The Pavilion At Ocean Point

Based on observation, interview record review, the facility failed to ensure food items were stored and labeled with contents, received dates, and use-by or expiration dates in the walk-in refrigerator, freezer, and dry storage areas for food prepared and served to residents. This failure had the potential to result in residents consuming expired or unidentified food products, increasing the risk of foodborne illness. During a kitchen observation on 2/24/26 at 8 A.M., the facility's walk in refrigerator was inspected.The following items in the refrigerator were found unlabeled with contents, a received date, or a use-by or expiration date: A. One small metal container covered in foil filled with a browned ground meat, unlabeled and undated. B. One small metal container covered in foil filled with a gelatinous tan substance, unlabeled and undated. C. Three large boxes of whole leaf lettuce with a use-by date of 2/20/26. D. One plastic container labeled lettuce with six large bags of chopped lettuce labeled with a use-by date of 2/20/26. E. One large whole ham stored in a plastic…

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 accurately code the Minimum Data Set (MDS- a nursing assessment tool) for one of three sampled residents reviewed for MDS accuracy. (Resident 2) This deficient practice resulted in providing inaccurate information to the Federal database (information maintained by the federal government).Findings:Resident 2 was admitted to the facility on [DATE] with diagnoses including dysphasia (inability to communicate effectively) following cerebral infarction (stroke) according to the facility's admission Record. During a review Resident 2's Minimum Data Set (MDS-a clinical assessment tool) dated 8/25/25, section I5600 indicated an x next to malnutrition. An interview and joint record review was conducted on 9/17/25 at 10:41 A.M. with the Minimum Data Set Nurse (MDSN- a nurse who assessed and evaluated the quality of care being given to residents). The MDSN reviewed Resident 2's MDS. The MDSN stated physician documentation was required to code…

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 four of seven residents were provided care in a manner that promoted dignity and respect when: 1. Staff did not answer Resident 1's call bell for seven hours;2. Resident 2 waited one hour to have his brief changed; 3. Resident 3 waited all night to have his brief changed; 4. Resident 4 waited one and a half hours for call light to be answered;5. Call light response was an issue verbalized by residents at theResident Council meetings for three consecutive months.These failures resulted in not ensuring residents' rights to be treated with respect and dignity, with the potential to cause psychosocial harm to the involved residents. In addition, this failure had the potential for residents who remained wet for an extended period to develop or worsening of bedsores and infection.Findings:1. Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (disrupted blood flow to the brain) due to thrombosis…

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 care plan was implemented related to falls for one of two residents reviewed for falls (Resident 1).As a result, Resident 1 was at risk for additional falls.Findings:Resident 1 was admitted to the facility on [DATE] with diagnoses to include muscle weakness and dementia (a loss of thinking, remembering, and reasoning that interferes with daily living and activities), per the admission Record.An interview was conducted with the Administrator (ADM) on 7/31/25 at 10:30 A.M. The ADM stated Resident 1 had fallen from his wheelchair on 7/21/25, and this was the first time Resident 1 had sustained an injury. Per the ADM, Resident 1 had been in his room, seated in a wheelchair with no staff present when the fall occurred. The ADM stated Resident 1 had hit his head and was bleeding from his forehead, so he was sent to the hospital to be assessed.On 7/31/25 at 10:45 A.M., an interview was conducted with the Director of Staff Development (DSD). The DSD…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement strategies to prevent a resident from falling (Resident 1).As a result, Resident 1 sustained a fall with injury.Findings:Resident 1 was admitted to the facility on [DATE] with diagnoses to include muscle weakness and dementia (a loss of thinking, remembering, and reasoning that interferes with daily living and activities), per the admission Record.An interview was conducted with the Administrator (ADM) on 7/31/25 at 10:30 A.M. The ADM stated Resident 1 had fallen from his wheelchair on 7/21/25, and this was the first time Resident 1 had sustained an injury. Per the ADM, Resident 1 had been in his room, seated in a wheelchair with no staff present when the fall occurred. The ADM stated Resident 1 had hit his head and was bleeding from his forehead, so he was sent to the hospital to be assessed.On 7/31/25 at 10:45 A.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated Resident 1 was often in her office,…

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 care in a respectful and dignified manner when an employee showed a soiled linen wipe with bowel movement to Resident 1's face. As a result, Resident 1 was disrespected and had the potential to decrease resident's self-worth. Findings: On 6/3/25 at 10:16 A.M. an interview and record with Licensed Nurse (LN) 1 were conducted. LN 1 stated he received a report form the nocturnal shift nurse that Certified Nurse Assistant (CNA) 1 had put the soiled linen wipes with bowel movement to Resident 1's face while CNA 1 was providing care to Resident 1. According to LN 1's progress notes on 5/25/25 at 11:56 A.M., CNA 1 was taking excessive amount of time to clean up urine and so Resident 1 asked CNA 1 what was going on. CNA 1 placed the soiled wet wipe 2 inches from my face and told Resident 1 had bowel movement. On 6/3/25 at 10:45 A.M. an interview was conducted with Resident 1. Resident 1 stated CNA 1 was providing care when CNA 1 placed the soiled wipes with bowel movement about one to two (1 to 2) inches to Resident 1's…

