Pioneer House

Based on interview and record review, the facility failed to ensure accurate reconciliation of controlled medications for two of 13 sampled residents (Resident 56 and Resident 57) when random controlled medication audits did not reconcile.These failures resulted in the facility not having an accurate accountability of controlled substances and increased the potential for diversion. The controlled medication record for two random residents (Resident 56 and Resident 57) who received as needed controlled medications were requested for review during the survey.During a review of Resident 57's Medication Administration Record (MAR) dated 11/1-12/31/25, Resident 57 had orders for Hydromorphone (opioid analgesic) 4 mg to be given every two hours as needed for pain.During a review of Resident 57's CONTROLLED DRUG RECORD [CDR], [a form that keeps count of the number of narcotics dispensed to a resident], entries dated from 11/30/25-12/2/25, the CDR indicated one tablet of Hydromorphone 4 mg was removed from the medication card (pre-packaged medications dispensed from a pharmacy) on 11/30/25…

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 protect the rights to be free from physical abuse for two of four sampled residents (Resident 2 and Resident 3), when: 1. Resident 1 entered Resident 2's room, touched Resident 2's belongings, ate his food, and swung her arms at Resident 2 when Resident 2 tried to intervene; and2. Resident 1 approached Resident 3 in the dining room and hit her on the back. These failures resulted in Resident 2 and Resident 3 sustaining pain and injury from physical contact and voicing their safety concerns.Findings:1. During a review of Resident 1's admission Record (AR), dated 9/5/25, the AR indicated Resident 1 was admitted to the facility in mid-2025 with diagnoses which included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and dementia with behavioral disturbance (a condition where cognitive decline is accompanied by significant behavioral changes). During a review of Resident 1's Minimum Data Set (MDS, an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews the facility failed to ensure one out of two sampled residents, Resident 1, was provided a therapeutic diet as ordered by the physician. This failure had the potential for Resident 1 to experience malnutrition and weight loss. Findings: A review of Resident 1's admission Record indicate Resident 1 was admitted to the facility on [DATE] with diagnoses which included encephalopathy (a broad term for any brain disease that alters brain function or structure) and dysphagia (difficulty swallowing). A review of Resident 1's Order Summary Report (OSR, physician orders) indicated an order for a regular diet, soft and bite sized texture (foods that are soft, and chopped into bite-sized pieces) with a start date of 2/7/25. During a concurrent observation and interview on 2/18/25 at 12:05 p.m. in Resident 1's room, with Certified Nurse Assistant (CNA) 1, Resident 1's lunch and lunch tray card were observed. Resident 1's tray card indicated mince moist (foods that 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 provide a safe discharge for one of three sampled residents (Resident 1), when Resident 1 was discharged to a room and board facility (a home that offers housing accommodations, may offer meals, but does not provide personal care services) and did not have care needed for activities of daily living (ADL). This failure resulted in Resident 1 living in an unsafe environment that could not meet Resident 1's needs which prompted a transfer to the hospital. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in September 2024 with multiple diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke- disrupted blood flow to the brain causing brain tissue death), right leg above the knee amputation, bipolar disorder (mental health condition causing extreme mood swings that include emotional highs and lows) and…

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

Based on interview and record review, the facility failed to make sure that an inventory of personal belongings sheet was completed, and a copy was given upon admission to one of three sampled residents (Resident 1.) This failure had the potential for the resident ' s personal belongings being lost or stolen. Findings: During a review or Resident 1 ' s admission Record (AR), the AR indicated, Resident 1 was admitted in late 2024 with diagnoses which included anxiety. During a review of Resident 1 ' s Inventory of Personal Effects (IPE – inventory sheet), dated 12/2/24, the IPE did not have the Resident 1 ' s signature on the ' Certification of Receipt ' portion of the document. During a review of Resident 1 ' s closed record, there was no documented evidence that Resident 1 signed the inventory sheet and was given a copy upon admission on the nurse ' s notes or admission record. During a review of Resident 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool) Section C, dated 12/5/24, the MDS indicated, Resident 1 was cognitively intact. During a telephone…

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 two sampled residents (Resident 3 and Resident 2) from abuse, when, Resident 3 was verbally threatened and punched by Resident 1 in the face and neck and Resident 2 experienced multiple episodes of sexual inappropriateness from Resident 1, who had a known history of verbal aggression and sexual inappropriateness. These failures resulted in Resident 3's physical injury and emotional distress and feeling dirty for Resident 2. Findings: A review of the facility's policy titled, Abuse, Neglect, Exploitation, and Misappropriation Program, revised 4/2021, indicated, Residents have the right to be free from abuse .This includes . freedom from . verbal, mental, sexual or physical abuse. According to the admission record, the facility admitted Resident 1 in the fall of 2024 with diagnoses which included multiple fractures of left leg. A review of Resident 1's Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen 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 interviews and record reviews the facility failed follow physician orders for one resident out of five sampled residents (Resident 1) when Resident 1 ' s weight was not measured at admission. This failure had the potential for facility to be unable to recognize if Resident 1 experienced unexpected weight loss. Findings: A review of Resident 1 ' s admission records indicate Resident 1 was admitted to the facility in October 2024 with diagnoses including dysphagia (difficulty swallowing) and severe protein-calorie malnutrition (critical deficiency in protein and calories in the diet). During a review of Resident 1 ' s Order Summary Report (OSR, physician orders), dated 10/31/24, an order for admission weight was noted. During a concurrent interview and record review on 11/26/24 at 4:03 p.m., with the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Nurse Consultant (NC), the following documents were reviewed: 1. Resident 1 ' s OSR, 2. Progress Notes, dated 10/31/24 – 11/17/24 and, 3. Weights and Vitals Summary, dated 10/31/24 – 11/13/24. The ADON,…

