Hillcrest Heights Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident safety for one of three residents (Resident 50), identified as requiring a smoking apron while smoking, when reviewed for accidents. This failure had the potential for Resident 50's clothing to catch fire when smoking. Findings: Resident 50 was admitted to the facility on [DATE], with diagnoses which included dementia (progressive memory loss), per the facility's admission Record. An observation was conducted of Resident 50 on 1/6/25 at 10:10 A.M. Resident 50 was sitting outside in the smoking area with four other resident's, including a smoking monitor (a person who supervises smoking residents and hands-out smoking material). Resident 50 was wearing a protective smoking apron and holding a cigarette in his right hand. An observation was conducted of Resident 50 on 1/7/24 at 8:10 A.M. Resident 50 was outside smoking with three other residents and a smoking monitor was present. Resident 50 was not wearing a protective…

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 the posted menu. In addition, two of 88 residents (Resident 32 and 86) did not receive a fortified (foods with nutrients added to them), meal as ordered, when reviewed for nutritional needs. This failure had the potential for residents' nutritional needs to not be met. Findings: A lunch tray line observation was conducted in the kitchen on 1/8/25 at 12:10 P.M. The lunch meal consisted of oven crisp fish, sweet potato fries or brown rice, seasoned carrots, wheat roll, and cranberry crunch bar for dessert. 1. An observation was conducted on 1/8/25 at 1:23 P.M., during lunch tray line service in the kitchen. Some lunch trays contained white rice, in lieu of the sweet potato fries. The posted daily menu listed brown rice or sweet potato fries as being served with the fish. The cook was questioned about the white rice and went to view the posted menu. The cook stated It does indeed say brown rice. The cook stated, I did not look at it…

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

Based on interview and record review, the facility failed to develop a comprehensive care plan for one of two residents (Resident 1). This failure had the potential to cause psychosocial harm because Resident 1 was unable to understand instructions and explanations of treatments and care that was being given by the facility staff. Findings: On 11/7/24 at 10:30 A.M. Resident 1 was interviewed with the assistance of a translator, (Resident 1 communicates primarily in Spanish). Resident 1 stated she had used the call light to ask for assistance when using a beside commode. Resident 1 stated she was unable to communicate in English with CNA 1, who had answered her call light to provide assistance. Resident 1 explained she was not able to use her hands to care for herself and was not able to communicate this in English to CNA 1. Resident 1 stated CNA 1 did not seem to understand her and started to shake the bedside commode and continued to give directions to Resident 1 in English. Resident 1 stated she was unsure about CNA 1's instructions. Certified Nursing Assistant 2 was interviewed…

