Vale Healthcare Center

Based on observation, interview and record review, the facility failed to maintain an effective infection control program when:1.The specimen refrigerator (a specimen refrigerator is a specialized cooling unit used to store various biological samples collected from patients, such as urine, stool, blood, or tissue) was observed to be stored in the same room with the ice container for residents' consumption. 2. Station 2 medication storage room drawer was found to be disorganized and contained medications mixed with specimen sample containers, central line dressing kit, needles and socks stored together. (a specimen container is used to store various biological samples collected from patients, such as urine, stool, blood, or tissue; Central Line Dressing kits are used for very clean resident dressing changes). These failures placed the facility residents at increased risk of healthcare associated infections. Findings:1.During a concurrent observation and interview on 7/22/25, at 4:19 p.m., with Registered Nurse Supervisor (RNS) 3, in the Station 1 utility room, the specimen…

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 and interviews, the facility had three Resident rooms (Rooms 35, 41 and 43) with multiple beds that provided less that 80 square feet (sq. ft) per Resident who occupied these roomsThis deficient practice had the potential to result in inadequate space for the delivery of care to each Resident in each of these rooms and/or for storage of the Resident's belongings.Findings: During an observation 7/24/25 at 3:15 p.m., following rooms and corresponding sq. ft per bed were identified: room [ROOM NUMBER] had three beds, total sq. ft. is 231.6 and 77.2 sq. ft. per bed. room [ROOM NUMBER] had three beds, total sq. ft. is 231.6 and 77.2 sq. ft. per bed. room [ROOM NUMBER] had three beds, total sq. ft. is 231.6 and 77.2 sq. ft. per bed.During an interview on 7/24/25 at 12:32 p.m. with Resident 107, Resident 107 stated regarding the room size that it feels at little like a cubicle but making do and not to bothersome.During an interview on 7/24/25 at 12:43 p.m. with Resident 44, Resident 44 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.

Based on interview and record review, the facility failed to update the code status (a medical term that indicates a patient's wishes regarding resuscitation and life-saving measures in the event of a medical emergency) for Resident 193.This deficient practice had the potential to result in the resident receiving treatments they may not want which could prolong their suffering or interventions inconsistent with their values and/or preferences.Findings: During a review of Resident 193's Face sheet, [undated], the Face sheet, indicated, that Resident 193 was admitted to the facility 7/9/25 and there was no Advance Directives (AD-a written statement of a person's wishes regarding medical treatment) or code status noted for this Resident. During a review of Resident 193's Progress Notes, dated 7/18/25, the Progress Notes, indicated, that at 8:50 p.m. Resident 193 was found unresponsive, no pulse, no respiration.Registered Nurse (RN) declare the time of death at 8:50 p.m. During a review of Resident 193's Physician Orders for Life-Sustaining Treatment (POLST- document to ensure that 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 follow up on a grievance for one of 36 sampled residents (Resident 38).This resulted in Resident 38's grievance to go unresolved. During a review of Resident 38's Facesheet (information containing contact details, brief medical history at a glance), the Face Sheet indicated, Resident 38 was admitted to the facility on [DATE]. Review of the resident's Minimum Data Set (MDS, an assessment tool used to guide care) dated 5/1/25, indicated Resident 38 had a brief interview for mental status or BIMS score of 15 (BIMS score of 13-15 indicates intact cognition).During an interview with Resident 38 on 7/21/25 at 12:03. p.m., Resident 38 stated my 500 dollars was stolen a few months ago and nothing has been done about it. Resident 38 also stated he had reported the missing money to the Director of Nursing (DON) and had not heard anything back.During a concurrent interview and record review, on 7/23/25, at 3:25 p.m., with DON, DON stated Resident 38 informed her…

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, for one of three sampled residents (Resident 200) who smoked, the facility failed to ensure a baseline care plan was developed to address Resident 200's smoking.This failure had the potential to result in the lack of interventions to promote safe smoking.During a review of Resident 200's RFS, the RFS indicated Resident 200 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis (infection in the bone), severe sepsis (serious condition resulting from the body's response to infection, can lead to tissue damage and death if not treated promptly), and generalized anxiety disorder (mental health condition, persistent and excessive worry about various aspects of life). During an observation and interview on 7/22/25 at 4:42 p.m. with Resident 200, there was an open pack of cigarettes on the overbed table. Resident 200 stated going out to smoke four times a day and that the facility staff had allowed cigarettes to be kept at the bedside. During…