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

Based on observation, interview and record review the facility did not ensure a TV (television) remote control was provided for 1 of 3 resident's (Resident 1) in a shared room. As a result, Resident 1 was upset and an altercation with another resident occurred/transpired. Findings: On 6/3/25 the Department received a facility reported incident about a resident-to-resident altercation on 6/1/25. On 6/3/25 at 11:27 A.M., an observation and interview with Resident 2 were conducted. Resident 2 was observed sitting in a wheelchair. Resident 2's room was observed to have three beds and each bed had TV. There was two TV remote control. Resident 2 stated about two days ago after dinner, he was upset because he could find the TV remote control. Resident 2 asked his roommate where the TV remote control was. Resident 2 stated his roommate hit him once in the chest. Resident 2 stated there was only one TV remote control at that time. On 6/3/25 at 11:55 A.M. an interview was conducted with Certified Nurse Assistant (CNA) 2. CNA 2 stated Resident was asking for his TV remote control. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an appropriate discharge plan was implemented for 1 of 2 sampled residents (Resident 1) when: Resident 1 was transferred from the skilled nursing facility to a general acute care hospital (GACH) and denied readmission to the skilled nursing facility (SNF) when the GACH medically cleared the resident for return. As a result, Resident 1 did not receive an appropriate discharge notice that included the reasons for the discharge, notification to responsible parties and the right to appeal the discharge decision. Findings: On 4/15/25 at 1:00 P.M. a joint interview and record review was conducted with the facility's Administration: Administrator (ADM), DON, ADON, Social Services Staff (SSD) 1 and SSD 2. Resident 1 was initially admitted to the facility on [DATE]. Resident 1 was transferred from the SNF to a GACH on 12/23/24 and re admitted to the SNF on 1/21/25 according to Resident 1's demographics and length of stay (LOS) reported by Administration.…