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 interviews and record reviews the facility failed to ensure one resident out of five sampled residents (Resident 1), who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene, when Resident 1 did not receive showers as scheduled. This failure had the potential for Resident 1 to experience a decrease in hygiene and psychosocial wellbeing. Findings: A review of Resident 1 ' s admission records indicate Resident 1 was admitted to the facility in October 2024 with diagnoses including cerebral infarction (blood flow to the brain is blocked, causing brain cells to die) and muscle weakness. A review of Resident 1 ' s Order Summary Report (OSR, physician orders), dated 10/31/24, indicated Resident 1 had the capacity to understand and make his own health care decisions. During a review of Resident 1 ' s 48 Hour Baseline Care Plan, (a document that provides person centered instructions for a resident's care), dated 10/31/24, indicated Resident 1 was dependent on staff for grooming and hygiene care, needed…

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 in their original containers and in a safe manner for 16 sampled residents. This failure had the potential for medications to be incorrectly identified and misused. Findings: During a concurrent observation and interview on 11/14/24 at 9:01 a.m. with Licensed Nurse (LN) 3, at Medication Cart 1 (Med Cart 1). LN 3 opened the top drawer to Med Cart 1 where there were three 30 mL (milliliters, a unit of measurement) plastic cups observed, stacked on top of one another, in the top drawer. Each plastic cup had two or more items in it, unlabeled and unidentified. LN 3 confirmed the plastic cups were not labeled and included the following: 1. One plastic cup had one pink pill and one red liquid-gel pill, 2. One plastic cup had two orange-colored pills, 3. One plastic cup had seven red and white liquid-gel pills. LN 3 acknowledged the medications should not be removed from their original packaging; this is a safety concern. During an interview on 11/15/24 at 10:42 a.m. with the Director 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 food was prepared and stored in a safe and sanitary manner for a census of 42 residents who received food prepared from the kitchen, when: 1. Expired half-gallon of milk, opened salad dressing and creamer containers without open dates labeled, and full egg crates without received or expiration dates labeled were found in the kitchen refrigerators; 2. No temperature monitoring logs for resident food freezer section and for the dry storage room; 3. Ice and water dispensers in the dining room were not clean; and, 4. Lids used for covering prepared food on the steam table were stored on top of the unclean oven top. These failures decreased the facility's potential to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Findings: 1. During a concurrent observation and interview on 11/12/24 commencing at 8:39 a.m. with the Dietary Manager (DM) the initial tour of the kitchen was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections when: 1. Housekeeping staff dipped contaminated gloves into mop bucket sanitizing solution; 2. Laundry room did not contain a hand washing station, and laundry room staff did not use gown for handling dirty laundry, did not sanitize equipment after handling dirty laundry, did not perform hand hygiene after glove removal, did not perform hand hygiene between resident room visits, and hung contaminated clothes hangers back on the clean linens cart; 3. Facility unable to provide evidence of timely corrective action following positive legionella tests in the water systems; 4. Licensed Nurse 1 (LN 1) did not perform hand hygiene when going in and out of residents' rooms while passing lunch trays; 5. Certified Nursing Assistant 2 (CNA 2) and CNA 3 did not perform hand hygiene when going in and out 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 interviews and record reviews the facility failed to ensure one out of 16 sampled residents (Resident 21), maintained their right to retain and use personal possessions when staff were aware Resident 21's cell phone was taken without his permission. This failure resulted in the unrecovered loss of Resident 21's personal cell phone. Findings: A review of Resident 21's admission record indicated Resident 21 was admitted to the facility in March 2024 with diagnoses including intracerebral hemorrhage (an emergency condition in which a ruptured blood vessel causes bleeding inside the brain) and hemiplegia (complete paralysis) and hemiparesis (partial paralysis) to the left dominant side. During an interview on 11/13/24 at 10:23 a.m., in Resident 21's room, Resident 21 stated, They took my cellphone away a few months ago because I called 911 a couple of times because the nurse at night wouldn't come help me when I was in pain. When questioned where the cell phone was currently, Resident 21 stated, I don't know. During a concurrent interview and record review on 11/14/24 at 12:25…