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, for two sampled residents (Resident 199 and 200), the facility failed to ensure an environment free of accident hazards and failed to ensure residents receive adequate supervision when:1. Resident 199 left the facility unsupervised. This failure had the potential to result in significant risks to resident's safety.2. Resident 200 had cigarettes at the bedside. This failure had the potential to result in fire hazards. 1.During a review of Resident 199's Resident Face Sheet (RFS), the RFS indicated Resident 119 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke), other non-toxic encephalopathy (brain disease), congestive heart failure and pleural effusion (fluid buildup around the lungs).During an interview on 7/21/25 at 10 a.m. with Resident 199, Resident 199 stated there was no reason to stay in the facility, and that staying longer would make Resident 199 lose the apartment. Resident 199 had expressed wanting to go…

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, for one of three (Resident 112) sampled residents reviewed for behavioral health services, the facility failed to follow the psychiatrist's recommendation when Complete Blood Count (CBC, a common blood test that measures various components of your blood that included red blood cells, white blood cells, hemoglobin, etc. ), Basic Metabolic Panel (BMP, blood test that measures glucose, calcium, electrolytes, etc. to detect conditions such as liver and kidney disease and diabetes) and Urinalysis (UA, used to detect and manage disorders such as urinary tract infection, kidney disease and diabetes) and Culture and Sensitivity (C&S, used to diagnose urinary tract infection and guide antibiotic therapy) were not conducted.This failure had the potential to result in undetected abnormal blood levels due to current treatment. During a review of Resident 112's Resident Face Sheet (RFS), the RFS indicated Resident 112 was admitted to the facility in July 2024 with diagnoses that included cellulitis of the left lower limb, acute kidney failure, sepsis…

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 Resident 91 was updated regarding the status of her power wheelchairThis deficient practice had the potential to result in a significant impact on the resident's independence, quality of life, physical and mental health. During a review of Resident 91's Face sheet, dated 7/24/25, the Face sheet indicated, an initial admission date of 11/3/2018 and latest return date of 7/20/25. During a review of Resident 91's Face sheet, dated 7/24/25, the Face sheet indicated, Resident 91 had diagnoses to include: chronic obstructive pulmonary disease (COPD-chronic lung disease that makes it hard to breathe), diabetes mellitus type 2 (body either doesn't produce enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels), chronic pain, anxiety disorder (excessive, persistent, and unreasonable fear and worry, often interfering with daily life), Major Depressive Disorder (MDD,persistent sadness, loss of interest, and other symptoms that significantly impair daily life),…

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, record review and interviews, the facility failed to provide call system (allows patients to request assistance from healthcare staff, typically nurses, by activating a call button or other alerting device. These systems are crucial for patient safety and efficient care delivery, enabling patients to quickly summon help when needed) to Resident 107.This deficient practice had the potential to result in resident having trouble accessing help for medication needs basic comfort or hygiene needs to prevent falls.Findings:During a review of Resident 107's Face sheet, [undated], the Face sheet indicated, Resident 107 was admitted to the facility 4/9/24 and has diagnoses to include Chronic Obstructive Pulmonary Disease (COPD- condition caused by damage to the airways or other parts of the lung), Fracture of Left and Right Humerus (break in the upper arm bones), Vertigo (sensation that you or your surroundings are spinning or moving) Anxiety (feelings of worry, nervousness, or unease) and Depression (mood disorder that can affect how you think, feel, and handle daily…

