Greenhaven Healthcare Center

Based on observation, interview, and record review, the facility failed to follow proper infection control measures for two of 31 sampled residents (Resident 37 and Resident 157), when:1. Licensed Nurse (LN) 10 did not maintain proper hand hygiene practices during wound care for Resident 37; and2. Two Certified Nurse Assistants (CNAs) did not wear the required personal protective equipment (PPE, protective clothing/gown, gloves, facemasks/face shields designed to protect the wearer from injury or the spread of infection) while providing care to Resident 157 who was on enhanced barrier precaution (EBP, an infection control method).These failures decreased the facility's potential to prevent spreading an infection among vulnerable residents.Findings: 1. A review of Resident 37's admission Record, dated 2/26/26, indicated Resident 37 was admitted to the facility in 2025 with diagnoses including foot ulcer (an open sore) and diabetes (a chronic condition characterized by high blood sugar levels). A review of Resident 37's Medication Review Report, dated 2/26/26, indicated Resident 37…

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 a copy of advance directives was obtained for one of 31 sampled residents (Resident 87), when a copy of Resident 87's advance directive was not available in the facility's medical records.This failure decreased the facility's potential to honor the end-of-life wishes of its residents.Findings:A review of Resident 87's admission Record, dated 2/26/26, indicated Resident 87 was admitted to the facility in January 2026 for 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).A review of Resident 87's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/8/26, indicated Resident 87'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 eight out of 15 with moderate decline in mental capacity.During an interview on 2/23/26 at 10:11 a.m. with Resident 87, Resident 87 was incapable to be…

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 31 sampled residents (Resident 72) was free from abuse, when Resident 91 verbally abused Resident 72 for three nights.This failure decreased the facility's potential to protect Resident 72 from verbal abuse and maintain residents' psychosocial wellbeing.Findings:A review of Resident 72's admission Record, indicated she was admitted to the facility in January 2026 with a diagnosis of obesity (excess body fat that increases the risk of health conditions like heart disease).A review of Resident 72's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 2/6/26, indicated her 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 15 out of 15 with intact memory.A review of Resident 91's admission Record, indicated she was admitted to the facility in January 2026 with a diagnosis of cerebral infarction (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 provide services according to accepted standards of quality for two of six sampled residents (Resident 74 and Resident 148), when: 1. Licensed Nurse (LN) 1 administered Xeljanz (tofacitinib; an immune suppressant medication) to Resident 74 without following the required hazardous drug handling procedures; and 2. LN 1 did not remain with Resident 148 to ensure MiraLAX (a powdered laxative) was taken as prescribed.These failures decreased the facility's potential to prevent hazardous drug exposure, incorrect dosing, wrong ingestion, and adverse effects due to lack of monitoring for residents.Findings: 1. During a medication pass observation on 2/23/26 at 8:28 a.m. on Unit D, LN 1 was observed preparing 13 medications for Resident 74, including Xeljanz without wearing gloves. During an observation on 2/23/26 at 8:40 a.m., LN 1 was observed at Resident 74's beside administering Xeljanz medication with a spoon, without wearing gloves. During a concurrent interview and label review on 2/23/26 at 8:49 a.m. with LN 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.

Based on observation, interview, and record review, the facility failed to ensure ancillary services were provided for one of 31 sampled residents (Resident 44), when Resident 44's eyeglasses prescription was not carried out as ordered by the physician and a hearing consultation was not scheduled promptly.These failures had the potential for a delayed delivery of care to help improve Resident 44's vision and hearing.Findings:A review of Resident 44's admission Record, indicated he was admitted to the facility in June 2025 with diagnoses including severe protein-calorie malnutrition and repeated falls.During a concurrent observation and interview on 2/23/26 at 10:54 a.m. with Resident 44 in his room, Resident 44 spoke in a loud voice and stated he had been requesting from staff to see an eye and ear doctor to improve his vision and hearing. Resident 44 also stated he feared to potentially lose vision in one eye if the consultation will be delayed further.A review of Resident 44's optometry (comprehensive primary eye and vision care) consultation notes, dated 10/5/25, 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 safe environment for one of 31 sampled residents (Resident 3), when floor mats were not placed beside Resident 3's bed as ordered.This failure increased Resident 3's potential to sustain injury after fall.Findings:A review of an admission record indicated Resident 3 was admitted to the facility in November 2025 with a diagnosis of repeated falls related to right hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body).A review of Resident 3's Care Plan, dated 11/18/25, indicated Resident 3 was at risk for falls due to impaired mobility related to cerebrovascular accident (CVA or stroke; loss of blood flow to a part of the brain) with right hemiplegia.A review of Resident 3's Medication Regimen Review (MRR), dated 11/21/25, indicated Resident 3 was at high risk for falls and staff should ensure floor mats were in place on both sides of Resident 3's bed every shift for fall prevention. During observations on 2/25/26 at 8:07 a.m., 11:15 a.m., and 12:10 p.m. in Resident 3'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 failed to provide pain management for one of 31 sampled residents (Resident 12), when Licensed Nurse (LN) 10 did not assess Resident 12's pain and administer pain medication prior to wound care.This failure decreased the facility's potential to provide Resident 12 with an effective pain management.Findings:A review of Resident 12's admission Record, dated 2/26/26, indicated Resident 12 was admitted to the facility in August 2025 with diagnoses including chronic pain (long term pain) and depression (a serious mood disorder characterized by persistent sadness, loss of interest in activities, and low energy).A review of Resident 12's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/31/25, indicated Resident 12 had some memory impairment.During a concurrent observation and interview on 2/25/26 at 2:56 p.m. with Certified Nursing Assistant (CNA) 5, CNA 5 assisted Resident 12 with turning and repositioning before wound care in bed. CNA 5 confirmed Resident 12 was moaning multiple times when…