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 interviews and record reviews the facility failed to investigate and report an allegation of abuse for one out of 16 sampled residents (Resident 21), when Resident 21 notified a Licensed Nurse (LN) of an allegation of sexual and physical abuse, which included an injury of unknown origin. This failure caused Resident 21 to feel unsafe within the facility. Findings: A review of Resident 21's admission record indicated Resident 21 was admitted to the facility in March 2024 with diagnoses including intracerebral hemorrhage (an emergency condition in which a ruptured blood vessel causes bleeding inside the brain) and hemiplegia (complete paralysis) and hemiparesis (partial paralysis) to the left dominant side. During an interview on 11/13/24 at 10:38 a.m. in Resident 21's room, when asked if Resident 21 had concerns with the way the facility addresses his mood, behaviors, and care planning, Resident 21 stated, I keep telling them [I need help], I'm scared I'm going to die here .the staff don't care about me, they're going to let me die here .the [Social Services Director (SSD)]…

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

Based on observations, interviews, and record reviews the facility failed to ensure one out of 16 sampled residents (Resident 21), was provided with an environment that supported Resident 21's quality of life when Resident 21 received meals in polystyrene containers with plastic utensils. This failure resulted in Resident 21's lack of self-worth, self-esteem, and well-being. Findings: A review of Resident 21's admission record indicated Resident 21 was admitted to the facility in March 2024 with diagnoses including intracerebral hemorrhage (an emergency condition in which a ruptured blood vessel causes bleeding inside the brain) and hemiplegia (complete paralysis) and hemiparesis (partial paralysis) to the left dominant side. During a concurrent observation and interview on 11/14/24 at 12:07 p.m., in Resident 21's room, Resident 21's lunch meal was served in a polystyrene container with plastic utensils. Resident 21 stated, I don't know why [meals are served in polystyrene with plastic utensils], they never told me, but I don't like it. They [staff] don't care about me; I'm going to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure facility corridors had firmly secured handrails for the two out of two facility corridors (Unit A and Unit B corridors). This failure had the potential to result in increased falls and potential for injury to the residents that used the corridors. Findings: A review of Resident 2's clinical record indicated Resident 2 was admitted April of 2024 and had diagnoses that included difficulty in walking. A review of Resident 2's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 4/11/24, indicated Resident 2 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 7 out of 15 which indicated Resident 2 had severely impaired cognition. During an observation on 7/18/24 at 12:56 p.m. of the Unit A corridor, Resident 2 was observed walking back and forth using a walker. There were no secured handrails on either side of the corridor walls. During a concurrent observation and…

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

Based on observation, interview, and record review, the facility failed to ensure two of 44 sampled residents' (Resident 2 and Resident 4), call lights were within reach and easily accessible. This failure placed Resident 2 and Resident 4 at risk of not being able to ask staff for assistance. Findings: Resident 2 was admitted to the facility in late 2023 with diagnoses which included dementia (loss of memory), history of falling and glaucoma (vision loss). Resident 4 was admitted to the facility in early 2024, with diagnoses which included dementia (loss of memory), chronic kidney disease, stage 3 (kidney damage) and hypertension (high blood pressure). During an observation on 4/2/24 at 2 p.m. in Resident 2's and Resident 4's room, the call lights were observed to be bundled up and placed in a black basket above the bedside dresser. During a concurrent observation and interview on 4/2/24 at 2:30 p.m. with Certified Nurse Aide (CNA) 1, in Resident 2's and Resident 4's room, CNA 1 confirmed the call lights were in the basket out of reach of the Residents and stated, We usually put the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was kept free from sexual abuse when a resident (Resident 4) was found in Resident 1's room touching her genital area (private parts). This failure violated Resident 1's right to be free from sexual abuse and had the potential to negatively impact Resident 1's psychosocial well-being. Findings: Resident 1 was admitted in the winter of 2023 with diagnoses that included urinary tract infection and severe morbid obesity (more than 100 pounds over ideal weight). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 12/27/2023, the MDS indicated Resident 1 was cognitively intact (has sufficient judgment). Resident 4 was admitted in the winter of 2024 with diagnoses that included cellulitis (infection of the skin) of left lower limb (foot), and cerebral infarction (stroke, a lack of adequate blood flow to the brain). During a review of Resident 4's MDS, dated [DATE], the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), in a census of 43, was free from abuse when Resident 2 punched him in the face. This failure caused Resident 1 to sustain a nosebleed. Findings: Resident 1 was admitted to the facility in the winter of 2023 with multiple diagnoses which included dementia (impaired memory) and schizophrenia (a mental illness characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 12/22/23, the MDS indicated Resident 1 had severe memory impairment and needed assistance with his activities of daily living During a review of Resident 1's admission - Nursing Assessment [NA], dated 12/22/23, the NA indicated Resident was admitted to the facility .started screaming at staff during assessment, telling staff to get out of his room . The NA had no facial injuries documented.…