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 track, find, replace, and follow up with two of two Residents (Resident 2 and Resident 3) whose dentures were lost at the facility. This failure resulted in two Residents not having their teeth to eat and talk which impacted their dignity and psychosocial well-being. Findings: During a review of Resident 2 ' s admission record titled Face Sheet, undated, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] for Heart Failure (A chronic condition where the heart doesn ' t pump blood as well as it should.). During a review of Resident 2 ' s Minimum Data Set (MDS- an assessment tool to guide care), the MDS assessment indicated Resident 2 had a Brief Interview for Mental Status (BIMS- a mental status exam) score of 15 indicating intact cognition. The MDS assessment also indicated Resident 2 required set up and assistance with oral hygiene, to include managing, denture soaking, and rinsing with use of equipment. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice when: 1. For one of four sampled residents (Resident 3), the Interdisciplinary Team ' s (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their residents) recommendation for Psychology (Psych) Consult related to an abuse allegation was not referred by Social Services (SS) Department. This failure had the potential to put Resident 3 ' s safety at risk and could lead to abuse re-occurrence and resident feeling depressed, angry, and vulnerable. 2. For one of four sampled residents (Resident 1), an appropriate physical abuse care plan (CP, a document that outlines the resident ' s assessment health and social care needs and how it will be supported) was not created. This failure had the potential to put Resident 1 ' s safety at risk and for resident to not receive the care that he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer medications timely for one of three sampled residents (Resident 1), when multiple medications for Resident 1 were administered after the ordered administration time. This failure had the potential for exacerbating Resident 1's health condition and compromising their overall health and well-being. Findings: A record review of Resident 1 ' s Face Sheet, (undated), indicated Resident 1 was re-admitted to the facility on [DATE] with primary diagnoses including Human Immunodeficiency Virus (HIV, a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases), Chronic Obstructive Pulmonary Disease (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis), End-Stage Renal Disease (ESRD, the final stage of long-term kidney disease when the kidneys are no longer sufficiently able to remove waste…

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 expired medications and COVID (a virus like the cold or flu) test kits were discarded when they were kept with ready to use medications in medication storage areas. This failure had the potential to result in residents receiving abnormal COVID test results, less potent or less effective doses of the medication which can lead to new health problems or adverse reactions. Findings: During an observation and interview on 05/21/24 at 2:18 p.m., with Registered Nurse (RN) Supervisor, in Nursing Station One refrigerator, an Emergency kit (E-kit- a small quantity of medications that can be used when pharmacy services are not available) was observed with two red tag clips. Expiration (EXP) date on this E-kit was observed to be 04/24. Opened this, E-kit had and it was observed to have the following expired meds in it: -Levemir 100 unit (u)/milliliter (ml) (medication used for high blood sugar) (EXP: 06/23) -Novolog 100 u/ml (medication used for high blood sugar) (EXP:02/23) -Novolin R 100 u/ml (fast acting…

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, medical record and document review, the facility failed to provide services for activities of daily living for 2 (Resident 36 and 73) of 35 sampled residents when: 1. For Resident 73, fingernails were long and had black debris under the fingernails. 2. For Resident 36, feet were dry and toenails long. 3. For Resident 36, nursing staff did not get resident up in his wheelchair for a substantial period of time. These failures resulted in basic needs necessary for a quality of life not being met. Findings: 1. During an observation on 5/20/24, at 9:42 a.m., Resident 73 was sitting in a wheelchair in the hallway. Resident 73 had black debris under his fingernails to both hands. Resident was not interviewable. During an observation and concurrent interview on 5/21/24, at 9:50 a.m., Resident 73 was sitting in a wheelchair in the hallway. Resident 73 had black debris under his fingernails of both hands. The licensed vocational nurse (LVN 1) stated his fingernails were dirty. LVN 1 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 interview and record review, for one of two sampled residents (Resident 178), the facility failed to respond to a pharmacist's Medication Regimen Review (MRR, a thorough evaluation of the medication regimen of a resident) recommendations when facility did not act upon pharmacy recommendations for Resident 178's psychoactive medications behavior and side effects monitoring and Lisinopril pulse monitoring. These failures had the potential for missed opportunities to prevent, identify, report, and resolve medication-related problems, medication errors, and/or other irregularities for Residents 178. Findings: A review of Resident 178's Resident Face Sheet indicated Resident 178 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease (a progressive disease that affects memory, thinking, and behavior) and dementia (memory loss). A review of Resident 178's Minimum Data Set (MDS, a resident assessment tool used to provide care), dated 2/24/24, indicated resident was usually able…

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 maintain a medication error rate below five percent (5%). During the medication pass on 05/21/24, three medication errors were observed out of thirty-five opportunities for two out of three residents, resulting in an error rate of 8.57%. This failure had the potential to result in more than minimal changes in the health and safety of Residents 78 and 155's conditions. Findings: During a review of the facility's policy and procedure (P&P) titled Medication Pass Guidelines [undated], it was indicated that Physician's Orders - Medications are administered in accordance with written orders of the attending physician. During a review of the facility's policy and procedure (P&P) titled Nursing Care Center Pharmacy Policy & Procedure Manual-Medication Administration, dated 2007, it was indicated Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record (MAR) .Medications are administered in accordance with the written orders of the…