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

Based on observation, interview and record review, the facility failed to follow infection control practices when the facility: 1.) Did not consistently check water temperature or test the water for germs. 2.) A personal belonging was on top of a clean bed that was intended for a new resident admission. 3.) Licensed Nurses (LNs) did not perform hand hygiene after administering medications between residents (16, 60). These failures had the potential to spread germs and placed residents at risk for infections. Findings: 1. Per the facility policy titled Water Management, revision date 5/25/23, .The facility will develop and utilize water management strategies .to reduce the risk of growth and spread of Legionella (a type of germs in water) and other opportunistic water-borne pathogens in facility water systems . Control Measures and Corrective Actions .1 .the team will identify needed control measures .and how to monitor them .2. Physical and chemical measures . that may be applied for the prevention and control of Legionella include, but are not limited to: a. Maintaining Water…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record reviews, the facility failed to obtain an informed consent for one of three sampled residents (18), reviewed for unnecessary medication. This failure had the potential for the resident to not be aware of the risks and benefits of taking psychotropic (chemicals which altered brain function) medications. FINDINGS: A record review of Resident 18's admission Record indicated that Resident 18 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a mental illness that can affect thought, mood, and behavior) and major depressive disorder (characterized by low mood and low self-esteem). A review of Resident 18's Physician's orders indicated the following: .Clonazepam (anxiety medication) 0.25 milligram (mg- unit of measurement) po (by mouth) twice a day - Dx (diagnosis). Anxiety (repeated episodes of sudden feelings of intense fear & worry) . .Valproic acid (medication to treat mental disorders) 20 millimeters (ml-unit of measurement) po three times 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 ensure one of two sampled residents (221) had a POLST (physician orders for life sustaining treatment, end of life wishes) signed by the Responsible Party (RP). As a result, there was a potential to not have the resident's end of life wishes honored. Findings: Resident 221 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, per Resident 221's admission Record. A review of Resident 221's History and Physical Examination, dated 10/4/24, indicated physician marked, .does NOT have the capacity to understand and make decisions . A review of the POLST, dated 10/5/24, indicated it was signed by the physician on 10/5/24. The section for Signature of Patient or Legally Recognized Decision Maker had a box titled, Signature (required) which was left uncompleted. On 10/23/24 at 10:48 A.M., an interview and record review was conducted with Licensed Nurse (LN) 31. LN 31 stated the POLST should have been signed 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 observation, interview, and record review, the facility failed to provide a homelike environment for one of six sampled residents (108) when there was a large opening observed in the wall under the sink. This failure had the potential for the resident to feel uncomfortable in their environment. Findings: Resident 108 was admitted to the facility on [DATE] with diagnoses including muscle weakness and other abnormalities of gait (walking) and mobility per the admission Record. Resident 108 was cognitively intact (aware of surroundings) based the resident's Minimum Data Set (MDS, an assessment tool), dated 9/10/24. A concurrent interview and observation was conducted with Resident 108 in Resident 108's room on 10/21/24 at 9:03 A.M. Resident 108 stated she would like to complain about the sink in her bathroom. She stated she feared the sink would fall. A large hole on the wall beneath the sink was observed. The hole spanned the length of the sink. A concurrent interview and observation was conducted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written notice of discharge to one of three sampled discharged residents (109). As a result, Resident 109 was not fully informed of his discharge. Findings: Per the facility's Face Sheet, Resident 109 was admitted to the facility on [DATE] with diagnoses which included cirrhosis of the liver (liver failure). On 10/23/24 at 2:10 P.M., a review of Resident 109's medical record was conducted. On 10/16/24 there was a physician's order to transfer Resident 109 to an acute care hospital. The 10/16/24 Progress Notes did not include any documentation of the staff providing a written notice of discharge to Resident 109. On 10/23/24 at 2:16 P.M., an interview was conducted with Licensed Nurse (LN) 1 and LN 2. LN 1 and LN 2 stated that they both coordinated Resident 109's discharge to an acute care hospital. LN 2 stated she was not familiar with the written notice of discharge form. LN 1 stated they did not provide the written notice of discharge 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 interview and record review, the facility failed to provide a written notice of the facility's bed-hold policy at the time of discharge to one of three sampled discharged residents (109). As a result, Resident 109 was not fully informed of his bed-hold rights. Findings: Per the facility's Face Sheet, Resident 109 was admitted to the facility on [DATE] with diagnoses which included cirrhosis of the liver (liver failure). On 10/23/24 at 2:10 P.M., a review of Resident 109's medical record was conducted. On 10/16/24 there was a physician's order to transfer Resident 109 to an acute care hospital. The 10/16/24 Progress Notes did not include any documentation of the staff providing a written notice of bed-hold to Resident 109. On 10/23/24 at 2:16 P.M., an interview was conducted with Licensed Nurse (LN) 1 and LN 2. LN 1 and LN 2 stated that they both coordinated Resident 109's discharge to an acute care hospital. LN 1 stated they did not provide a written notice of bed-hold to Resident 109 at the time of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medication was properly documented in the Minimum Data Set (MDS, resident assessment tool), for one of 24 sampled residents (88). As a result, medical decisions based on the MDS had an increased risk for error. Findings: Per the facility's admission Record, Resident 88 was admitted to the facility on [DATE]. Per the facility's MDS, dated [DATE], Section N - Medications, Resident 88 received one insulin (a medication to control blood sugar) injection over the previous seven days. A review of Resident 88's medical record was conducted. Resident 88's record did not include any orders for insulin. On 10/23/24 at 10:59 A.M., an interview was conducted with the MDS coordinator (MDS 21). MDS 21 stated that he reviewed Resident 88's medical record and could not find orders for insulin. MDS 21 further stated that he marked Resident 88's MDS in error when he documented that she was receiving insulin. Per the facility's policy, titled RAI (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 complete the PASARR (Preadmission Screening and Resident Review, a federal requirement to help ensure individuals are not inappropriately placed in a nursing facility) II in a timely manner for one of three residents (67)sampled for PASARR. This failure had the potential to result in Resident 67's mental health needs to be unmet. Findings: Resident 67 was initially admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental health disorder causing hallucinations, delusions, and mood changes), major depressive disorder (a mental health condition characterized with low or loss of interest in things that once brought joy), and generalized anxiety disorder (a mental disorder characterized by excessive worry about everyday events) per the admission Record. A concurrent interview and record review was conducted with the Director of Nursing (DON) on 10/24/24 at 8:58 A.M. The DON stated the PASARR II for Resident 67 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a care plan was developed for psychotropic medication (chemical that alters the brain) for two (47, 105) of five residents reviewed for care plan implementation. This failure had the potential for Residents 47 and 105 's current psychotropic drug monitoring to not be communicated to all health care providers. Findings. 1) A review of Resident 47's admission Record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses that included Vascular Dementia (problems with reasoning, planning, judgement, memory, and other thought process) and Major Depressive Disorder (a serious mental disorder that affects how a person feels, thinks, and acts). An interview and record review on 10/23/24 at 9:27 A.M., with Licensed Nurse (LN) 1 was conducted. LN 1 stated Resident 47 was on Seroquel (medication to treat mental disorder) 12.5 milligram (mg- metric unit of measurement) at bedtime. LN 1 stated there was no care plan for the Seroquel 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide routine nail care to one of three residents (91) reviewed for Activities of Daily Living (ADL, activities related to personal care) for dependent residents. As a result, Resident 91 was at risk for skin injury and infection. Findings: Resident 91 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke, loss of blood flow to a part of the brain), ataxia (lack of muscle coordination and control) and reduced mobility, per the facility's admission Record. A review of the History and Physical Examination, dated 7/6/23, indicated diagnosis included muscle weakness and has the capacity to understand and make decisions . On 10/21/24 at 10:52 A.M., an observation and interview was conducted with Resident 91. Resident 91 was lying on his bed. Resident 91's fingernails were long with yellowish discoloration. Resident 91 stated he wanted his fingernails cut. On 10/22/24 at 3 P.M., an 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medication was delivered from the pharmacy in a timely manner for one of 24 sampled residents (88). As a result, Resident 88 did not receive ropinirole (a medication to treat restless leg syndrome [uncomfortable legs]) as ordered for three days. Findings: Per the facility's admission Record, Resident 88 was admitted to the facility on [DATE] with diagnoses which included chronic pain. Per the facility's Medication Administration Record (MAR), dated 10/23/24, Resident 88 had an order to have/take ropinirole two times per day for restless leg syndrome. On October 1st, 2nd, and 3rd, the medication was marked as not administered. Per the facility's Progress Notes, there was a note dated 10/1/24 at 6:10 A.M., by Licensed Nurse (LN) 11, that read, .med (medication) not available . The progress note did not indicate if the medication was reordered from the pharmacy. Per the facility's Progress Notes, there was a note dated 10/2/24 at 5:02 A.M., that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of three residents (47, 105) reviewed for psychotropics (a drug or other substance that affects how the brain works) had specific behavior monitoring in place for the use of psychotropic medications. This failure placed Resident 47 and Resident 105 at an increased risk of receiving unnecessary psychotropic medications. Findings: 1. A review of Resident 47's admission Record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses that included Vascular Dementia (problems with reasoning, planning, judgement, memory, and other thought process) and Major Depressive Disorder (a serious mental disorder that affects how a person feels, thinks, and acts). An interview and record review on 10/23/24 at 9:27 A.M., with Licensed Nurse (LN) 1 was conducted. LN 1 stated Resident 47 was on Seroquel (medication used to treat mental disorders) 12.5 milligram (mg- metric unit of measurement) at bedtime. LN 1 stated there was no specific…