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 prevent a significant medication error for one resident (Resident 74) of a census of 144, when Resident 74 received 12 doses of insulin (a medication to regulate blood sugar) from a pen used past the manufacturer's opened expiration date. This failure resulted in the administration of expired medication to Resident 74, creating the potential for reduced potency, elevated blood sugar levels, adverse effects, and bacterial contamination.Findings: During a concurrent observation and interview on [DATE] at 9:19 a.m. with Licensed Nurse (LN) 2, Unit D Medication Cart 2 was inspected. One Lantus Solostar (insulin glargine-long-acting insulin) pen assigned to Resident 74 was observed with a hand written date of 1/13 on the prescription label. LN 2 confirmed this was the open date, then calculated 28 days from the open date and stated the insulin pen expired on [DATE]. A review of Resident 74's order report, revised on [DATE], indicated an order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure physician orders were followed in accordance with professional standards of care and per facility policy for Resident 1, when Resident 1's physician ordered a CT scan (medical imaging technique used to obtain detailed internal images of the body) that was not implemented timely. This failure had the potential to negatively affect Resident 1's health and their ability to achieve their highest practical well-being by delaying ordered care. Findings:Resident 1 was admitted to the facility in January 2025 with multiple diagnoses which included traumatic hemorrhage of cerebrum (bleeding within the brain caused by a traumatic injury). A review of Minimum Data Set (MDS, an assessment tool), dated 7/2/25, indicated Resident 1 had severe cognitive impairment. A review of Resident 1's discharge document titled, SNF ORDERS, with faxed date of 1/8/2025, indicated, Lab/Imagining Orders.CT head without contrast in two weeks (around 1/20/2025).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 interview and record review, the facility failed to protect the resident's right to be free from physical abuse for one out of four sampled residents (Resident 1) when Resident 2 punched Resident 1 on his left arm.This failure resulted in Resident 1 not free from physical abuse by Resident 2.Findings:During a review of Resident 1's admission record (AR), indicated Resident 1 was admitted [DATE] with diagnosis including multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord).During a review of Resident's 1 Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 6/7/25, indicated Resident 1 had intact cognition.During a review of Resident 1's Social Services Note dated 7/17/25 at 2:35 p.m., indicated Resident [1] was involved in a resident-to-resident altercation .with another male resident [Resident 2]. Staff observed this encounter.Per Resident [1], he was punched to his left arm.During a review of Resident 2's AR,…

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 interviews, and record review, the facility failed to protect one of seven sampled residents ' (Resident 1) right to be free from physical abuse when Resident 2 struck Resident 1 on her left arm and Resident 2 continued to have access to Resident 1 after the altercation. This failure resulted in Resident 1 being fearful to leave her room or attend activities. Findings: Resident 1 was admitted to the facility in January of 2025 with diagnoses that included difficulty with walking. A review of Resident 1 ' s Minimum Data Set (a standardized assessment tool used in nursing homes), dated 5/5/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident 1 had no mental impairments or deficits. Resident 2 was admitted to the facility in August of 2023 with diagnoses that included decline in cognitive function that interfers with daily life. A review of Resident 2 ' s MDS, dated [DATE], indicated Resident 2 had significant mental and cognitive impairment. 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 observation, interview, and record review, the facility failed to ensure 1 of 5 sampled residents (Resident 2) was protected from physical abuse when Resident 2 was slapped by Resident 1 on the left cheek and head. This failure had the potential to cause injury, fear, and distress to Resident 2. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted to the facility in late 2023 with multiple diagnoses including Alzheimer ' s disease (a brain disorder that leads to memory loss and other thinking difficulties). A review of Resident 1 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/20/25, reflected a 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 of 6 out of 15 which indicated Resident 1 had severe cognitive impairment. A review of Resident 2 ' s admission record indicated Resident 2 was admitted to the facility in late…

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 call light was placed within easy reach for 1 of 5 sampled residents (Resident 3). This failure had the potential for Resident 3 being unable to call for assistance with care needs. Additionally, Resident 3 was assessed to be at high risk for falls. Findings: A review of Resident 3 ' s admission record indicated Resident 3 was admitted to the facility in late 2019 with multiple diagnoses including Alzheimer ' s disease (a brain disorder that leads to memory loss and other thinking difficulties). A review of Resident 3 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 2/10/25, reflected a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of residents) score of 3 out of 15 that indicated Resident 3 had severe cognitive impairment A review of Resident 3 ' s Fall Risk Evaluation dated 2/10/25, indicated Resident 3 ' s score was a 19 that indicated resident was at high risk for falls.…

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 professional standards of care was provided for one of 4 sampled residents (Resident 1) when skin assessment (involves visual and tactile examination of the skin to identify potential issues such as change in skin color) was not conducted prior to resident's discharge. This failure to conduct skin assessment increased the potential for Resident 1 to not receive immediate treatment and prevent further skin breakdown. Findings: A review of the clinical record indicated Resident 1 was initially admitted December of 2023 with diagnoses including chronic venous hypertension with ulcer of bilateral lower extremities (persistent high blood pressure in the veins of both legs leading to open sores on the skin), lymphedema (swelling caused by buildup of fluid in the body's tissues often in the arms and legs), and type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). 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.

Based on observation, interview and record review, the facility failed to ensure a comprehensive assessment, treatment and care was provided in accordance with professional standards of practice for one of three sampled residents (Resident 1), when treatment orders were not obtained, and a nursing care plan was not developed and implemented for a newly sustained skin tear. This failure had the potential for Resident 1 ' s wound to have delayed or compromised healing. Findings: Resident 1 was admitted in the middle of 2024 with diagnoses which included diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), memory impairment and respiratory failure. During a review of Resident 1 ' s Minimum Data Assessment (MDS- a federally mandated resident was totally dependent with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1 ' s physician ' s orders, there was no treatment orders associated with Resident 1 ' s skin tear.…

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 necessary care was provided when the ordered liquid consistency was not followed as ordered by the physician for one of four sampled residents (Resident 1). This failure increased the potential for Resident 1 to experience aspiration (when food or liquid enters the airway and into the lungs by accident). Findings: A review of the admission Record indicated Resident 1 was admitted [DATE] with diagnoses including dysphagia (difficulty swallowing) following cerebral infarction (stroke- disrupted blood flow to the brain causing brain tissue death). A review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool) dated 1/14/25 indicated Resident 1 had a 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 of 7 out of 15 which indicated Resident 1 had severe cognitive impairment. A review of Resident 1's…