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 thoroughly investigate an allegation of missing money for one of three residents (Resident 1) reviewed for Resident Rights under Grievances. As a result, Resident 1 ' s grievance was not promptly resolved and there was limited documentation to prove a thoughtful, meaningful investigation was conducted. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (weakness on one side of the body) following cerebral infarct (stroke) affecting the left non-dominant side, per the facility ' s admission Record. An observation and interview was conducted with Resident 1 on 10/16/24 at 11:50 A.M., within the resident ' s room. Resident 1 was dressed, groomed, and sitting in a self-propelling wheelchair. Also observed in his room was a walker with an adjustable seat, next to the bed. Resident 1 stated about two months ago, he realized he would need to sell his truck, since he could no longer afford 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 update the care plan for one of three residents (Resident 1) reviewed for falls. As a result, Resident 1 had the potential to have further incidences of falls and/or injuries. Findings: A record review conducted on 9/23/24 indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included repeated falls, dementia (a condition that causes forgetfulness, confusion and memory loss), and polyneuropathy (a disease which causes weakness, numbness and pain). A review of the Progress Note dated 8/23/24 at 10 A.M. indicated Resident 1 had an unwitnessed fall on 8/22/24. A review Resident 1 ' s Progress Note dated 8/29/24 at 10:10 A.M. indicated Resident 1 had an unwitnessed fall on 8/27/24. On 9/23/24 at 12:55 P.M., a concurrent interview and record review was conducted with the Assistant Director of Nursing (ADON). The ADON stated the Interdisciplinary Team (IDT) determined the root cause of the fall on 8/22/24 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 notify residents and/or the resident representatives when their care plans and physician ' s orders were updated to reflect exposure to Legionella bacteria (bacteria causing a serious lung disease) for three of three sampled residents (Resident 1, Resident 2 and Resident 3). As a result, residents and/or the resident representatives were not aware of the risks involved in being exposed to Legionella bacteria. In addition, the residents and/or the resident representatives were not involved in their plan of care. Findings: On 2/6/24, an unannounced onsite visit at the facility was conducted related to a reported facility ' s water testing positive for Legionella bacteria. During an interview and joint observation on 2/6/24, at 9:06 A.M. with the Assistant Director of Nursing (ADON), a sink at the nurse ' s station had a sign posted which indicated the sink was out of order. According to the ADON, the water from the sink tested positive 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 observations, interviews and record reviews, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when: 1. The [NAME] (CK) 1 did not perform hand hygiene consistently during food preparation, 2. The Dietary Aide (DA) crossed over from dirty station to clean station while working in the dishwashing station, and 3. [NAME] (CK) 1 and the Dietary Assistant Manager (DAM) were unable to verbalize the cool down process. These failures had the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne pathogens to come in contact with the residents' food and may cause food borne illness to the residents. The facility's census was 91. Findings: 1. On 1/30/24 at 10:19 A.M., an observation and an interview of CK 1 was conducted. CK 1 put on a pair of gloves, did not perform hand hygiene. CK 1 put two ladle full of hot butter to the milk, added some water, then poured the mixture into the mixer. CK 1 stated he was preparing for mashed potato. CK 1 added…

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 notify the physician regarding a significant weight loss for one of two sampled residents reviewed for nutrition. (Resident 69) This deficient practice had the potential to delay necessary care and services to prevent Resident 69 to have further weight loss. Findings: Resident 69 was re-admitted to the facility on [DATE] with diagnoses including chronic kidney disease according to the facility's admission Record. During an observation on 1/30/24, at 8:32 A.M., Resident 69 was in bed with unfinished food on her breakfast tray. Resident 69 stated she did not feel well and covered herself with a blanket. During an interview on 1/30/24, at 3:41 P.M. with Certified Nurse Assistant (CNA) 31, CNA 31 stated Resident 69 was independent with eating, but only ate less than 50% of her meals. CNA 31 stated Resident 69's family brought in bottles of a nutritional supplement and water. On 1/31/24 at 8:30 A.M., Resident 69 was observed in bed with a full…