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

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5 percent when three of 27 medications were not given as ordered by the physician. This failure had the potential for significant medication errors which could have caused residents to experience harmful side effects. Findings: 1. A medication administration observation was conducted on 10/23/24 at 8:01 A.M. for Resident 16. Licensed Nurse (LN) 22 administered famotidine (medication used to prevent heartburn) to Resident 16. A review of Resident 16's active physician's orders, dated October 2024, was conducted on 10/23/24. This record did not include a physician's order to administer famotidine to Resident 16. A concurrent observation and interview was conducted with LN 22 on 10/23/24 at 10:59 A.M. LN 22 reviewed the medication packets in Resident 16's section of the medication cart. It was found that famotidine was from Resident 60, who was assigned to the bed next to Resident 16. LN 22 acknowledged a medication error had occurred which could have negatively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure medication storage rooms were free from expired medical supplies when: 1. Expired needles and eyewash solutions were found in one of two medication storage rooms. 2. Expired needles were found in one of three medication carts. These failures had the potential to cause infection if the expired items were used on residents. Findings: 1. An observation of a medication storage room was conducted on [DATE] at 7:50 A.M. Needles used for injections, were observed in the medication storage room with expiration dates of [DATE], [DATE], and [DATE]. The expired needles were mixed with needles that were not expired. In addition, eyewash solution bottles were observed in the medication storage room with an expiration date of 7/2024. A concurrent observation and interview was conducted with Licensed Nurse (LN) 31. LN 31 stated the needles and eyewash solution were expired and should not have been in the medication storage room. LN 31 stated the expired items…

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 one of one sampled kitchen staff (Cook 12) properly tested the kitchen disinfectants. As a result, the disinfectant may not have been at the proper strength to disinfect surfaces. Findings: On 10/22/24 at 8:30 A.M., an observation was conducted in the kitchen. [NAME] 12 tested the disinfectant in a red bucket used for sanitizing surfaces in the kitchen. [NAME] 12 dipped a test strip into the disinfectant then immediately pulled it out to check the color. [NAME] 12 stated, he only needed to dip the strip in the disinfectant for one second. The test strip container's directions read, .Immerse for 10 seconds, compare when wet . After being asked why he did not follow the directions on the test strip container, [NAME] 12 retested the disinfectant by immersing a test strip for seven seconds. On 10/22/24 at 8:35 A.M., an interview was conducted with the Registered Dietician (RD). The RD stated, when the kitchen staff were testing the disinfectant in the red buckets, they should have held the test strip in the liquid for 10…

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 frozen meat was thawed appropriately during one of two sampled observations of thawing meat. As a result, there was an increased risk of food-borne illness. Findings: On 10/22/24 at 11:55 A.M., an observation and interview was conducted with the Dietary Manager (DM). A plastic bag containing cubes of meat was observed floating in a container of water on a counter in the kitchen. The DM stated, it was frozen chicken thawing in sitting water. The DM further stated, it should have been thawing in the refrigerator, or under running water. The DM stated that the cook who placed the frozen chicken in standing water knew that was not the proper way to thaw frozen meats. Per the facility's policy, titled Food Storage and Handling, revised 2/29/24, .Thaw foods .in the refrigerator .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure arbitration agreements (a legal contract) were signed by the Responsible Party (RP) for two of three residents sampled for arbitration agreements (67, 171). As a result, Resident 67 and Resident 171 entered into a legal agreement when they did not have the ability to understand what they were signing. Findings: 1. Resident 67 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a mental disorder involving a disconnection from reality). Per the facility's History and Physical Examination (a physician's assessment), dated 1/16/24, Resident 67 did not have the capacity to understand and make decisions. A review of Resident 67's medical record was conducted. Resident 67 signed the Arbitration Agreement on 1/16/24. The staff member responsible for completing Arbitration Agreements was not available for interview. 2. Resident 171 was admitted to the facility on [DATE] with diagnoses that included schizophrenia…

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 food preparation area was free of insects for one of one sampled kitchens. As a result, there was an increased risk of food-borne illness. Findings: On 10/22/24 at 11:05 A.M., an observation was conducted in the kitchen. [NAME] 13 was chopping roast pork, while a winged black insect (Insect 1) was flying around the pork. [NAME] 13 repeatedly waved her hand at Insect 1 while she was chopping the roast pork. Insect 1 landed on a piece of chopped pork and then flew away. [NAME] 13 did not remove the contaminated piece of food and continued chopping the roast pork. On 10/22/24 at 11:15 A.M., an interview was conducted with the Registered Dietician (RD). The RD stated, the facility was planning on getting an air curtain (a device to stop flying insects from entering) installed on the exterior kitchen door. The RD further stated, the Maintenance Director (MD) knew more about the plans for installing the air curtain. On 10/22/24 at 11:30 A.M., an observation was conducted of the kitchen. A winged small…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control policies when Certified Nursing Assistant (CNA) 1 and CNA 3 did not wear appropriate personal protective equipment (PPE – gown and gloves) when providing care to one of two residents (Resident 2) who was on Enhanced Barrier Precaution (EBP - a type of precaution indicating the need for PPE when providing care to a resident). This failure had the potential to result in the spread of multidrug-resistant organisms (MDRO – microorganisms, mainly bacteria, that are highly resistant to many types of antibiotics) among the residents at the facility. Findings: Resident 2 was admitted to the facility on [DATE] with a diagnosis of chronic kidney disease (longstanding kidney disease) and retention of urine (inability to empty the bladder when urinating) per Resident 2 ' s face sheet. Per Resident 2 ' s physician ' s orders, dated 11/10/22, Resident 2 had a urinary catheter (a tube inserted into the bladder to collect urine).…

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 comfortable temperature environment for five of seven residents (Residents 3, 4, 5, 6, and 7) interviewed during an air conditioning (AC) malfunction. In addition, the facility failed to document and maintain a temperature log as a proactive maintenance tool. As a result, temperatures were not checked during the AC failure. These failures had the potential to affect the resident ' s comfort, health, and physical well-being related to the building ' s warm internal temperature. Findings: On 8/21/24, an unannounced visit was made to the facility. On 8/21/24 at 10:35 A.M., during a tour of the west/south hallway the wall thermostat indicated a temperature of 79 degree Fahrenheit (F). The director of maintenance (DM) was not available for interview. A concurrent observation of the west/south hallway thermostat and interview with the maintenance aide (MA) was conducted on 8/21/24 at 10:39 A.M., The MA stated the air conditioner (AC)…

