management and abuse prevention training for a census of 93 when documentation of the nurse aide in-services could not be provided for one of 5 sampled employees. This failure had the potential to affect the quality of care and services provided to the residents. Findings: During a concurrent interview and record review on 1/31/24 at 2:35 p.m., the Director of Staff Development (DSD) confirmed there was no documented dementia hours training and abuse training for Certified Nursing Assistant 3 (CNA 3). Review of the facility's policy titled, In-Service Training, All Staff, revised 8/2022, indicated the required annual in-service training topics were dementia management and resident abuse prevention. Review of the facility's policy titled, In-Service Training, Nurse Aide, revised 8/2022, indicated the annual in-services are no less than 12 hours per employment year.

Based on interview and record review, the facility failed to provide sufficient preparation for discharge for one of four sampled residents (Resident 1), when Resident 1 was sent home without written instructions for medication administration. This failure had the potential to result in incorrect administration of medications and lack of coordination of care after discharge for Resident 1. Findings: Resident 1 was admitted in the fall of 2023 with diagnoses that included perforation of the intestine (hole in the bowel), sepsis (blood poisoning) and atrial fibrillation (abnormal heartbeat). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 10/20/23, the MDS indicated Resident 1 was able to think and reason. During a review of Resident 1's NSG [nursing]: Skilled Charting (NSC), dated 10/31/23, the NSC indicated, Pt. [patient] A&O [alert & oriented] with episodes of forgetfulness. During a review of Resident 1's IDT [interdisciplinary team]: Planned Discharge Summary (IDT), dated 11/1/23, the IDT indicated, Medication Reconciliation, Medications…

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 provide a homelike environment for Resident 1 and Resident 4 when a broken piece of sink linoleum and a pair of discarded gloves were found in the residents' bathroom. This failure had the potential for the residents to be injured, experience an unsanitary environment, and negatively impact residents' highest practicable well-being. Findings: During an observation on 9/18/23 at 11:52 a.m. in room [ROOM NUMBER], an inspection of the bathroom revealed an area of broken linoleum that was separating on the front facing right side of the sink and a pair of used gloves on the floor under the sink. During an interview on 9/18/23 at 1:13 p.m., with the DON, the DON stated that rooms need to be kept clean and maintenance needed to be contacted for repairs in a timely fashion. Upon review of photographic evidence of the damaged area, she stated .that could cause injury to a resident, it could possibly cause skin damage and that could lead to a possible infection.

Based on interview and record review, the facility failed to ensure that the proper medication administration policy was followed when a licensed nurse gave Resident 1 a medication that was taken from another resident's supply. This failure decreased the facility's potential to ensure safe medication administration for Resident 1. During a phone interview on 9/18/23 at 9:58 a.m., with Resident 1's husband, he stated one of the nurses stated he was going to give his wife medication that he took from another resident. During a record review of progress notes, dated 9/9/23 at 1:07 p.m., the health status note indicated on 9/8/23, the pm [after noon] shift nurse was administering meds and mentioned to the resident that one of the meds was borrowed from another resident. During an interview on 9/18/23 at 1:13 p.m. with the DON, the DON stated .that medications should be administered as policy. Medications should not be borrowed from another resident. During a record review of the facility's policy titled Administering Medications, revised December 2012, indicated Medications ordered for…

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