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 the review, the facility failed to prevent physical abuse for 2 of 5 (Resident 2, Resident 3) sampled residents when: 1. Resident 1 threw a container of water at Resident 2, hit Resident 2 on the shoulder, and pushed a wheelchair into Resident 2's bed while Resident 2 was in bed; 2. Resident 1 pushed a wheelchair into Resident 3. This failure resulted in physical injury to Resident 1 and Resident 3 and emotional distress to Resident 2. Findings: 1. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility July 2023 with multiple diagnoses including schizophrenia (disorder characterized by thoughts or experiences out of touch with reality and affects ability to think and behave clearly) and Lewy body dementia (brain disorder that leads to problems with thinking and behavior). A review of Resident 1's Minimum Data Set (MDS- an assessment tool), Cognitive Patterns, dated 8/23/23, indicated Resident 1 had a Brief Interview for Mental…

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 report to the Department a physical altercation between two residents (Resident 1 and Resident 3) that caused physical injury to both residents, within the regulatory time frame. This failure had the potential to cause harm to other residents without proper reporting. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility July 2023 with multiple diagnoses including schizophrenia (disorder characterized by thoughts or experiences out of touch with reality and affects ability to think and behave clearly) and Lewy body dementia (brain disorder that leads to problems with thinking and behavior). A review of Resident 1's Minimum Data Set (MDS- an assessment tool), Cognitive Patterns, dated 8/23/23, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 7 out of 15 that indicated he was severely cognitively impaired. A review of Resident 1's Nurse Progress Note, dated 10/29/23 at 2:07 a.m., indicated .[Resident 1] came out to the…

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

Based on interview and record review, the facility failed to provide Social Services (SS) follow up for three days following abuse allegations for 3 of 5 sampled residents (Resident 1, Resident 2, and Resident 3). This failure had the potential for Resident 1, Resident 2, and Resident 3 to not receive competent and sufficient psychosocial support. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility July 2023 with multiple diagnoses including schizophrenia (disorder characterized by thoughts or experiences out of touch with reality and affects ability to think and behave clearly) and Lewy body dementia (brain disorder that leads to problems with thinking and behavior). A review of Resident 1's Minimum Data Set (MDS- an assessment tool), Cognitive Patterns, dated 8/23/23, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 7 out of 15 that indicated he was severely cognitively impaired. A review of Resident 1's Nurse Progress Note, dated 10/21/23, indicated .Resident 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.

Based on observation, interview, and record review, the facility failed to ensure one dietary personnel was competent to carry out the functions of the food and nutrition service when the Dietary Aide (DA) 1 was unable to practice correct hand hygiene practices during dishwashing with the dish machine performed by one person and unable to verbalize the process of manual (3-compartment sink) dishwashing (cross refer to F812, finding number 5). These failures had the potential to cause food borne illness in a potentially compromised population of 42 out of 44 residents who received food from the facility kitchen. Findings: During an initial kitchen tour on 10/9/23, a few observations conducted at 9:47 a.m., 9:51 a.m., and 9:56 a.m., observed the Dietary Aide (DA) 1 washing dishes with dish machine alone by himself. The DA 1 used his same bared hands touching the dirty dishes from the dirty side of dish machine, and then touching the clean dishes from the clean side without any handwashing in between. During a follow-up observation on 10/9/23, at 10:15 a.m., the DA 1 touched the dirty…

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 food was prepared, stored, served, or distributed in accordance with professional standards of food serve safety when: 1. food items with missing or incorrect labeling and dating were found, 2. food items with opened packages were found not covered to prevent cross contamination (the unintentional transfer of bacteria and/or substances from one food to another), 3. food items that were expired were found and available for use, 4. ice machine was not clean located in the dining room, 5. Dietary Aide (DA) 1 was not able to verbalize the process of manual (3-compartment sink) dishwashing, and not practicing handwashing during dishwashing when perform by one person, 6. The food storage racks were not well maintained, and the condenser unit (a unit converts the refrigerant gas back into a liquid) with dripping water on the food in the walk-in refrigerator, 7. Juice dispenser machine was not clean, 8. Staff personal belongings were found…