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 a maintain a hazard free environment when: 1. Liquids (shampoo, body wash, and shaving cream containers) were unsecured in two of three resident showers (west/east hallway and west/south hallway) 2. A red sharps container (a one-way device that contains needles and other sharp devices) was unsecured, and over-flowing with blue used razors, in one of three showers rooms (west/east hall) 3. Water was leaking from an adjacent wall in the west/east hallway, next to the east nursing station. These failures had the potential for confused residents to ingest shampoo, body wash, lotions, shaving cream and to have access to used razors, along with potential for slipping on the wet floor. Findings: On 8/12/24, an unannounced visit was conducted. 1. An observation of the shower room located in the west/east hallway was conducted on 8/12/24 at 10:31 A.M. The shower room was unlocked and appeared recently used, due to the presence of wet towels on the ground. On a metal shelf to the right of the interior door, just…

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 secure one of two medication carts (cart north), one of two treatment carts (cart north), and one of one intravenous (IV) cart all stored on the east unit, reviewed for safe medication storage. As a result, residents, visitors, and staff had access to unauthorized medications and IV needles. Findings: On 8/21/24, an unannounced visit was made to the facility. An observation was conducted of a medication cart on 8/21/24 at 10:52 A.M., on the east station, north hallway. The medication cart was backed against a wall, in a hallway between two resident rooms and was unlocked. The first and second right drawers contained multiple medications, the top left drawer contained insulin (a hormone used for people with diabetes) pens (injection device preloaded with insulin). On 8/21/24 at 10:53 A.M., licensed nurse (LN) 2, exited a resident room and approached the medication cart. LN 2 acknowledged that she left the cart unlocked and proceeded to lock it. LN 2 stated when the (medication) cart was left unlocked, anyone could have access…

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 a person-centered care plan for one of two resident ' s (Resident 1) for repeated refusals of care and Activities of Daily Living (ADL- basic daily care such as bathing, dressing, brushing teeth, and combing hair). This failure had the potential to result in miscommunication of necessary care, and inconsistent care that could result in delayed wound healing and infections for Resident 1. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included functional quadriplegia (the inability to move arms or legs) with joint contractures (shortening of muscles, causing deformities of the joints), per the facility ' s admission Record. On 8/21/24, Resident 1 ' s clinical record was reviewed: According to the Minimum Data Set, (MDS-a clinical assessment tool), dated 7/9/24, Resident 1 had a cognitive assessment score of 12, indicating cognition was intact. The Functional Abilities assessment indicated the resident 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 interview and record review, the facility failed to provide routine showers and/or bed baths to one of two residents (Resident 1) reviewed for Activities of Daily Living (ADL-basic daily care such as bathing, dressing, brushing teeth, and combing hair). As a result, Resident 1 was at risk for skin infections and skin injuries. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included functional quadriplegia (the inability to move arms or legs) with joint contractures (shortening of muscles, causing deformities of the joints), per the facility ' s admission Record. Resident 1 ' s clinical record was reviewed on 8/21/24: According to the Minimum Data Set, (MDS-a clinical assessment tool), dated 7/9/24, Resident 1 had a cognitive assessment score of 12, indicating cognition was intact. The Functional Abilities assessment indicated the resident was dependent on staff for turning, transferring from bed to chair, toileting, and showering. The skin assessment listed surgical…

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 wound treatments as ordered for one of seven residents (Resident 1). As a result, Resident 1 had the potential for delayed healing and worsening of wounds. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included functional quadriplegia (the inability to move arms or legs) with joint contractures (shortening of muscles, causing deformities of the joints), per the facility ' s admission Record. On 8/21/24, Resident 1 ' s clinical record was reviewed: According to the Minimum Data Set, (MDS-a clinical assessment tool), dated 7/9/24, Resident 1 had a cognitive assessment score of 12, indicating cognition was intact. The Functional Abilities assessment indicated the resident was dependent on staff for turning, transferring from bed to chair, toileting, and showering. The skin assessment listed surgical wounds and moisture associate skin damage, (MASD-skin inflammation or erosion caused by prolonged exposure 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 interview and record review, the facility failed to safeguard one resident's (1) protected health information (PHI). As a result, Resident 1's protected health information was disclosed without a proper authorization. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD; lung disease causing restricted airflow and breathing problems), per the facility's admission Record Form. On 7/31/24, an unannounced visit was conducted in response to a complaint that involved an allegation of improper disclosure of personal health information without prior authorization. A review of Resident 1's Minimum Data Set (MDS; assessment tool), dated 7/24/24, indicated Resident 1's brief interview for mental status (BIMS; cognition status) was 15 (score of 13 to 15 indicated that a patient had intact cognitive abilities). A review of Resident 1's history and physical (H & P) record, dated 6/9/24, indicated Resident 1 could make his own…

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 medications were administered as ordered by the physician for two residents (1, 2). Resident 1 was administered Ativan (medication to relieve anxiety) 0.5 milligrams (mg) more times than what the physician ordered. For Resident 2, Cefazolin (medication to treat an infection) 2 grams (gm) was ordered to be administered intravenously (IV; method of administering medication into a vein), every eight hours, but was not administered on four separate times as the IV therapy was ordered. These failures had the potential to affect Resident 1 and Resident 2's well-being and health. Findings: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, per Resident 1's face sheet. On 6/28/24, a review of Resident 1's clinical record was conducted. Resident 1's physician's orders, dated June 2024 included an order dated 1/31/24 for Ativan 0.5 mg, give 0.5 mg by mouth in the afternoon for anxiety. Upon 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 observation, interview, and medical record review, the facility failed to develop and implement a baseline nutrition care plan within 48 hours of admission for one reviewed resident (Resident 1) during a complaint investigation. This had the potential for weight loss and a decline in health status due to poor meal intake. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included a history of chronic obstructive pulmonary disease (COPD: a lung disease causing restricted airflow and breathing problems). A record review of Resident 1's Minimum Data Set (MDS- a nursing assessment tool that is used to develop a plan of care) dated 5/20/24, indicated a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 12 points out of 15 possible points which indicated Resident 1 had moderate cognitive (pertaining to memory, judgement and reasoning ability)…