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

Based on observation, interview, and record review, the facility failed to provide a clean fan for Resident (5) to use. In addition, the facility failed to provide a homelike environment for one of two sampled residents (5) reviewed for homelike environment whose room had bubbling in the ceiling surface. As a result, Resident 5 did not feel comfortable with using a dirty fan or looking at a ceiling in need of repair. Findings: During a review of Resident 5's admission Record dated 8/20/18, the admission Record indicated Resident 5 was admitted to the facility from another nursing facility with diagnoses which included lung disease. During a review of Resident 5's history and physical (H&P) dated 11/19/19, the H&P indicated Resident 5 had the capacity to understand and make decisions. a. During an observation and interview with Resident 5 in her room on 1/29/24 at 10:16 A.M., Resident 5 was lying in bed, watching a movie. A standing fan was turned on with lint and brown substance (dust) in the fan blades and the blade guard. Resident 5 stated, Yes, I saw that, it was gross. No one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure a resident's right to be free from abuse when Resident 17 wandered into Resident 78's room. As a result, Resident 78 was punched on the right upper chest by Resident 17. FINDINGS: Resident 78 was admitted to the facility on [DATE]. The resident's diagnoses included but is not limited to chronic pain, falls and depression. A review of Resident 78's Minimum Data Set (MDS- an assessment tool), dated 12/26/23, indicated Resident 78's mental cognition, to understand and make herself understood. A review of Resident 78's History and Physical (H and P - a physician's assessment and examination of the resident), dated 12/22/23, indicated the resident has the capacity to understand and make her own decisions. Resident 17 was originally admitted to the facility on [DATE] with a recent re-admission date of 12/30/23. Resident 17's diagnoses include but is not limited to dementia (impaired ability to remember, think, or make decisions), falls 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 submit a PASARR Level 1 (Preadmission Screening and Resident Review- a federally required document to ensure residents are appropriately placed) when one resident, Resident 17, received a new mental health diagnosis while living in the facility. This failure resulted in Resident 17's mental health needs potentially being unmet. Findings: A review of the facility's admission Record indicated Resident's 17's diagnoses included other psychotic disorder not due to substance or known psychological condition (severe mental health disorder that causes abnormal thinking and perceptions not caused by drugs). Resident 17's original admission date was 5/19/2016. On 1/30/24 at 11:06 A.M., an interview and concurrent record review were conducted with the Case Manager (CM). The CM stated a new PASARR Level 1 was not completed after Resident 17 received a new psychiatric (mental illness) diagnosis. The CM stated the Minimum Data Set (MDS- ) nurse was responsible for updating the PASARR Level 1 for residents with a new mental health…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review Level 1 (PASRR-- a federal requirement to prevent individuals with mental illness [MI], developmental disability [DD], intellectual disability [ID], or related conditions from being inappropriately placed in nursing homes for long term care) was accurately completed for one of two residents reviewed. (Resident 79) This failure resulted in the resident to not be appropriately evaluated through the PASARR process and had the potential for the facility to not be aware of possible services needed to address Resident 79's mental illness. Findings: Resident 79 was admitted to the facility on [DATE] according to the facility's admission Record. Resident 79's psychiatric assessment dated [DATE] indicated diagnoses including bipolar disorder (a mental illness causing intense mood swings from one extreme to another) and schizoaffective disorder (a mental health disorder with combination 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 comprehensive resident-centered care plans were developed for two of 25 sampled residents reviewed for care plans: 1. Resident 17 did not have a care plan to address his behavior of going into other residents' rooms. 2. Resident 79 did not have a care plan to address Resident 79's diagnosis of PTSD (post-traumatic stress disorder- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Cross reference F 699. These failures could potentially affect residents not receiving the proper treatment and care. This includes protection of other residents from Resident 17 and the prevention of potential triggers that will cause re-traumatization for resident 79. The facility did not ensure a care plan was developed for 2 residents related to PTSD and wandering. Findings: Resident 17 was originally admitted to the facility on [DATE] with a recent re-admission date of 12/30/23. Resident 17's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain a resident's range of motion (ROM-how far or stretch a part of body that can be moved around a joint) for one of two residents reviewed for activities of daily living (ADL-bathing or showering, dressing, getting in and out of bed or a chair, walking, toileting and eating). (Resident 48) This failure resulted in Resident 48 to have contractures (shortening of muscles and tendons, often leading to permanent deformity and stiffening of joints) of the left hand and left elbow. Findings: Resident 48 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebrovascular disease (group of conditions affecting blood flow and blood vessels in the brain) affecting left dominant (left handed) side according to the facility's admission Record. An observation and interview was conducted with Resident 48…