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 clean environment for the residents and visitors when one garbage dumpster and one food waste bin, located outside the facility, were not secure with the dumpster lids closed. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility. Findings: During the kitchen initial tour observation on 10/9/23, at 11:14 a.m., one dumpster garbage bin and one food waste bin located outside nearby facility kitchen were not securely closed by the lids, and there were bags of trash inside both of bins. A concurrent interview with the Dietary Supervisor (DS), and she confirmed and stated both bins should have the lids completely close to prevent pest and rodents. During an interview with the Registered Dietitian (RD) on 10/11/23, at 3:11 p.m., the RD stated the trash bin and food waste bin should be covered with the lids closely to prevent the pest, rodents, and odor. A review of facility policy and procedure,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the rights for dignity, privacy and homelike environment were promoted for six of 21 sampled residents (Resident 35, Resident 10, Resident 43, Resident 29, Resident 32, and Resident 146) to maintain and enhance the residents' self-esteem and self-worth and incorporate the residents' preferences, and choices, when: 1. Resident 35's finger nails were long with brownish discoloration under the nails with flaking nail polish; 2. The urinary catheter bag was not covered for Resident 10; 3. Window blind sheet was missing in the room of Resident 29; 4. Several items including loose pieces of metal panels, metal boxes and three large framed paintings, and a meal tray not picked up for two days, were found in Resident 32's room; 5. There was no wall clock or television for Resident 10 and Resident 43; and 6. A non-working wall clock was found in Resident 146's room. These failures had the potential to result in negatively impacting the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs and preferences for four of 21 sampled residents (Resident 446, Resident 29, Resident 10, and Resident 43) when: 1. Water was not within reach for Resident 446; 2. Diet request for double protein portions was not provided to Resident 29; 3. The call light device was broken and not working in Resident 10 and Resident 43's room; and 4. There was no wall clock or television in Resident 10 and Resident 43's room. These failures had the potential to result in the residents' not attaining their needs and not maintaining their highest practicable physical, mental, emotional, and psychosocial well-being. Findings: 1. Resident 446 was admitted to the facility in the fall of 2023 with multiple diagnoses which included aphasia (inability to speak), dysphagia (difficulty in swallowing), hemiplegia (paralysis of one side of the body), and pneumonitis (inflammation of the lungs). During a review of 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 interview and record review, the facility failed to develop and implement comprehensive care plans for three out of 21 sampled residents (Resident 300, Resident 1, and Resident 32), when: 1. No care plan developed or implemented on medication for Resident 300's skin rash; 2. No care plan developed or implemented after teeth extraction for Resident 1; and 3. No care plan was developed or implemented for Resident 32's psychotropic medication. These failures had the potential to result in residents not attaining their highest practicable physical, mental and psychosocial well-being.Findings: 1. Resident 300 was admitted to the facility in the fall of 2023 with diagnoses which included brain tumor, difficulty swallowing. During a review of Resident 300's Order Summary Report, (OSR), order start date 9/19/23, the OSR indicated, Triamcinolone Acetonide Cream 0.1% [medication used to treat skin conditions] Apply .every 12 hours as needed for rash . During a review of Resident 300's Nursing Care Plan, (NCP),…

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 physician's orders in accordance with the professional standards of quality care for two of 21 sampled residents (Resident 1 and Resident 13), when: 1. Resident 1 was not weighed daily; and 2. Out of range blood sugar levels were not reported to the physician for Resident 13. These failures had the potential to result in the residents not obtaining their highest practicable well-being. Findings: 1. Resident 1 was admitted in the middle of 2017 with diagnoses which included difficulty in walking, edema (swelling caused by too much fluid trapped in the body's tissues) and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 8/29/23, the MDS indicated Resident 1 had no memory impairment. During a review of Resident 1's Order Summary Report (OSR) dated 10/9/23, the OSR indicated a physician's order for daily weights. During a review of Resident 1's Weight Summary History, the summary indicated 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: 1. Ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when random controlled medication audits of the Medication Administration Record (MAR) and Controlled Drug Record (CDR) for two out of three residents (Residents 2 and 31) did not reconcile to indicate they were given to the residents. 2. Implement a system to accurately document and secure emergency medications (E-Kit) for a census of 44. These failures resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of these medications, the potential for emergency medications to be unavailable when needed, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions. Findings: 1. Resident 31 had a physician's order, dated 10/5/23, for hydromorphone (a medication to treat pain) 2 milligrams (mg, a unit of measurement), one tablet by mouth every four hours as needed for…

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

Based on observation, interview, and record review, the facility had a 10.53% error rate when four medication errors out of 38 opportunities were observed during a medication pass for two of six residents (Residents 31 and 299). This failure resulted in medications not given in accordance with the prescriber's orders and potential to affect the residents' clinical conditions. Findings: During a medication pass observation on 10/9/23 at 8:21 a.m. with Licensed Nurse 1 (LN 1), LN 1 was observed preparing five medications for Resident 31 including one tablet docusate sodium (medication to treat constipation) 100 milligrams (mg, a unit of measurement), one capsule fluoxetine (medication to treat depression) 40 mg, one capsule gabapentin (medication to treat pain) 300 mg, two tablets allopurinol (medication used to treat gout, a form of inflammation in the joints) 100 mg, and miralax (medication used to treat constipation) 17 grams (g, a unit of measurement). A review of Resident 31's medical record indicated physician's orders for aspirin (medication used to prevent blood clots) enteric…

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: 1. Prepared medications were properly stored and labeled, and administered at the time of preparation; 2. Controlled medications were stored in accordance with facility policy and procedure; 3. Expired and discontinued medications were not available for resident use; and 4. Opened biologicals, eye drops, and inhalation solutions were dated once opened, to ensure they were not used beyond the discard date, and appropriately labeled with a pharmacy label or name to correctly identify which resident they were for. The deficient practices had the potential for residents to receive medications with unsafe or reduced potency from being used past their expiration date or improper storage, and diversion or misuse of medications from not being securely stored. Findings: 1. During a medication administration observation on 10/9/23 at 9:07 a.m. with Licensed Nurse 1 (LN 1), two unlabeled medication cups containing white powder were observed on Resident 299's bedside. One of the medication cups indicated groin.…