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 comprehensive discharge care plan was completed for one of three sampled discharged residents (Resident 2). This failure had the potential to compromise Resident 2 ' s safety on discharge and delay post-discharge care for Resident 2 ' s ongoing health care needs. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses which included a history of diabetes mellitus type 2 with circulatory complications (occurs when the body is unable regulate blood sugar causing risks for heart attacks, strokes, and other circulatory problems such as poor wound healing), per the facility ' s admission Record. A review of Resident 2's medical record was conducted. The Minimum Data Set (MDS- assessment tool) dated 1/24/24 indicated that Resident 2 had a moderate cognitive (mental processes that occur in the brain, including thinking, attention, language, learning, memory, and perception) impairment. The MDS section Q indicated that there was no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medication orders for two of 3 sampled residents (Resident 1 and Resident 2) were administered as ordered. This failure had the potential to affect Resident 1 and Resident 2's health and safety. Findings: 1. Resident 1 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included muscle weakness, fracture of right femur head, unsteadiness on feet according to the facesheet. A review of Resident 1's physician's orders, dated 2/2/2024, indicated Resident 1 was to receive Lidocaine gel 4% topically (on the skin) every morning. On 4/18/2024 at 7:30 A.M., a medication administration observation was conducted for Resident 1's morning medications. Lidocaine gel 4% was not administered to Resident 1 by licensed nurse (LN) 1. On 4/18/2024 at 11:07 A.M., an interview was conducted with Resident 1 in his room. Resident 1 stated he does not remember receiving lidocaine gel every morning. On 4/18/2024 at 11:35…

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) received an anticonvulsant medication (used to treat epilepsy [seizures]; burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements) as ordered by the physician. This failure had the potential for Resident 1 to experience life threatening seizure complications such as increased seizure activity, head trauma, or death. Findings: A record review of Resident 1's clinical record, titled admission Record (face sheet; contains demographic information) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm (cancerous tumor) of the brain and epilepsy. A record review or Resident 1's medication administration record (MAR), dated 12/28/23, indicated that Resident 1's Divalproex (anticonvulsant medication) was not signed (indicating medication was administered) by the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one resident (Resident 1) was free from physical abuse when activity aid (AA) 1 did not de-escalate and manage Resident 1 ' s inappropriate behavior during a bingo game. As a result, Resident 2 reacted to Resident 1 ' s inappropriate behavior by punching Resident 1 in the face (Cross reference F-656). Findings: A review of Resident 2 ' s admission Record indicated the resident was readmitted to the facility on [DATE] with diagnosis to include bipolar disorder (associated with mood swings) and dementia (characterized by thinking and social symptoms that interferes with daily functioning). A review of Resident 2 ' s progress notes dated 11/22/23, indicated, Reported by activity that resident hit another resident on the face while playing bingo . [Resident 2] stated ' I hit him [Resident 1] because he was being rude to me. ' A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis 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 interview and record review, the facility failed to implement one resident ' s (Resident 1) written care plan interventions to address and de-escalate the resident ' s aggressive behavior. As a result, Resident 1 continued to behave aggressively during a bingo game and was punched in the face by Resident 2 (Cross reference F600). Findings: A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis to include stroke and major depressive disorder (characterized by persistent feeling of sadness). A review of Resident 1 ' s progress notes dated 11/22/23, indicated, [Resident 1] was aggravating residents at bingo and was punched by [Resident 2] in face .The two residents are trying to fight when passing each other in hallway A review of Resident 1 ' s written care plan for, The resident is/has potential to be verbally aggressive by yelling profanities, sexually inappropriate comments toward staff, racial comments . poor impulse control 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.

Based on interviews, record review, and facility policy review, the facility failed to ensure a bariatric geriatric chair (geri-chair; a supportive recliner designed to provide more substantial support and comfort than a traditional wheelchair; bariatric geri-chairs are constructed to provide more room and are typically utilized for residents with high body mass index scores) was available for 1 (Resident #42) of 1 resident reviewed for accommodation of needs. Findings included: A review of a facility policy titled, Resident Rights-Accommodation of Needs, revised on 01/01/2012, revealed, Purpose To ensure that the Facility provides an environment and services that meet residents' individual needs. Policy The Facility's environment is designed to assist the resident in achieving independent functioning and maintaining the resident's dignity and well-being. Facility Staff will assist residents in achieving these goals. A review of an admission Record revealed the facility most recently admitted Resident #42 on 01/08/2017 with diagnoses that included polyneuropathy (a condition that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and facility policy review, the facility failed to provide a homelike environment that was well maintained in 4 (Rooms 301, 309, 312, and 314) of 54 resident rooms. Findings included: Review of a facility policy titled, Resident Rooms and Environment, with a revision date of 01/01/2012, revealed Purpose To provide residents with a safe, clean, comfortable and homelike environment. 1. On 10/23/2023 at 10:37 AM, a portable air conditioning (AC) unit was observed in room [ROOM NUMBER]. On the bottom of the wall to the right of the portable AC unit, an area that measured approximately 6-inches long by 12-inches wide had water damage. During an interview on 10/25/2023 at 8:37 AM, the Maintenance Director stated portable AC units were used during the summer months because some of the residents liked their rooms to be cooler than what the facility's AC provided. The Maintenance Director stated the water damage on the wall in room [ROOM NUMBER] was related to the portable AC unit. In 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 record review, interviews, and facility policy review, the facility failed to refer a resident with a newly evident or possible serious mental disorder for a Level II Preadmission Screening and Resident Review (PASARR) for 1 (Resident #83) of 6 sampled residents reviewed for PASARR requirements. This had the potential to cause the resident to not obtain the specialized mental health services needed for quality of life. Findings included: A review of the facility policy titled, Pre-admission Screening Resident Review, revised 08/15/2016, revealed, Purpose To ensure that all Facility applicants are screened for mental illness and mental retardation prior to admission. A review of Resident #83's admission Record indicated the facility admitted the resident on 03/29/2022 with a primary diagnosis of cerebral palsy. Per the admission Record, Resident #83 received a new diagnosis of schizoaffective disorder and anxiety disorder on 06/09/2022. A review of an annual Minimum Data Set (MDS) with an Assessment…