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 nail care to three of nine sampled residents (5, 14 and 75), reviewed for Activities of Daily Living (ADL, activities related to personal care). As a result, Resident 5, Resident 14, and Resident 75's health and wellbeing were at risk. Findings: a. During a review of Resident 5's admission Record dated 8/20/18, the admission Record indicated Resident 5 was admitted to the facility from another nursing facility with diagnoses which included lung disease and needed assistance with personal care. During a review of Resident 5's history and physical (H&P) dated 11/19/19, the H&P indicated Resident 5 had the capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS - an assessment tool), dated 11/7/23, the MDS indicated Resident 5's brief interview for mental status (BIMS, ability to recall) score was 2, which meant Resident 2's cognition was severely impaired. The functional abilities section 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 oxygen (O2) was administered per physician's order for one of two sampled residents (1) reviewed for respiratory therapy. This failure had the potential for Resident 1 to develop oxygen toxicity. Findings: During a review of Resident 1's admission Record dated 10/31/18, the admission Record indicated Resident 1 was readmitted to the facility from acute care hospital with diagnoses which included respiratory failure. During a review of Resident 1's history and physical (H&P) dated 6/28/23, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During an observation of Resident 1 in her room on 1/29/24 at 10:40 A.M., Resident 1 was lying in bed, and did not respond when her name was called. Resident 1 wore a nasal cannula (tubing) connected to an oxygen concentrator (machine that delivers oxygen). The concentrator flow meter was set at 3 - 3.5 Liters per minute (LPM). The oxygen concentrator was observed 10 times on 1/29/24 through 1/30/24. Resident 1's O2 concentrator…

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 identify one of two residents reviewed for Trauma Informed Care (TIC - an intervention and organization approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health), received care and services in accordance with professional standards when Resident 79's PTSD (post-traumatic stress disorder- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) was not identified and addressed by the healthcare providers. This failure resulted in the facility's inability to identify possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past traumatic experience). Findings: Resident 79 was admitted to the facility on [DATE] with diagnoses including PTSD according to the facility's admission Record. During observation and interview with Resident 79 on 1/30/24, 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 provide a routine dental hygiene appointment for one resident, Resident 11. This failure resulted in Resident 11's dental needs being unmet. Findings: A review of the facility's admission Record indicated Resident 11 had diagnoses including muscular dystrophy (a condition marked by progressive weakening of the muscles) and need for personal care. On 01/29/24 at 10:16 A.M., an observation of Resident 11's teeth was made. Resident 11's teeth had visible discoloration and her gums were reddened. Resident 11 stated, I have not seen a dentist in a long time. On 1/31/24 at 1:35 P.M., the Director of Nursing (DON) stated the CM had the information regarding dental appointments. On 2/1/24 at 3:12 P.M., an interview and concurrent record review were conducted with the Case Manager (CM). The CM stated a Dental Progress Note dated 9/12/23 by Medical Doctor (MD) 11 indicated, Patient overdue for hygiene. A review of a Progress Note dated 1/31/24 by MD 11 indicated, There is evidence of coronal loss (enamel on the exposed…

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.

The facility failed to follow infection control practices when a Licensed Nurse (LN) 1, did not consistently perform hand hygiene during wound treatment for one resident. This failure had the potential to spread germs and placed residents at risk for infections. During a review of Resident 1's admission Record dated 10/31/18, the admission Record indicated Resident 1 was readmitted to the facility from acute care hospital with diagnoses which included stage four pressure ulcer (a bedsore affective muscle and bone). During a review of Resident 1's history and physical (H&P) dated 6/28/23, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During an observation of Resident 1 in her room on 1/29/24 at 10:40 A.M., Resident 1 was lying in bed, and did not respond when her name was called. On 1/30/24 at 3:24 P.M. an observation of a wound treatment performed by Licensed Nurse (LN) 1 on Resident 1's tailbone. LN 1 prepared supplies and placed them in a small tray. LN 1 asked assistance from Certified Nursing Assistant (CNA) 3. LN 1 brought the supplies…