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

Based on observation, interview, and record review, the facility failed to ensure the order and care plan for the use of left hand splint was documented in a consistent manner for one of four sampled residents (Resident 1). This failure had the potential for Resident 1 to experience further loss of function on the left hand. Findings: A review of the admission Record indicated Resident 1 was initially admitted May of 2024 with multiple diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on side of the body) following nontraumatic intracerebral hemorrhage (bleeding within the brain without external trauma) affecting left non-dominant side and dementia (a progressive state of decline in mental abilities). A review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool) dated 1/14/25 indicated Resident 1 had a 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 of 7 out of 15 which indicated Resident 1 had severe…

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 accurate accountability of controlled medications (those with high potential for abuse or addiction) for three of five sampled residents (Resident 1, Resident 2, and Resident 3) when: 1. Controlled medications delivered by the pharmacy for Resident 1, Resident 2, and Resident 3 were missing and unaccounted for; and, 2. Two doses of Resident 1's Hydrocodone-Acetaminophen (Norco, a medication used to relieve moderate to severe pain) were missing and unaccounted for. These failures resulted in the facility not having accurate accountability of controlled medications, the potential for abuse or misuse of these medications, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions. Findings: 1. During a review of a report from the facility submitted to the Department, dated 3/21/23, the report indicated, During our ongoing plan of correction audits .dated March 6, 2023, the following findings were made: On 3/13/23 it was reported that we are missing a medication card and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident representative for one of 3 sampled residents (Resident 1) was informed of resident's rights when the admission agreement (a legally binding contract between the facility and a new resident or their representative which outlines the terms and conditions of their stay including the services provided, costs, and the rights and responsibilities of both parties involved) was not signed. This failure had the potential for Resident 1's representative not to receive information inorder to make informed decisions for resident 's care and treatment. Findings: A review of the clinical record indicated Resident 1 was admitted first week of December 2024 with diagnoses including fusion of spine, lumbar region (surgery to connect two or more bones in the lower part of the spine). A Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure on investigating allegations of abuse/mistreatment for one of three sampled residents (Resident 1) when an allegation of mistreatment was not investigated. This failure decreased the facility's potential to protect vulnerable residents and provide a safe environment. Findings: Resident 1 was admitted to the facility on [DATE]. During a review Resident 1's Annual MDS (Minimum Data Set-an assessment tool), dated 11/12/24 described Resident 1 as having clear speech, able to make herself understood and as able to understand others. Resident 1 ' s BIMS (a brief screening that aids in detecting cognitive impairment) score was 14 which indicated she was cognitively intact. The MDS described Resident 1 as having no signs or symptoms of delirium or behavioral symptoms. The MDS for Functional Abilities indicated she required substantial/maximal assistance with mobility from staff. During an interview on 11/16/24 at 9:02 a.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.

4c. A review of Resident 77's admission Record, indicated Resident 77 was admitted to the facility in August 2023 with multiple diagnoses including congestive heart failure (heart does not pump blood as well as it should), diabetes (too much sugar in the blood) and anxiety disorder (mental health disorder characterized by fear or dread out of proportion to the situation). A review of Resident 77's Minimum Data Set (MDS- a federally mandated assessment tool), Cognitive Patterns, dated 8/12/24, indicated Resident 77 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 13 out of 15 that indicated Resident 77 was cognitively intact. During an interview on 11/6/24 at 9:31 a.m. with Resident 77, Resident 77 stated food was cold night before last. A review of Resident 86's admission Record, indicated Resident 86 was admitted to the facility in June 2023 with multiple diagnoses including chronic obstructive pulmonary disease (lung disease that blocks airflow), fibromyalgia (chronic condition that causes pain and tenderness throughout the body) and diabetes. 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 the recipe for the preparation of pureed bread rolls was followed for 25 residents, who had chewing or swallowing difficulties and were on pureed diet (texture-modified, pudding like consistency), when the pureed bread served to residents was observed dry and lumpy. This failure had the potential to result in chewing difficulties and increase residents' risks for choking and/or aspiration (a condition in which food is breathed into the airway). Findings: A review of the facility's document titled, Recipe: Pureed Breads .Sweet Rolls .and Other Bread Products, dated 3/17, directed kitchen staff to measure out the number of portions needed, and then to puree it on low speed adding milk gradually, as needed to achieve the desired consistency. The recipe indicated further, Puree should reach a consistency of apple sauce. During a concurrent interview and observation of the preparation of pureed food on 11/6/24, commencing at 11 a.m., [NAME] 1 stated 25 residents received pureed diet from the kitchen due 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 follow proper infection control practices for four (Resident 349, Resident 97, Resident 79, and Resident 13) of 30 sampled residents when: 1. A Certified Nursing Assistant (CNA) did not don a gown when performing resident care; 2. Resident 97's enteral feeding pump (pump used to deliver liquid nutrition into the digestive tract) and pole (used to hold pump up) had brown crusted material; 3. Resident 79's CPAP (continuous positive airway pressure/a breathing machine designed to increase the air pressure, keeping the airway open when the person breathes) nasal face mask was not cleaned as ordered, and; 4. A BiPAP mask (bilevel positive airway pressure, a machine that delivers air through a mask to help person with breathing) hazy from condensation, was observed inside the plastic bag on the nightstand of Resident 13. These failures had the potential to increase the spread of infection among residents. Findings: 1. Resident 349 was admitted…

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 treat residents with dignity and respect, when staff referred to residents, who required assistance with eating, as feeders. This failure had the risk potential to minimize the residents self-worth and self-esteem. Findings: During an interview on 11/5/24 at 12:20 p.m. in the facility's dining room with Licensed Nurse (LN 3), LN 3 stated she was monitoring the dining room during lunch. LN 3 stated, The residents in the dining room are mostly independent but [we] do have some feeders. During an interview on 11/6/24 at 12:23 p.m. with Certified Nursing Assistant (CNA 9) during delivery of lunch trays to residents, CNA 9 stated, Two trays are for my isolation residents and one is for my feeder. When CNA 9 was asked to verify what she had stated, CNA 9 referred to one resident as my feeder. During an interview on 11/8/24 at 8:50 a.m. with the Director of Nursing (DON), the DON stated the expectation is that residents who require assistance with meals be referred to as assisted diners, not as feeders. 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.