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, record reviews, and facility policy review, the facility failed to identify major mental illness diagnoses on Level I Preadmission Screening and Resident Reviews (PASARRs) completed on admission for 2 (Resident #62 and Resident #98) of 6 residents reviewed for PASARRs. Findings included: A review of a facility policy titled, Pre-admission Screening Resident Review, with a revision date of 08/15/2016, revealed, Purpose To ensure that all Facility applicants are screened for mental illness and mental retardation prior to admission. 1. A review of Resident #98's admission Record indicated the facility admitted the resident on 03/22/2023 with a primary diagnosis of schizophrenia. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/29/2023, revealed Resident #98 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had an active diagnosis to include schizophrenia. According to the MDS, the resident received antipsychotic…

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, record review, and facility policy review, the facility failed to ensure 1 (Resident #87) of 1 sampled resident reviewed for hospice services, medical record contained pertinent documentation regarding the delivery of hospice care/services. Findings included: A review of the facility's policy titled, Hospice Care of Residents, with a revision date of 01/01/2012, indicated, B. The Hospice and Facility will collaborate on a Care Plan for the resident. Further review of the policy indicated, B. Hospice notes will be included in the Facility Progress Notes. i. Nursing Staff will be informed of any changes recommended by the hospice staff. C. All documentation concerning hospice services will be maintained in the resident's medical record. A review of Resident #87 admission Record indicated the facility admitted the resident on 01/31/2022 with diagnoses that included dementia and severe protein-calorie malnutrition. A review of Resident #87's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/11/2023, indicated the resident received…

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, record review, and review of the Centers for Disease Control and Prevention (CDC) guidance provided by the facility, the facility failed to ensure staff removed their personal protective equipment (PPE) before they left the room of 1 (Resident #28) of 27 residents who tested positive for Coronavirus disease 2019 (COVID-19) during the survey. Findings included: Review of undated CDC guidance titled, How to Safely Remove Personal Protective Equipment (PPE) Example 1, indicated, There are a variety of ways to safely remove PPE without contaminating your clothing, skin, or mucous membranes with potentially infectious materials. Here is one example. Remove all PPE before exiting the patient room except a respirator, if worn. Remove the respirator after leaving the patient room and closing the door. Review of undated CDC guidance titled, How to Safely Remove Personal Protective Equipment (PPE) Example 2, indicated, Here is another way to safely remove PPE without contaminating your clothing, skin, or mucous membranes with potentially infectious…