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

Based on interview and record review the facility failed to monitor and re-evaluate antibiotic therapy prescribed for one resident, Resident 251. This failure had the potential for Resident 251 to receive the wrong antibiotic and or to develop antibiotic resistance. Findings: A review of the facility's admission Record indicated Resident 251 had a diagnosis of abscess of mid-back (a collection of pus). On 2/1/24 at 9:06 A.M., an interview and concurrent record review were conducted with the Infection Preventionist (IP) who stated (Resident 251) has had a purulent wound on his back and has been on Bactrim (an antibiotic most commonly used for treatment of urinary tract infections) for an extended time. No wound culture has been done here. It's important to make sure the antibiotic is correct for the organism to kill it fully and prevent resistance. No Infectious Diseases consultation has been done. The IP stated no organisms were identified for Resident 251's skin infection. The IP further stated he did not know the facility's policy for culturing skin infections. A review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to arrange transportation for 1 of 2 sampled residents (1) who should receive a hemodialysis (HD) treatment (a procedure done by a trained professional to remove waste and excess fluid from the body) as ordered by the physician. As a result, Resident 1 missed the HD treatment appointment, and Resident 1 had to be transferred to the hospital. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (kidneys were damaged and could not filter blood), per the admission Record. A review of Resident 1's medical record was conducted. Per the hospital Discharge summary dated [DATE], Resident 1 has a chair in the HD center on Monday, Wednesday, and Friday. Per the Progress Notes dated 11/22/23, Resident 1 returned to the facility after hospitalization with permacath (a device inserted into a blood vessel) for HD. Per the Order Summary Report, dated 11/23/23, Resident 1 had an appointment to receive HD…

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 document sufficient preparation and orientation before discharge for 1 of 2 sample residents (1), when Resident 1, who has a diagnosis of Dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities) was transferred to an Independent Living Facility (ILF- a place where resident need no to assistance). As a result, Resident there was a potential for unsafe discharge. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included Dementia, and anxiety, per the facility's Face Sheet. A review of Resident 1's clinical record was conducted. Per the History and Physical, dated 7/13/23, Resident 1 could not make a decision. Per the Care Plan, dated 9/21/23, The staff was to coordinate discharge plans with Resident 1 and the IDT (interdisciplinary team - a group of professionals from various disciplines collaborating to address the resident's needs). Per the Progress Notes, 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 observation, interview, and record review, the facility failed to consistently provide showers and/or bed baths to three of four dependent residents (Residents 1, 2, and 3), reviewed for Activities of Daily (ADL). As a results, Resident 1, 2, and 3 had the potential for low self-esteem and possible skin infections. Findings: On 9/8/23, an unannounced visit was made to the facility in response to a complaint regarding resident hygiene. 1. Resident 1 was admitted to the facility on [DATE], with diagnoses which included encephalopathy (disease of the brain), per the facility's admission Record. On 9/8/23, Resident 1's clinical record was reviewed: According to the Minimum Data Set, (MD-a clinical assessment tool) dated 7/29/23, the cognitive score was listed as 00, indicating severely impaired cognition. The Functional Status, indicated one-person staff assistant was required for personal care, dressing, and eating. Resident 1 was transferred to the hospital on 8/27/23 at 3 P.M., per the facility's nursing…