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

Based on observation, interview and record review, the facility failed to ensure safe, sanitary storage of food when: 1. A thawed pork loin tied closed with a disposable glove was found on a dirty plastic platform and was not labeled with a thaw or use by date, 2. The same thawed pork loin was later found in the freezer and red liquid was leaking from the package. This failure had the potential to place all residents getting meals from the kitchen to be at risk for foodborne illness potentially leading to hospitalization or death. Findings: 1. During an observation on 5/20/24, at 9:30 a.m., the kitchen walk-in refrigerator was inspected. A pork loin was resting on a plastic platform. The pork loin had a disposable glove tied to one end of the package to close the package. The plastic platform had accumulated debris on the surfaces which the pork loin was resting. The pork loin did not have a label indicating the thaw or use by date. During a concurrent observation and interview on 5/20/24, at 9:40 a.m., with Certified Dietary Manager (CDM), in the walk-in refrigerator the CDM 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.

Based on observation, interview and record review, the facility failed to provide accurate pain assessment and pain management for one of 60 sampled residents (Resident 18) when Resident 18's left foot pain was not accurately and regularly assessed using an appropriate pain scale (numerical expression of pain severity out of ten, 0, no pain, 1-3 mild pain, 4-7 moderate pain and 8-10 severe pain) and pain medications were not provided in a timely manner. This failure resulted in Resident 18 having 9/10 to 10/10 left foot pain which was not relieved for over one hour and was not accurately assessed during administration of pain medications delaying additional pain interventions. Findings: A review of Resident 18's admission record indicated an admission date of 4/2024 for a diagnosis of Crohn's disease (disease affecting the digestive tract), peripheral vascular disease (disorder of the blood vessels causing reduced blood flow) and unspecified atrial fibrillation (a disease of the electrical conduction of the heart). A record review of Resident 18's minimum data set (MDS, a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect one of four sampled residents (Resident 3) from physical abuse when Resident 2 attempted to hit Resident 3 with Resident 2 ' s walker. The failure to protect Resident 3, a wheelchair dependent resident, from Resident 2, a resident with known aggressive behaviors, caused Resident 3 to slide off her wheelchair to the floor and had the potential to cause Resident 3 emotional and/or psychological distress. Findings: A review of Resident 3 ' s Face Sheet, dated 12/7/23, indicated resident was admitted to the facility on [DATE] with diagnoses of dementia (memory loss) and Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A review of Resident 3's Minimum Data Set (MDS, a comprehensive assessment tool to guide care), dated 10/18/23, indicated Brief Interview for Mental Status (BIMS, a screening tool to identify resident's cognitive status) score of 8, which showed Resident 2 had mildly impaired…

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, for one of four sampled residents (Resident 2), the facility failed to evaluate the effectiveness of the care plan and update as needed to include measurable objectives and timeframes to meet Resident 2 ' s immediate care and psychosocial needs. This deficient practice resulted in a care plan that did not accurately reflect specific medical interventions necessary to meet the resident ' s current nursing care needs. Findings: A review of Resident 2 ' s Face Sheet, dated 12/7/23, indicated resident was admitted to the facility on [DATE] with diagnoses of cerebral infarction (also known as stroke, refers to damaged tissues of the brain) and depression. A review of Resident 2's Minimum Data Set (MDS, a comprehensive assessment tool to guide care), dated 9/7/23, indicated Brief Interview for Mental Status (BIMS, a screening tool to identify resident's cognitive status) score of 12, which showed Resident 2 had intact cognitive function. The MDS indicated Resident 2…

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 four sampled residents (Resident 1) was referred to and provided Podiatry Services. This deficient practice resulted in Resident 1 having pain and at risk of injury because of his thick, long toenails to left foot. Findings: A review of Resident 1's Face Sheet, undated, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of Diabetes Mellitus (increased blood sugar level) and venous insufficiency (a condition when the heart cannot pump blood from the leg veins back to the heart). A review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment tool to guide care), dated 11/21/23, indicated Brief Interview for Mental Status (BIMS, a screening tool to identify resident's cognitive status) score of 15, which showed Resident 1 had intact cognitive function. A review of Resident 1 ' s Physician Order Report, dated 11/7/23-12/7/23, indicated, Start Date 11/19/22 – Refer to Podiatry Services 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 interview and record review, the facility failed to ensure an allegation of abuse was reported to appropriate authorities within the required regulatory timeframe for one of three sampled residents (Resident 1) when: Resident 1 had a verbal altercation with Certified Nursing Assistant 1 (CNA 1) on 5/22/23, at 11 a.m., but was not reported by either CNA 1 or the witness staff CNA 2 until Resident 1 herself reported the incident to administration on 5/22/23, at 5:30 p.m. This failure resulted in the potential to negatively impact the protection of Resident 1 and the other residents in the facility from abuse. Findings: A review of Resident 1's Face Sheet, undated, indicated Resident 1 was admitted to the facility in November 2018, with diagnoses of morbid obesity, depression, and anxiety disorder. A review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 4/26/23, indicated Resident 1 had a score of 15 on the Brief Interview for Mental Status exam. (BIMS is a scoring system used to determine the resident's cognitive status regarding…