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 maintain pharmaceutical clinical records in accordance with accepted professional standards of practices for two of three sampled residents (Resident 1 and Resident 2) when; 1. Schedule II medications (a class of drugs with a high potential for substance abuse) were signed out of a medication cart by licensed nurse (LN) 1 and LN 2 but were not documented as given to Resident 1 in the medication administration record (MAR, a record used to document medication administration). 2. The number of Schedule II tablets documented as removed from the medication cart was different than the total number of Schedule II tablets documented as administered in the MAR. 3. The facility was not able to provide evidence of a controlled substance record for Schedule II medications documented as administered in the MAR. As a result, there was a lack of medication accountability and a potential for medication diversion. In addition, there was a potential for Resident 1 and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure that all residents were kept safe from hazards when a treatment cart was left unlocked and unattended inside the facility and the external perimeter of the facility property was found to have numerous safety hazards. In addition, the facility did not correctly assess and create care plan risks for residents who smoke and apply personalized strategies for smoking risks (Resident 17, 8, 11, 13, and 4). These failures had the potential for residents to be placed at risk for hazards and could result in inconsistent staff oversight for smoking safety, and inconvenienced other residents in their free use of common areas. Findings: On 9/12/23 at 10:15 A.M., an observation was conducted of an unlocked treatment cart in a hallway continually accessed by residents. An interview was conducted with the Care Manager (CM). The CM stated, That should be locked when not in use. On 9/13/23 at 10:30 A.M., an observational perimeter walk was conducted with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to contain the spread of COVID-19 infection between staff and residents. This failure allowed an outbreak to occur which affected 59 people who became positive for COVID-19 as of 9/4/23. Findings: 1. On 9/11/23 at 9:10 A.M., an observation was made of double fire doors closed between the COVID isolation hall and non-COVID hall. Multiple staff passed through the doors. The Director of Staff Development Assistant (DSDA) entered a Covid isolation room wearing only a surgical mask as PPE. An interview was conducted with the DSDA assistant who stated, We have to gown up for Covid resident rooms. On 9/11/23 at 9:20 A.M., an observation was made of Resident 5 in a wheelchair outside of room [ROOM NUMBER]. Resident 5 was noted to have a productive cough and was unmasked. The Social Services Director (SSD) spoke to the resident but did not redirect her to the Covid unit. The doors to the COVID unit were opened. An unmasked resident in a wheelchair…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure residents were treated with respect and dignity by staff when one resident (Resident 8) expressed concerns, one resident (Resident 14) requested assistance from staff, and other staff and residents overheard personal care concerns for one resident (Resident 12). This failure had the potential for residents to be fearful of making requests and their rights violated. Findings: Resident 8 was admitted to the facility on [DATE] with diagnosis that included unspecified fracture of the right femur (broken right thigh); displaced intertrochanteric fracture of right femur (broken right hip), unsteadiness on feet, nicotine dependence, cigarettes, uncomplicated. On 9/12/23 at 11:50 an interview was held with Resident 8. Resident 8 stated staff were trying to get his roommate, Resident 7, to walk on his own, and Resident 8 told staff that Resident 7 could not because of a stroke. Resident 8 stated staff replied that they did not know that. Resident 8 stated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 3 of 3 sampled residents (Resident 1, Resident 2 & Resident 3) were not provided a meal or drink substitute of their preference when: Resident 1 & Resident 2 did not receive their preferred choice of soy milk with their meal. Resident 3 received chicken and gravy instead of fish for lunch instead of his documented preference of a hamburger. This deficient practice did not accommodate Resident's 1, 2 & 3's food preferences and placed them at risk of altered nutrition. Findings: 1.Resident 1 was admitted to the facility on [DATE] with a diagnosis of malnutrition (a condition when the body does not receive enough nutrients to keep tissues and organs healthy) per the facility ' s admission record. On 9/15/23 at 1:11 P.M., an observation and interview were conducted with Resident 1. Resident 1 was observed in bed with a lunch tray at her bedside table. Resident 1's meal ticket on her lunch tray indicated Resident 1 had, milk listed as a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to inform a Responsible Party (RP) for one of one sampled residents, (Resident 1) of a change in antipsychotic (a type of prescription psychiatric medication) medication order. This failure violated the rights of Resident 1's RP. Findings: 1. A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Dementia with other behavioral disturbance (impaired ability to remember, think, or make decisions that interfere with everyday activities). On 9/14/23 at 10:45 A.M., an interview and concurrent record review was conducted with the Minimum Data Set nurse (MDS). The MDS stated, There was no note about notifying the RP prior to the discontinuation of the Seroquel (an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia and bipolar disorder). The normal process is to speak to the RP prior to medication changes. 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 observation, interview, and record review, the facility failed to create a comprehensive person-centered care plan for two of two sampled residents (2, 3) reviewed for psychotropic medication care plan. This failure had the potential to not identify and meet the needs of two residents. Findings: 1. A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included major depressive disorder single episode (persistently low mood diagnosed on ce), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), schizoaffective disorder unspecified (a mental health disorder that is marked by a combination of schizophrenia symptoms and mood disorder symptoms) and unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (A condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems but…

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 document an appropriate reason for prescribing an antipsychotic medication for two of three sampled residents (1,2). This failure had the potential to harm Resident 1 and 2. Findings: 1. A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Dementia with other behavioral disturbance (impaired ability to remember, think, or make decisions that interfere with everyday activities). On 9/12/23 at 9:35 A.M., an observation and interview were conducted with Resident 1. Resident 1 was alert and oriented to person, place, month, and year. On 9/13/23 at 12:25 P.M., an interview and concurrent record review were conducted with the Regional Quality Management Consultant (RQMC). The RQMC stated, Seroquel was discontinued on 7/7/23. There were no behaviors documented after the medication was discontinued. The Psychiatric Progress Note dated 7/12/23 showed no indication 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 resident's motorized wheelchair were accounted for one of one sampled resident (Resident 1). This failure resulted in Resident 1's motorized wheelchair unaccounted for. Findings: Resident 1 was re-admitted to the facility on [DATE] with the diagnosis of quadriplegia (loss of ability to move both arms and legs) according to Resident 1's admission Record. During an interview on 7/10/23, at 9:49 A.M., with Resident 1, Resident 1 stated the facility was unable to find her motorized wheelchair. Resident 1 further stated the facility delivered a motorized wheelchair but Resident 1 stated, it was the wrong one. An observation was conducted on 7/10/23, at 12:22 P.M. The East station of the facility did not have any motorized wheelchair in the hallway or outside of resident rooms. At 2:22 P.M., the [NAME] station and the activity room was also observed and there were no motorized wheelchairs stored. The Director of Rehab (DOR) 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 provide adequate number of staff to respond to resident's daily needs for three of three sampled residents (Resident 1, 11 and 2) when: 1. Resident 1 waited one hour and a half to be cleaned after a bowel movement. In addition, Resident 1 waited four hours to receive a stool softener. 2. Resident 11 waited an hour to get assistance to use the restroom. 3. Resident 2 waited 45 minutes to get assistance to use the restroom. This failure resulted in resident's need not being met timely. Findings: 1. Resident 1 was admitted to the facility on [DATE] with the diagnosis of pressure ulcer (bed sore) of sacral region (bottom of the spine and above the tailbone) according to Resident 1's admission Record. A review of Resident 1's Minimum Data Set (MDS-tool that measures health status of residents) dated 5/26/23, was conducted. The MDS indicated Resident 1's Brief Interview for Mental Status (BIMS) score was 15, cognitively intact. During 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 observation, interview, and record review, the facility failed to identify and provide treatment interventions for residents with impaired skin conditions (2,3). As a result, Residents 2 and 3 did not receive appropriate treatment according to standards of care. A review of Resident 2 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness, unsteadiness on feet (walking in an abnormal or uncoordinated manner), paraplegia (the inability to voluntarily move the lower parts of the body) and type two diabetes mellitus (abnormal blood sugar condition that can cause foot damages). On 8/1/23 at 9:45 A.M., an observation and interview were conducted of Resident 2. Resident 2 had dressings on both of his feet. Resident 2 ' s heels were resting directly on the bed with one dressing on the ball of his right foot (the area where the toes attach to the foot), one on his right heel and one on his left heel. A small amount of dark red…

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.