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 a safe, homelike environment when: 1. Sections of ceiling panels were missing in the front north and south hallways, and in the back south hallway, exposing wires, cables, and air conditioning vents; and 2. A shared male resident bathroom sink remained clogged for months; and 3. A shared female resident bathroom had missing linoleum on the floor, directly in front of the sink area. These failures had the potential of placing residents at risk for low self-esteem and living in an unkempt environment. Findings: 1. On 5/16/22 at 9:24 A.M., a ceiling panel approximately 2 x 4 feet was observed missing in the back south hallway. Wires, cables and an air conditioning vent were viewable from below. Three additional ceiling panels in the front north hallway, approximately 2 x 4 feet in size were missing. A ceiling panel outside the social service office, approximately 2 x 2 feet was secured with scotch tape and partially bulging down. An additional 2 x 4 ceiling panel outside the rehabilitation department 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, interviews, and record review, the facility failed to ensure the staff followed the recipes and therapeutic menus as planned and printed, according to facility policy when: 1. Kitchen staff did not follow the facility recipe for pureed (liquid food for easy swallowing) meats. 2. Kitchen staff did not use the correct utensil size for portion control. This failure had the potential to result in weight loss of residents due to reduced food intake, which could have resulted in a decline in activities of daily living, and may have further compromised their nutritional status. Findings: 1. On 5/16/22 at 11:37 A.M., an observation of the lunch tray line was conducted. CK 11 plated the food and was noted to be using the same size and colored serving utensils for each food item being served. On 5/16/22 at 11:58 A.M., and concurrent interview and record review with CK 11 was conducted. CK 11 stated he was not aware of the different colored portion controlled utensils and the cook spreadsheets listing the portion size for each diet. On 5/17/22 at 1:25 P.M., 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 observation, interview and record review, the facility failed to ensure proper, safe and sanitary food practices, storage, and sanitation requirements were met when: 1. Stored utensils, plate warmer and can opener had visible residue on them. 2. There was no air gap underneath the three-compartment sink. 3. The kitchen flooring had several areas of uneven surfaces and cracks. 4. A kitchen fan had thick black dust on its frame. These failures had the potential to result in harmful bacteria growth and cross-contamination that could lead to food-borne pathogens (disease-causing organism) to come in contact with the residents' food; and can cause food-borne illnesses to residents. Findings: 1. On 5/16/22 at 8:18 A.M., during the initial tour, an observation of the kitchen was conducted. A container with several different sizes of serving utensils had visible dried residual particles noted on its metal surface area. A plate warmer cabinet with a dozen plates in it, had bits and pieces of residual particles on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to demonstrate safe infection control practices when: 1. Resident 72's dentures were left out on a shared shelf sink; and 2. A visitor was inside Resident 193's, designated yellow zone room (a room on isolation precautions for COVID-a highly transmittable virus), without wearing personal protective equipment (PPE); and 3. A urinary catheter bag (a flexible tube inserted into the body that drains urine into a drainage bag via gravity) was in contact with the floor for one of one resident, (Resident 12), reviewed for catheter care; and 4. An emergency eyewash station was not routinely cleaned and maintained. These failures had the potential for cross-contamination of microorganisms. Findings: 1. Resident 72 was admitted to the facility on [DATE] with diagnoses which included cerebrovascular disease (stroke) affecting the left side, per the facility's admission Record. On 5/16/22 at 9:19 A.M., an observation was conducted of Resident 72 in bed.…

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 Resident 92's needs and preferences were met. As a result, 1. Resident 92 did not have a working bathroom and 2. Resident 92's preferred in-room activity of watching television (TV) was not provided. Findings: Resident 92 was admitted to the facility on [DATE] per the facility's admission Record. 1. On 5/16/22 at 10:37 A.M., an observation of room [ROOM NUMBER] was conducted. There were four male-occupied beds in the room. The restroom had an out of order sign on the door. A review of the Maintenance Log was conducted. On 4/27/22, the restroom in room [ROOM NUMBER] was documented as toilet not working it's broken. On 5/17/22 at 8:12 A.M., an interview with Resident 92 was conducted. Resident 92 stated the restroom in room [ROOM NUMBER] was not working since he was transferred there about six or seven days ago. Resident 92 stated he had to use other resident's restrooms when he needed to go to the bathroom. Resident 92 also stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Follow a physician's order regarding the necessity of oxygen use for one of one resident (Resident 19) reviewed for oxygen administration; and 2. Develop and implement a person-centered plan of care for one of one resident (Resident 19), reviewed for limited ROM (range of motion). As a result, there was a potential for oxygen dependency and worsening contractures. Findings: 1. Resident 19 was admitted to the facility on [DATE], with diagnoses which included cerebrovascular disease (stroke), per the facility's admission Record. On 5/16/22 at 8:42 A.M., and at 11:34 A.M., Resident 19 was observed in bed with oxygen being administered at two liters a minute via nasal canula (a clear, plastic flexible tube placed in the nostrils) connected to an oxygen condenser (a machine which delivers oxygen). On 5/17/22 at 8:17 A.M., 2:48 P.M., and 3:51 P.M. Resident 19 was observed in bed and receiving oxygen at 2 liters per minute via nasal cannula…