Based on observation, interview, and record review, the facility failed to provide a homelike environment for one of 30 sampled residents (Resident 106) when the wall at the head of the bed was in disrepair. This failure had the potential to negatively impact Resident 106's psychosocial well-being. Findings: A review of the admission Record for Resident 106 indicated diagnoses including history of stroke (a medical event that occurs when blood flow to the brain is disrupted, damaging brain tissue) and depression (a mental health disorder characterized by low mood or loss of interest in activities). A concurrent observation and interview was conducted on 11/5/24 at 10:33 a.m. inside Resident 106's room. There was a large hole on the wall above the bed measuring approximately 12 x 12 inches. Resident 106 stated the wall had been like that since he was admitted . A concurrent observation and interview on 11/5/24 at 3:41 p.m., Licensed Nurse (LN 6) verified there was a large hole in wall at the head of Resident 106's bed. LN 6 stated this should be fixed and it was not a good…

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 one of 30 sampled residents (Resident 14) from abuse when Resident 93 inappropriately touched Resident 14's breast. This failure had the potential to result in Resident 14 experiencing discomfort and feeling unsafe in the facility. Findings: Resident 14 was admitted to the facility in October of 2024 with diagnoses that included: Cerebral infarction (condition that results in reduced blood flow to the brain) due to embolism (blood clot) of left middle cerebral artery, and aphasia (difficulty with speech). A review of Resident 93's admission Record indicated Resident 93 was admitted to the facility in August 2022 with multiple diagnoses including multiple sclerosis (disease causing nerve damage disrupting communication between the brain and the body) and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction. A review of Resident 93's Minimum Data Set (MDS-federally mandated assessment tool), Cognitive Patterns, dated 9/4/24,…

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 30 sampled residents (Resident 79) received treatment and care in accordance with professional standards of practice when the licensed staff did not accurately document the BG (blood glucose is simple sugar- the body's primary source of energy from food) reading and notify the physician of BG readings below 100 as ordered for a total of 9 days. This failure had the potential to result in Resident 79's care being compromised, and necessary medication adjustments not being addressed. Findings: A review of the admission Record for Resident 79 indicated he was admitted with a diagnoses including Type 2 Diabetes Mellitus (a disorder characterized by difficulty in blood sugar control). A Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 8/20/24 indicated Resident 79 was cognitively intact. A review of Resident 79's physician's order dated 11/16/23 indicated, . HOLD [medication] IF BG <100 AND NOTIFY MD [Medical Doctor]. A concurrent interview and record review was conducted on 11/7/24 at…

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

Based on observation, interview, and record review, the facility failed to promote and maintain ability to perform ADL's (Activities of Daily Living) for one of 30 sampled residents (Resident 348) when Resident 348 was not assisted to his wheelchair prior to meals. This failure had the potential to affect Resident 348's oral intake and ability to feed himself. Findings: Resident 348 was admitted to the facility in October of 2024 with diagnoses that included muscle weakness, lack of coordination, and unsteadiness on feet. A review of Resident 348's Minimum Data Set (MDS, an assessment tool), dated 11/4/24, indicated Resident 348 had no cognitive (ability to remember, think, and reason) impairment. A review of Resident 348's Physician Orders, dated 10/25/24, indicated, .PNA [Pneumonia, an infection of the lungs] Prevention: If not in conflict with Activity orders, Patient to be up in chair/wheelchair for all meals and 30 mins [minutes] after meals. During a concurrent observation and interview on 11/6/24 at 7:29 a.m., with Resident 348 and CNA 6 (Certified Nursing Assistant 6),…

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 there was coordination of care for one of 30 sampled residents (Resident 66) when Resident 66's ulcer [shallow lesion, center was yellowish with redness on the border] on the tongue area was not communicated to the physician. This failure increased the potential for Resident 66 to experience pain and discomfort due to lack of coordination with care. Findings: A review of Resident 66's admission Record indicated a diagnoses including encounter for palliative care (focuses on providing relief from pain and other symptoms of a serious illness). A review of Resident 66's clinical records indicated a care plan for open area on left lateral side of tongue dated 9/8/24 and a care plan for Hospice (a program that provides comfort, pain relief, emotional support and help with everyday tasks) services dated 10/11/24. A review of Resident 66's Treatment Administration Record (TAR) for September and October 2024 indicated a clobetasol cream (steroid, reduce redness and swelling) treatment for the tongue ulcer was…

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

Based on observation, interview, and record review, the facility failed to ensure the orders and the care plan for use of a left hand splint were clear and documented in a consistent manner for one of thirty sampled resident's (Resident 97). This failure had the potential for Resident 97's left hand splint to be used incorrectly causing further loss of function. Findings: A review of Resident 97's admission Record indicated Resident 97 was admitted to the facility in December 2022 with diagnosis of hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on side of the body) affecting the left side due to cerebral infarction (stroke- disrupted blood flow to the brain causing brain tissue death). A review of Resident 97's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 9/23/24, indicated Resident 97 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 4 out of 15 that indicated Resident 97 was severely cognitively impaired. A review of Resident 97's Order Summary Report indicated order dated 5/22/24,…

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 document glucometer (machine to measure how much sugar is in the blood) calibration (ensures glucometer is working properly). This failure had the potential for residents' glucose readings to be inaccurate causing errors in residents' blood glucose management. Findings: A review of Unit C, Glucose Machine 2, Quality Control Record Blood Glucose Monitoring System, for September 2024 , indicated only six entries for the month. A review of Unit C, Glucose Machine 3, Quality Control Record Blood Glucose Monitoring System, for September 2024, indicated only six entries for the month. During an interview on 11/6/24 at 8:58 a.m. with Licensed Nurse (LN) 4, reviewed the glucose machine monitoring logs for glucose machine 2 and glucose machine 3 for September 2024. LN 4 confirmed that entries were missing for September 2024 for both machines. LN 4 stated the expectation is that the NOC (night) shift nurse checks the glucose machine calibration every day. LN 4 stated, If not checked we won't be getting the correct…