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

Based on observation, interview, and record review, the facility failed to ensure the menu was followed for the therapeutic diet (a modification of a regular diet, tailored to fit the nutritional needs of a particular person. It could be part of a treatment or medical condition and is normally prescribed by a physician) during the lunch meals on 10/10/23 and 10/11/23 when: 1. Five residents (Resident 1, 6, 9, 14, and 19) with small portion diets who got the incorrect portion size with their meals, 2. Eight residents (Resident 1, 10,14, 21,23,28,31, and 32) with mechanical altered texture diets (a modified texture diet is soft and moist for people who has chewing or swallowing issues), and seven residents (Resident 4, 8, 15, 17, 19, 97, and 446) with puree texture diets (a modified texture diet in a consistency of pudding-like for people who has chewing and/or swallowing difficulties), who received ambrosia (a creamy fruit salad usually with pineapple, mandarin oranges, coconut and marshmallows) instead of mandarin orange as dessert, 3. [NAME] (CK) 1 prepared pureed meat and pureed…

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 4. During a medication administration observation by the Health Facility Evaluator Nurse (HFEN) and the Pharmacy Consultant (PC) on 10/9/23 at 8:21 a.m. with LN 1, LN 1 prepared medications for Resident 299 which included megestrol (medication used to treat loss of appetite and weight loss) 40 milligrams/milliliter (mg/mL, unit of measurement), 10 milliliter (mL, unit of measurement). During preparation, LN 1 drew 10 mL from the bottle with a syringe. After measuring the medication, LN 1 placed the syringe directly on the medication cart. LN 1 then entered Resident 299's room and administered the medication directly into the resident's mouth with the syringe. During an interview on 10/10/23 at 9:53 a.m., with the Director of Nursing (DON), the DON indicated staff were expected to not place a syringe used to measure medication directly on top of the medication cart. The DON stated, The syringe should have only been used to measure the medication, which should have been poured into a medication cup for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an informed consent was obtained when the dose of quetiapine (a medication used to balance hormones that help regulate mood, behaviors, and thoughts) was increased for one of 44 residents (Resident 32). This failure increased the potential for Resident 32's Responsible Party (RP) to not be informed of the risks and benefits of the medication. Findings: During a review of Resident 32's clinical record, the record indicated Resident 32 was admitted to the facility on [DATE] with diagnoses which included depression, schizophrenia (a mental disorder in which people interpret reality abnormally), and dementia (a group of symptoms affecting memory, thinking and social abilities). During a review of Resident 32's clinical record, the record indicated that Resident 32 was discharged from the hospital and readmitted to the facility on [DATE]. During a review of Resident 32's hospital Discharge summary, dated [DATE], the summary indicated Resident 32…

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

Based on observation, interview, and record review, the facility failed to ensure one of 21 sampled resident's (Resident 300) responsible party (RP, person in charge of making decisions) was notified of change in services. This failure had the potential to not allow the responsible party (RP) to appeal the decision in a timely manner. Findings: Resident 300 was admitted to the facility fall of 2023 with diagnoses of brain tumor and difficulty swallowing. Family Member 1 (FM 1) was listed as the RP. During a concurrent observation and interview on 10/11/23 at 10:47 a.m., with Resident 300, Resident 300 was observed lying in bed, wearing only an adult incontinence brief. Resident 300 was asked if he does any exercises, he stated, No. During an interview on 10/11/23 at 10:48 a.m., with the Director of Rehabilitation (DOR), the DOR was asked if Resident 300 was receiving physical therapy. The DOR stated, No, he is not on services [physical or occupational therapy]. His last covered day [last day he received therapy] was 10/8. During an interview on 10/11/23 at 10:57 a.m., with…