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 range of motion (ROM) services to one of three residents (Resident 19), reviewed for limited ROM. This failure had the potential for a decline in Resident 19's already limited ROM. Findings: Resident 19 was admitted to the facility on [DATE], with diagnoses which included cerebral vascular disease (stroke), per the facility's admission Record. On 5/16/22 at 8:42 A.M., an observation was conducted of Resident 19 in bed. Severe contractures (permanent tightening of the muscles, tendons, and nearby tissues that causes the joints to shorten and become very stiff), were visible to the fingers, wrist, and elbows. On 5/17/22, Resident 19's clinical record was reviewed. According to the physician's order, dated 3/23/22, .Active range of motion exercises of both upper extremities with RNA [restorative nurse's assistant-a CNA with specialized training], 3x/week one time a day every other day for Risk for decline in BUE ROM [bilateral upper…

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 an environment that was free from accident and hazards in the resident dining room when a microwave was placed into service and staff were unaware of its presence. This deficient practice had the potential to result in resident(s) risk for injury. Findings: On 5/17/22 at 10:32 A.M., an observation of the resident dining room was conducted. A microwave was observed to be in the corner of the resident dining room and was plugged into wall outlet on top of cabinet. On 5/17/22 at 10:51 A.M., an interview with CNA 21 was conducted. CNA 21 stated, the microwave was not in the resident dining room over the weekend. CNA 21 stated, the resident dining room had never had a microwave before. CNA 21 stated she noticed the microwave in the resident dining room this morning. CNA 21 further stated she had not received any in-services regarding the use of the microwave in the resident dining room. On 5/17/22 at 11:05 A.M., an interview with the DSD was conducted. The DSD stated, the microwave should not be in the…

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

Based on observation, interview, and record review, the facility failed to ensure the kitchen staff carried out the tasks of the food and nutrition services department in accordance with the standard of practice for the following kitchen competencies: 1. A kitchen DSW (dishwasher) did not know how to correctly test PPM concentration of the dishwashing solution with the chlorine test strip. 2. Kitchen staff did not know how to calibrate food thermometers. 3. The kitchen staff did not follow policy and procedure for fortifying resident diets. These failures had the potential to expose all residents who consumed food from the kitchen to practices associated with the transmission of food-borne illness. Findings: 1. On 5/16/22 at 9:50 A.M., an observation and interview of the DSW was conducted. The DSW pulled out a chlorine test strip from a container and dipped it in the dishwasher machine water; color change indicated a reading of 50-100 PPM. On 5/16/22 at 9:55 A.M., an interview with the CDM was conducted. The CDM stated the facility followed the contracted provider 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Resident 74's mechanical bed was maintained in a safe condition. As a result, Resident 74, staff and visitors were exposed to a potential hazard, exposed electrical wires. Findings: Resident 74 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body) per the facility's admission Record. On 5/16/22 at 9:54 A.M., an observation of Resident 74 was conducted. The foot of the bed had missing panels on the control buttons. On 5/18/22 at 9 A.M., a concurrent observation of Resident 74's bed and interview with the DON was conducted. The DON stated there should not be any missing panels (covers for the electrical wiring of the bed controls) on Resident 74's bed. On 5/18/22 at 1:02 P.M., a concurrent observation of Resident 74's bed and interview with CNA 2 was conducted. CNA 2 stated there were no covers on some of the bed control buttons. CNA 2 stated someone could get electrocuted…

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.