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 two of 30 sampled residents (Resident 18 and Resident 117) were free of unnecessary psychotropic medications (drugs that affects behavior, mood, thoughts or perception) when residents were prescribed antipsychotic medication without adequate indication and target behaviors. These failures resulted in the use of unnecessary psychotropic medications that could cause adverse consequences. Findings: 1. A review of the admission Record indicated Resident 18 was admitted with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and major depressive disorder (loss of interest in activities causing significant impairment in daily life). A review of Resident 18's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 9/15/24, indicated Resident 18 had severe cognitive impairment, had no verbal or physical behaviors directed toward others, and had no behaviors 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 implement their medication storage policy when expired medications were not removed from a medication cart. These failures had the potential for residents to receive medications with unsafe and reduced potency from being used past their discard date. Findings: A review of the Fluticasone Propionate/Salmeterol (drugs to aide in breathing) manufacturer box indicated to discard the product one month after opening. During a concurrent observation and interview on 11/7/24 at 2:38 p.m., with Licensed Nurse 10 (LN 10), in the A wing of the facility, an expired medication bottle of 4 milligram (mg, a unit of measurement) glucose (sugar) tablets with an expiration date of 10/16/24 and a Fluticasone Propionate/Salmeterol inhaler 250 micrograms (mcg, a unit of measurement)/50 mcg with an opened date of 8/31/24 were found in medication cart one. LN 10 confirmed the glucose tablets were expired and the inhaler was expired with an opened date of 8/31/24. LN 10 indicated medications can lose effectiveness if they are past…

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 resident (Resident 49) of 30 sampled residents' records were accurate when Resident 49's admission assessment note did not reflect Resident 49's health status. This failure had the potential to result in Resident 49 receiving care not suited to their health status. Findings: Resident 49 was admitted to the facility in October of 2024 with diagnoses that included: Infection following a procedure, other surgical site, and Sepsis. A review of Resident 49's admission Nursing Note ([NAME]), dated 11/5/24, indicated, SKIN ASSESSMENT SHOWED OPEN AREA 0.5CM [centimeters, a unit of measurement] X 0.5 TO COCCYX [tailbone] .PICC [peripherally inserted central catheter, a device inserted into the bloodstream to give medications and take blood samples] LINE TO RUA [right upper arm], SURGICAL SITE TO POSTERIOR RT [right] HIP 19.8CM WITH 23 STAPLES. During an observation on 11/6/24 at 12:35 p.m., Resident 49 was lying in his bed wearing a gown that allowed…

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 Quality Assurance and Performance Improvement (QAPI, a data-driven proactive approach to improve quality of care and life for nursing home residents) Committee met with the required members for a census of 134, when the Medical Director (MED) did not attend the QAA meetings. This failure had the potential to negatively impact the quality of care for residents. Findings: A review of the facility's QAPI monthly meeting sign in sheets ranging from 11/2023 to 10/2024 indicated that the MED or their designee were not present during these meetings. During an interview on 11/8/24 at 1:39 p.m., with the Administrator (ADM) and Director of Nursing (DON), the DON stated, The Medical Director doesn't usually make it. The DON confirmed that the MED did not attend the QAPI meeting in October of 2024 or the last QAPI quarter meeting. The ADM indicated that the attendance of the MED is important to help guide health care decisions in the facility. During a review of the facility's policy and procedure (P&P) titled, Quality…

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

Based on observation, interview, and record review, the facility failed to provide a safe environment when a raised round plate was loose with a large center bolt extending above the plate in the center of the floor of the resident hallway. This failure had the potential for residents to trip and fall in the hallway with resulting injury. Findings: During a concurrent observation and interview on 11/5/24 at 3:38 p.m. with Licensed Nurse (LN 12), observed in the center of the floor in D wing hallway an, approximately, 6 inch diameter loose round plate with large bolt extending from the plate. LN 12 pulled up on the plate and the bolt and was able to pull off the plate. Observed drain underneath. LN 12 acknowledged that the plate and bolt are a trip hazard for residents. During a concurrent observation and interview on 11/5/24 at 3:41 p.m. with the Maintenance Assistant (MA), observed the 6 inch loose round plate with large bolt extending from the plate in the center of D wing hallway. The MA stated the drain underneath the plate is used to clean out clogs in the pipes. The MA…

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 adequate monitoring and supervision for one of three sampled residents (Resident 1), when Resident 1 eloped from the facility. This failure had the potential to cause harm to Resident 1. Findings: Resident 1 was admitted Summer of 2023 with diagnoses which included Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and age-related cataracts (a cloudy area in the lens of your eye). During a review of Resident 1's Face Sheet (a document that gives a patient's information at a quick glance), the Face Sheet indicated Resident 1's family member was the Responsible Party (person who is responsible for the patient; can make decisions on their behalf). During a review of Resident 1's Change in Condition (CIC), dated 8/30/24 at 8 a.m., the CIC indicated, .She had an episode of elopement this AM [morning]. She was found next door in the courtyard of the [apartment…

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 for one of three sampled residents (Resident 1) to ensure Resident 1's physician was notified when Resident 1 ' s Blood Glucose (main sugar in the body that gives you energy) was below 70 mg (milligram-dosage)/dl (deciliter-unit of measurement)(normal blood glucose level is 70-100mg/dl), as ordered. This failure had the potential to delay medical care and treatment for Resident 1. Findings: Review of Resident 1's admission Record, indicated she was admitted to the facility on [DATE] with diagnoses that included protein-calorie malnutrition (when a person does not eat sufficient calories and protein), muscle weakness, and diabetes (disease where blood sugar is too high). During a review of Resident 1's admission Minimum Data Set (MDS-an assessment tool), dated 2/15/24, indicated Resident 1 as able to make herself understood and able to understand others. Resident 1's Brief Interview for Mental Status (BIMS- a brief screening that aids in detecting…