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

Based on interview and record review, the facility failed to ensure a transfer notice for one of 21 sampled residents (Resident 26) was sent to the Office of the State Long Term Care Ombudsman (resident advocate) as required when Resident 26 was transferred to the hospital. This failure had the potential to deny Resident 26 access to an advocate who could inform residents of their options and rights. Findings: Resident 26 was admitted to the facility in the fall of 2023 with diagnoses which included sepsis (life-threatening complication of an infection). During a review of Resident 26's Minimum Data Set (MDS, an assessment tool), the MDS indicated Resident 26 discharged from the facility on 9/3/23. During a review of Resident 26's Nursing Progress Notes (NPN), dated 9/3/23, the NPN indicated, The staff nurse called 911 .The resident left the building at 1900 [7 p.m.] via gurney . During an interview on 10/12/23 at 11:23 a.m., with the Medical Records Director (MRD), the MRD was asked to provide a copy of the Notice of Transfer (document which indicated the resident left the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a comprehensive assessment was performed in accordance with regulatory time frames for three of 21 sampled residents (Resident 29, Resident 146 and Resident 300), when the admission MDS (Minimum Data Set, an assessment tool) assessments were not completed. This failure had the potential to result in the residents not attaining their highest practicable physical, mental and psychosocial well-being. Findings: 1. Resident 29 was admitted in late 2023 with diagnoses which included altered mental status, weakness, repeated falls, depression, and diabetes (abnormal blood sugar levels). During a review of Resident 29's MDS, dated [DATE], the MDS indicated the assessment was incomplete, still in progress, and overdue. During a review of Resident 29's Nursing Care Plan (NCP), dated 8/11/23 and revised 10/6/23, the NCP indicated, [Resident 29] at risk for altered nutritional status R/T [related to] .feeling hungry between meals, requesting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a comprehensive assessment was performed in accordance with regulatory time frames for one of 21 sampled residents (Resident 10), when the significant change of condition MDS (Minimum Data Set, an assessment tool) assessment was not completed. This failure had the potential to result in Resident 10 not attaining the highest practicable physical, mental and psychosocial well-being. Findings: Resident 10 was admitted in late 2023 with diagnoses which included memory impairment, prostate cancer, repeated falls, difficulty walking and low back pain. During a review of Resident 10's Nursing Progress Notes (NPN) dated 9/8/23, the NPN indicated, [Resident 10] was running fever of 103.6 .positive for UTI [urinary tract infection] .MD notified with orders to send to hospital. During a review of Resident 10's significant change of condition MDS, dated [DATE], the MDS indicated still in progress, incomplete and 18 days overdue. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a baseline care plan (BCP, document that outlines care needs) for one of 21 sampled residents (Resident 300) within 48 hours of the resident's admission. This failure had the potential to place the resident at risk for unmet care needs. Findings: Resident 300 admitted to the facility in the fall of 2023 with diagnoses which included brain tumor and difficulty swallowing. Family Member 1 (FM 1) was listed as the responsible party. During a review of Resident 300's 48 HOUR BASELINE CARE PLAN, the BCP indicated, admission: [DATE]. The BCP was not completed. The notification of completion, and date reviewed with Responsible Party (person responsible for resident) were blank. During a concurrent interview and record review on 10/11/23 at 2:45 p.m., with the Minimum Data Set Coordinator, the MDSC stated, .The time frame to complete the BCP should be within 48 hours .for sure on [Resident 300] it looks like his baseline care plan was not…

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

Based on observation, interview, and record review, the facility failed to review and revise the comprehensive care plan for one of 21 sampled residents (Resident 13), when the care plan did not reflect the removal of the urinary catheter (a tube used to empty the bladder and collect urine). This failure had the potential to result in Resident 13's receiving outdated care and placing the resident at risk for not meeting her highest practicable well-being. Findings: Resident 13 was admitted to the facility in August 2023 with diagnoses which included retention of urine (difficulty emptying the bladder of urine) and urinary tract infection (UTI, infection of the bladder). During a review of Resident 13's Minimum Data Set (MDS, an assessment tool), dated 9/29/23, the MDS indicated Resident 13 had no memory impairment. During a review of Resident 13's Order Summary Report (OSR) dated 9/22/23, the OSR order indicated an antibiotic (a medication to treat infection) to be given with an end date of 9/27/23, and another order to remove Resident 13's urinary catheter. During a concurrent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure orders were followed for three of 21 sampled residents (Resident 15, Resident 298, and Resident 300) when thin liquids were served instead of thickened liquids (beverage that is specifically designed for people who have difficulty swallowing; helps prevent choking by moving slower than thin liquids). These failures had the potential to increase the risk of choking. Findings: Resident 15 admitted to the facility late 2022 with diagnoses that included lung cancer, stroke and weakness. During a review of Resident 15's Minimum Data Set (MDS, an assessment tool), dated 3/26/23, the MDS indicated Resident 15 had a mechanically altered diet (diet that required a change in texture or liquids). During a review of Resident 15's Order Summary Report (OSR), order date 6/26/23, the OSR indicated, .Puree textures [food that is ground into smooth pudding texture], Nectar Thick Consistency [liquid comparable to heavy syrup consistency]. During a…

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

Based on observation, interview, and record review, the facility failed to properly apply bed rails for one of 21 sampled residents (Resident 300), when Resident 300 did not have a side rail assessment, risk for entrapment assessment or informed consent for the use of the two 1/2 bed rails. This failure had the potential to cause Resident 300 restricted exiting from the bed, increased risk of injury, increased depression, and entrapment. Findings: Resident 300 admitted to the facility in the fall of 2023 with diagnoses which included brain tumor. During a review of Resident 300's document titled, SIDE RAIL ASSESSMENT, effective date 9/20/23, the contents of the assessment had not been completed. The assessment was blank. During a concurrent observation and interview on 10/11/23 at 3:59 p.m., with the Physical Therapy Assistant (PTA 1) 1, in Resident 300's room, PTA 1 confirmed Resident 300 had two half side rails on his bed. During a concurrent interview and record review on 10/12/23 at 11:31 a.m., with the Director of Nursing (DON), the DON was asked about the process for placing…