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 supervision to ensure safety for one of three sampled residents, (Resident 2) when Resident 1 slapped Resident 2 on the face while both residents were in their wheelchairs at the nurse's station. This failure had the potential to cause Resident 2 physical injury and emotional distress. Findings: A review of Resident 1's clinical records indicated she was admitted to the facility fall of 2019 with multiple diagnoses that included Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks). Her Minimum Data Set (MDS, an assessment tool) indicated she had severe cognitive impairment. A review of the State Agency's records indicated Resident 1 had three previous incidents of alleged altercations with other Residents. A review of Resident 1's care plan indicated, [Resident 1] was involved in a resident to resident altercation on 05/26/2024 .interventions .redirect resident . Resident 1's care plan did not indicate 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 ensure an allegation of abuse was reported to the authorities as required by their abuse policy/procedure and as stipulated by the regulations when a Licensed Nurse (LN 2) failed to report an allegation of Resident 1 being touched inappropriately by Resident 2 as reported to her by the victim. This failure resulted in 4 (four) days delay in investigations and caused Resident 1 to be fearful of living in the facility. Findings: Resident 1 was admitted by the facility in April 2024, with diagnoses which included depression and difficulty walking. A Minimum Data Set (MDS, an assessment tool), dated 4/23/24, contained a Brief Interview for Mental Status (BIMS , tests memory and recall) with a score of 13 out of 15 which indicated Resident 1 was cognitively intact. On 4/24/24, the Department received a report from the facility for an alleged abuse event which occurred on 4/20/24. No initial report of this event was received by the Department. The report indicated that on 4/24/24, Resident 1 alleged Resident 2 .touched me, he…

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 1 of three sampled residents (Resident 1) was treated with dignity and respect when a Certified Nursing Assistant (CNA 1) failed to honor her wish not be changed and re-approach her later. This failure resulted in Resident 1 being accidentally hit on the face by her dirty diaper (incontinent brief) while CNA 1 was providing care to her and had the potential to minimize her dignity and self-esteem. Findings: A review of Resident 1's clinical record indicated Resident 1 was admitted to the facility early 2023 with multiple diagnoses that included dysarthria following cerebral infarction (speech impairment that can occur after a stroke). Her Minimum Data Set (MDS, an assessment tool) indicated she was cognitively intact. A review of Resident 1's NURSE PROGRESS NOTE , effective date 4/19/24, indicated, ON 04/19/24 AT AROUND 0030, RESIDENT WAS NOTED TO BE CRYING OUT LOUD AND CNA WENT IN TO ROOM TO CHECK ON RESIDENT. PER CNA, NOTED…

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 adequate supervision and assistive devices were provided to prevent falls for 1 of 4 sampled residents (Resident 2) when Resident 2 had an unwitnessed fall. This failure resulted in Resident 2 being admitted to the acute care hospital for scratches on left face and left hip and left rib pain. Findings: A review of Resident 2's clinical record indicated, Resident 2 was admitted to the facility fall of 2024 with multiple diagnoses that included, Diabetes Mellitus (uncontrolled blood sugar) and below knee amputation. Resident 2's Minimum Data Set (MDS, an assessment tool) indicated his memory was intact. A review of Resident 2's Order Listing Report indicated, Bilateral bed rails to enable mobility .Order date 4/10/24 . A review of Resident 2's Care Plan indicated the following: The Resident requires the use of side rails to assist in mobility and transfers .Date Initiated: 04/10/2024 .Interventions .Assess and document how the side rails are…

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 issue a written bed hold notice for one resident (Resident 1) out of 3 sampled residents, when Resident 1 was transferred to the hospital on [DATE], 12/19/23, and 12/20/23. These failures had the potential for Resident 1 to be prevented from returning to the facility which could cause emotional and psychological stress. Findings: A review of the admission Record indicated Resident 1 was admitted to the facility in late 2023 with diagnoses including inability to sleep, right and left below knee amputation, and left leg above knee amputation. A review of the eInteract Transfer and Bedhold Form V5, dated 12/12/23, 12/19/23, and 12/20/23, indicated Resident 1 was sent to the emergency room (ER) for evaluation .the resident or Responsible Party (RP) was not issued a written bed hold notice during the time of transfer. During a concurrent interview and record review on 1/17/24 at 3:35 p.m., the Director of Nursing (DON) confirmed there was no documentation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow infection control guidelines for two of five sampled residents (Resident 4 and Resident 5) with confirmed Covid (+) infection (highly contagious respiratory infection), when: 1. Certified Nursing Assistant 2 (CNA 2) did not wear the full required Personal Protective Equipment (PPE) while in Resident 5's isolation room when she delivered his lunch tray; and 2. Occupational Therapist (OT) did not wear the required full PPE while in Resident 4's isolation room when he brought in the wheelchair for the resident's use. These deficient practices had the potential to spread infection and disease among residents, staff, and visitors. Findings: 1.During a review of the clinical record for Resident 5, Resident 5 was last admitted to the facility on [DATE], with diagnoses that included acquired absence of right leg above knee, and acute osteomyelitis (inflammation of the bone). Resident 5 had ineffective breathing pattern; dyspnea (difficult…

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, employee file, and policy review, the facility failed to ensure their policy on background screening was followed for four of five sampled newly hired employees (consisting of Certified Nursing Assistants and Licensed Nurses), for a census of 137, when reference checks and background screening were not consistently done. This failure had the potential to put the residents' health and safety at risk. Findings: During a review of newly hired employee files, four employees had no documented evidence of reference checks being completed and two employees had no documented evidence of having background checks completed. In a concurrent interview and record review with the Administrator (ADM) on 11/2/23 starting at 1:15 p.m., the ADM confirmed four employees had no reference checks and two employees had no background checks prior to being hired. A review of the facility policy titled, Background Screening Investigations revised March 2019, indicated, Our facility conducts employment background screening checks, reference checks and criminal conviction checks on all…

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 locked for a census of 132, when a medication cart was left unlocked and unattended. This failure had the potential for medication misuse and drug diversion. Findings: During an observation in the B-wing hallway on 10/26/23 at 10:59 a.m., the medication cart was left unlocked and unattended. During an interview in the B-wing hallway on 10/26/23 at 11:06 a.m., Licensed Nurse 1 (LN 1) confirmed the medication cart should have been locked when unattended. During an interview on 10/26/23 at 11:46 a.m., the Director of Nursing (DON) confirmed the medications should have been locked when the nurse was not close by. A review of the facility's policy titled, Medication Storage . dated 2007, indicated, Medication rooms, cabinets and medication supplies should remain locked when not in use or attended .

Based on interview and record review, the facility failed to complete training for dementia (loss of memory, language, problem-solving and abstract thinking, with personality change) for a Certified Nursing Assistant (CNA) to assure the resident received the highest practicable mental and physical well-being for one of three sampled residents (Resident 1) when CNA 1 did not have a record of dementia training. This failure had the potential to reduce the mental and physical well-being for Resident 1. Findings: According to the Face Sheet, Resident 1 was admitted to the facility in 2019 with multiple diagnosis including dementia and degeneration of the brain. During a concurrent interview and record review with the Director of Nursing (DON) on 10/26/23 at 12:20 p.m., the DON confirmed there were other residents with dementia in the facility, and there was no dementia training in the record indicating CNA 1 completed the dementia training. The facililty was unable to produce or provide dementia training documentation upon request. A review of the facility's policy titled, Nurse Aide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a safe environment and ensure one of three sampled residents (Resident 1) was free from abuse when Resident 2 kicked Resident 1's wheelchair and yelled at her. This failure resulted in Resident 1's reporting being emotionally abused and had the potential to further affect her psychosocial well-being. Findings: A review of an admission record indicated Resident 1 was admitted to the facility in the summer of 2022 with multiple diagnoses including cerebral infarction (stroke caused by disrupted blood flow to the brain) and diabetes. Resident 1's medical history indicated that the resident had multiple eye disorders related to diabetes which affected her vision. A review of a Minimum Data Set (MDS, an assessment and care planning tool), dated 6/18/23, indicated that Resident 1 scored 11 out of 15 on a cognitive assessment which indicated a moderately impaired cognition. According to the MDS assessment, Resident 1 had no delusions, no memory…

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 101 residents who ate facility prepared meals when: 1. One out of nine cutting boards was found with stain and deep scratches; 2. One out of two electric wall fans was found with gray particles on its blade edges; 3. A package of turkey in the refrigerator, a package of corn and a package of sausage patties (with ice crystals build-up) in the freezer were all found open and exposed to air; 4. A bag of lettuce and a bag of parsley that had changed its original color were in the refrigerator; 5. A box of bacon that was past its safe refrigeration time was in the refrigerator; 6. A bin of brown rice and a bin of thickener were found labeled with only the month and date; 7. A can opener was found with metal blade worn and had a brownish build-up; and 8. One out of two ice machines was found with brownish-blackish build-up around the edges of the cover 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 implement their medication storage policy when: 1a. A medication storage refrigerator was left unlocked and unattended, with the potential for access by unlicensed staff or facility residents. 1b. One medication cart was left unlocked and unattended, with the potential for access by unlicensed staff or facility residents. 2a. Medications requiring storage at room temperature were kept in a medication room without monitoring the room temperature, a thermometer, or a temperature log with the potential for negative impact on potency of the stored medications. 2b. Medications requiring storage in the refrigerator were kept at a temperature lower than the recommended temperature range, with the potential for a negative impact on effectiveness of the medications stored in the refrigerator. 3a. Loose, unlabeled, and undated pills were found in the medication carts, with potential for medication errors. 3b. Pharmaceutical products with shortened expiration dates were found without open date labels, with the potential…

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 staff had the specific competencies of the dietary function when: 1) Maintenance department was unfamiliar with cleaning of ice machines, and 2) Two out of 2 dietary staff were unable to correctly state the sanitizing procedure of manual dish washing. This had the potential of leading to food borne illness for the 101 residents who ate facility prepared meals. Findings: 1) During an interview on 6/6/23 at the ice machine in the hallway leading to unit A, at 11:21 a.m. with Maintenance Staff (MS), he stated that he was responsible for taking care of the ice machines. He stated cleaning was done monthly unless it was needed sooner and showed the antibacterial wipes that were used to clean the ice bin. When asked about the internal cleaning process he admitted he was unsure and proceeded to print out the cleaning instructions. Upon review of the process, he admitted the steps were not always done due to lack of training. The contracted outside vendor equipment technician (OVET) was onsite inspecting 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 maintain the dignity and privacy of 1 of 22 (Resident 360) sampled residents when Resident 360's nephrostomy (a tube inserted into the kidney to drain urine) drainage bag was not covered. This failure had the potential to result in Resident 360 experiencing embarrassment. Findings: A review of Resident 360's Resident Face Sheet indicated he was admitted to the facility in May 2023 with multiple diagnoses including malignant neoplasm (cancerous tumor) of the spinal cord and prostate, chronic kidney disease (kidneys cannot filter the blood as well as they should), and artificial opening of the urinary tract (diverts urine when the normal flow out of the body is blocked). A review of Resident 360's Minimum Data Set (MDS-an assessment tool) Cognitive Patterns, dated 5/30/23, indicated Resident 360 had a Brief Interview for Mental Status (BIMS-tool to assess cognition) score of 12 out of 15 which indicated he was moderately cognitively impaired. A review of Resident 360's MDS Functional Status, dated 5/30/23,…

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 a Significant Change in Status Assessment (SCSA) (part of the MDS, an assessment tool) was completed within 14 days of enrollment in a hospice program for one resident (Resident 34), for a census of 102. This failure had the potential for plan of care not to be updated to meet the current needs of Resident 34. Findings: A review of Resident 34's clinical record indicated a primary diagnosis of encounter for palliative care-Hospice care (a specialized medical care focused on providing relief from pain and other symptoms of a serious illness). Further review of Resident 34's clinical records indicated the following: - a physician order, dated 4/14/23 indicated, ADMIT TO [name of hospice agency] .WITH TERMINAL DX [diagnosis] .; and - a progress note, dated 4/14/23 indicated, [Resident 34] WAS PLACED ON [name of hospice agency] EARLIER THIS SHIFT. [Medical Doctor] NOTIFIED . In a concurrent interview and record review on 6/7/23 at 2:56 p.m., the Minimum Data Set Coordinator (MDSC) confirmed Resident 34 was admitted to…