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 pharmacist identified an irregularity for an antipsychotic (medication used to treat hallucinations [seeing or hearing things that are not there] and delusions [fixed beliefs with no basis in reality] medication during the monthly drug regimen review for one of 21 sampled residents (Resident 32). This failure had the potential for Resident 32 to receive unnecessary medication, or inappropriate medication dosage, which had potential for increased risk and exposure to side effects such as sedation, memory loss, falls and abnormal involuntary movements. Findings: During a review of Resident 32's clinical record, the record indicated that Resident 32 was admitted to the facility on [DATE] with multiple diagnoses which included depression, schizophrenia (a mental disorder in which people interpret reality abnormally), and dementia (a group of symptoms affecting memory, thinking and social abilities). During a record review of Resident 32's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 21 sampled residents (Resident 32) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 32's antipsychotic was increased without documented clinical rationale and was given in excess for the indication for use. This failure resulted in unnecessary medication for Resident 32, which had the potential for increased risk and exposure of side effects associated with psychotropic medications such as sedation, memory loss, falls and abnormal involuntary movements. Findings: During a review of Resident 32's clinical record, the record indicated Resident 32 was admitted to the facility on [DATE] with multiple diagnoses which included depression, schizophrenia (a mental disorder in which people interpret reality abnormally), and dementia (a group of symptoms affecting memory, thinking and social abilities). During a record 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 food of appropriate nutritive content was provided for one of 21 sampled residents (Resident 29), when the resident did not receive and consume food as prescribed by the physician. This failure had the potential to result in the resident not attaining the treatment and plan of care in accordance with his goals and preferences. Findings: Resident 29 was admitted in late 2023 with diagnoses which included altered mental status, weakness, repeated falls, depression, and diabetes (abnormal blood sugar levels). During a review of Resident 29's MDS, dated [DATE], the MDS indicated Resident 29 had memory impairment and had no swallowing problems. During a review of Resident 29's Nursing Care Plan (NCP), dated 8/11/23 and revised 10/6/23, the NCP indicated, [Resident 29] at risk for altered nutritional status R/T [related to] .feeling hungry between meals, requesting more food .Diet as ordered-Double protein portions with meals. During a…

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

Based on observation, and interview, the facility failed to ensure essential equipment was working for two of 21 sampled residents (Resident 10 and Resident 43), when the residents' call light button devices did not work. This failure had the potential to result in the residents not being able to ask staff for assistance. Findings: During a review of the facility's Work History Report (WHR) for 9/23, the WHR indicated, Nurse Call System Test: Conduct a test of the nurse call system .Marked done on-time .on 9/5/23. During a review of the facility's Maintenance Request Log (MRL) for 9/12/23 to 10/10/23, the MRL indicated a call light device repair request on 10/9/23. During a concurrent observation and interview on 10/9/23 at 8:57 a.m., Resident 10 and Resident 43 were both in bed having breakfast, both awake and alert and both verbally responsive. Resident 10 stated, These call lights, these things don't work .I turn it on and they don't respond. Resident 43 joined the conversation, and stated, [Resident 10] is right. I have turned on this call light, but I guess it is broken .I have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, sanitary, functional and comfortable homelike environment for three of 21 sample residents (Resident 32, Resident 10 and Resident 43), when: 1. Several items including loose pieces of metal panels, metal boxes and large framed paintings, and a meal tray not picked up for two days, were found in Resident 32's room; 2. The call light device was broken and not working in Resident 10 and Resident 43's room; These failures had the potential to result in the residents not attaining their highest practicable physical, mental and psychosocial well-being. Findings: 1. Resident 32 was admitted in the middle of 2023 with diagnoses which included memory impairment, infection, bone fracture, difficulty walking, and depression. During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32 had severe memory impairment and needed moderate assistance with activities of daily living (ADLs). During a review of Resident…

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

Based on observation, interview and record review, the facility failed to provide safety and supervision for one of three sampled residents (Resident 1), when the resident walked out of the building, seen and not prevented by staff, and was found unattended and unsupervised four blocks away from the facility. This failure had the potential to result in accidents, falls and injury. Findings: Resident 1 was admitted in the middle of 2023 with diagnoses which included stroke, altered mental status (change in mental functioning), dementia (cognitive/memory impairment), and difficulty walking. During a review of Resident 1's Order Summary Report (OSR), dated 7/17/23, the OSR indicated, [Resident 1] (DOES NOT) have the capacity to understand choices and make medical decisions. During a review of Resident 1's Nursing Care Plan (NCP), dated 8/16/23, the NCP indicated, Cognitive Loss R/T [related to] .Dementia Manifested by: Compromised short term memory .Compromised Long term memory Impaired capacity to make decisions .Keep environment free of hazards. During a review of Resident 1's NCP,…

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 equipment in safe operating condition when one of three sampled residents (Resident 1) had a call light (a device used to request assistance from facility staff) that did not light outside of the room indicating Resident 1 was calling for help. This failure had the potential for Resident 1's needs not being met and to negatively impact his physical and psychosocial well-being. Findings: Resident 1 was admitted to the facility in the summer of 2023 with diagnoses that included fracture of the neck (broken neck) and difficulty in walking. During a concurrent observation and interview on 8/21/23 at 2 p.m. with Resident 1, outside of his room, Resident 1 stated the light above the door did not go on when Resident 1 pushed the call light at the bedside. Resident 1 went on to say it has been like this for several days. The call light at the bedside was pushed and the light above the door outside Resident 1's room did not come on. During a concurrent observation and interview on 8/21/23 at 2:22 p.m. with…

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