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

Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a resident assessment tool used to guide care) was accurate for 1 of 22 sampled residents (Resident 26) when the Skin Conditions section did not indicate that Resident 26 had a venous stasis ulcer (wound on the leg caused by damaged veins). This failure had the potential to result in Resident 26 not receiving appropriate care and interventions. Findings: A review of the clinical record indicated Resident 26 was readmitted to the facility mid 2021 with diagnoses including high blood pressure and high blood sugar. A review of Resident 26's MDS for Cognitive Patterns, dated 3/7/23 indicated, he had moderate cognitive impairment. Resident 26's MDS for Skin Conditions, dated 3/7/23, 12/5/22, and 9/4/22, were marked 0 for total number of venous and arterial ulcers present. A review of Resident 26's Skilled Nursing Facility Custodial Rounding Note, dated 1/5/23 indicated .Chronic RLE (Right Lower Extremity) venous stasis wound .Seen by [Name of Hospital] wound RN (Registered Nurse)…

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 comprehensive person-centered care plan for 1 of 22 sampled residents (Resident 1) when she did not have a Care Plan that addressed her hospice needs after being admitted to hospice services. This failure placed the resident at risk for unmet hospice and nursing care needs. Findings: A review of the clinical record indicated Resident 1 was admitted to the facility early 2023 with diagnoses including heart failure and high blood pressure. Her clinical records also indicated she was admitted to hospice services on 5/19/23. Her Minimum Data Set (MDS- an assessment tool) for Significant Change in Status Assessment (SCSA) was done 5/25/23. A review of Resident 1's Comprehensive Care Plan was conducted on 6/9/23. Resident 1's Comprehensive Care plan did not include a Hospice Care Plan to address her Hospice care needs. During a concurrent interview and record review on 6/9/23 at 9:30 a.m., with the Licensed Nurse (LN) 7, the LN 7 verified that Resident 1 did not have a Care Plan for hospice. She stated, typically 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 and interview, the facility failed to ensure services provided met professional standards for one resident (Resident 64) of 22 sampled residents when staff did not use two resident identifiers during medication pass. This failure reduced the facility's potential to prevent medication errors. Findings: A review of Resident 64's face sheet (medical record summarizing basic resident information), dated 6/6/23, indicated, the resident was admitted in summer of 2019 with multiple diagnoses which included malignant neoplasm of the endometrium (cancer in the lining of the uterus), chronic kidney disease (a disease characterized by damaged kidneys unable to filter blood as they should), and Type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). A review of Resident 64's Minimum Data Set (MDS, an assessment tool), dated 3/21/23, indicated resident had no memory problems. During medication pass observation on 6/6/23 at 8:32 a.m., in Resident 64's room, Licensed Nurse (LN 1) was observed giving prescribed medications to Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 22 sampled residents (Resident 50) received treatment and care in accordance with professional standards and practice, when: 1. The physician's orders to notify him of resident's weight gain were not followed consistently; 2. The physician was not informed of Resident 50's refusals to be weighed every morning; 3. Resident 50's refusals of daily weights were not addressed in his personalized at risk for impaired fluid balance care plan; and 4. Nurses performed manual disimpaction (digital evacuation of a fecal mass) without a physician order. These failures had the potential to contribute to Resident 50 being admitted to the hospital with fluid overload (a condition where you have too much fluid volume in your body) and had the potential to put Resident 50's health at risk for injury. Findings: According to the admission records, Resident 50 was admitted to the facility earlier this year with multiple diagnoses, including…

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 prevent 1 of 22 (Resident 357) sampled residents from developing a Stage 3 (full thickness skin loss that extends to the subcutaneous, fat layer) Pressure Ulcer (PU-injury to skin and underlying tissue due to pressure). This failure caused Resident 357 to have a worsening PU with the potential to develop infection or experience pain. Findings: A review of Resident 357's Resident Face Sheet, indicated Resident 357 was admitted to the facility in May 2023 with multiple diagnoses including bilateral osteoarthritis (wearing down of the cartilage at the end of bones causing stiffness and pain) of knees, diabetes (too much sugar in the blood), morbid obesity (excessive body fat), and Stage 2 (an open wound) sacral (area between lower back and tailbone) PU. A review of Resident 357's Minimum Data Set (MDS- an assessment tool) Cognitive Patterns, dated 5/23/23, indicated Resident 357 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out 15 which indicated Resident 357 was…

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

Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% (percent) for two sampled residents (Resident 64, and Resident 57) when: 1. For Resident 64, a licensed staff was stopped from administering a double dose of prescribed cetirizine (a medication used to treat allergy symptoms). 2. For Resident 57, a licensed staff did not follow auxiliary pharmacy label warning to administer diltiazem extended-release capsule (a medication used to treat heart condition) on an empty stomach and administered medication after breakfast. These failures resulted in two errors identified out of 28 opportunities during the observation of medication administration; the facility medication error rate was 7.14 %. Findings: 1. During an observation of medication administration on 6/6/23 at 8:32 a.m., Licensed Nurse (LN 1) prepared and administered Resident 64's medications and she took two tablets of cetirizine 10 mg (unit of mass) into medicine cup instead of one tablet prescribed in the order. LN 1 completed initial count of 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 and interview the facility failed to ensure infection prevention and control practices were followed when: 1. Staff did not perform hand hygiene during medication administration. 2. Staff did not disinfect the blood pressure cuff between use on different residents. These failures had the potential of increased transmission of infections among staff and residents. Findings 1. During observation on the C wing on 6/6/23 at 8:32 a.m., Licensed Nurse (LN 1) administered medications to Resident 64. LN 1 failed to wash or sanitize her hands prior to room entry, after changing gloves, and upon exiting the resident's room. In an interview with the LN 1 on 6/6/23 at 12:30 p.m., LN 1 acknowledged not conducting hand hygiene during medication pass with Resident 64. LN 1 stated that she did not conduct hand hygiene when gloves were removed. A review of the facility's policy, titled, Hand Hygiene Program, revised 6/6/20, indicated, All personnel shall follow established hand hygiene procedures to prevent the spread of infection and disease to other personnel, residents, 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.