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 protect one of three sampled residents (Resident 1), from abuse when: Certified Nursing Assistant 1 (CNA 1) had a verbal altercation with Resident 1, called the resident inappropriate names, and threatened to run over resident with CNA 1's car when resident goes out to the store. This failure resulted in Resident 1 feeling upset, intimidated, and scared creating emotional distress. Findings: A review of Resident 1's Face Sheet, undated, indicated Resident 1 was admitted to the facility in November 2018, with diagnoses of morbid obesity, depression, and anxiety disorder. A review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 4/26/23, indicated Resident 1 had a score of 15 on the Brief Interview for Mental Status exam. (BIMS is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. The scale is from zero to 15, with a score of 15 as intact cognition). The MDS indicated Resident 1 was 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 ensure two of two residents (Resident 17, Resident 133) with a gastrostomy feeding tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach) received adequate nutrition and fluids when: 1.Resident 17's tube feeding was not administered according to physician order, the dietician recommendations were not communicated to the physician, and his weights were not monitored in three of the preceding six months. 2. Resident 133's tube feeding was not administered according to physician order, and the dietician recommendations were not communicated to the physician. These failures had the potential to result in undesirable weight loss or weight gain, dehydration, and malnutrition. Findings: 1. During a review of Resident 17's admission Record, undated, the record indicated Resident 17 was admitted to the facility in 2021. The admission Record indicated Resident 17 had difficulty swallowing, was on a tube…

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

Based on observation, interview, and record review, the facility failed to maintain staff competency records for four of four sampled licensed staff: Licensed Vocational Nurse 3 (LVN 3), Licensed Vocational Nurse 4 (LVN 4), Registered Nurse 1 (RN 1), and Registered Nurse (RN 2). This failure had the potential to result in inadequate and/or inappropriate nursing care for any of the 176 residents. Findings: During an interview with Director of Staff Development (DSD) on 7/28/22, at 10:01 a.m., in Sunshine Dining room, DSD stated she was responsible for maintaining documentation and records of staff training and staff probationary and annual evaluations. DSD stated the nursing staff probationary period was ninety days from date of hire. A review of the facility Employee Performance Appraisal form dated May 2021, indicated the purpose of the form was to, reflect the overall performance of the employee considering each factor as knowledge, skills, and abilities, but primarily on whether the employee 's performance produced the desired results. The form had seven sections titled: Job…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. During a review of Resident 18's Physician's orders dated [DATE], the order indicated resident was on a prescription mouthwash, Peridex, two times a day. During a concurrent observation and record review on [DATE] at 10:20 a.m., a bottle of Peridex prescription mouthwash was on Resident 18's bedside table. The label indicated the name of a resident, not Resident 18's name, at the top of the label, with black lines across the resident name. During an interview on [DATE] at 10:20 a.m. with Certified Nursing Assistant 7 (CNA 7), CNA 7 stated she had used the prescription mouthwash with the scratched label to clean Resident 18's mouth that morning. During an interview with Registered Nurse Supervisor (RNS) on [DATE] at 10:13 a.m., stated medication belonging to another resident should not be left at Resident 18's bedside, or used for Resident 18. During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration General Guidelines, dated 1/21 indicated Medications supplied for 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.

Based on observation, interview and record review, the facility failed to ensure its medication error rate did not exceed five percent. There were eight medication errors out of 25 opportunities for error that totaled 32 percent (%) error rate when: 1. Resident 35 received four medications more than one hour after the scheduled administration time: metoprolol (used to lower blood pressure and treat heart failure), Xarelto (a blood thinner used to prevent clot formation which can cause heart attacks and strokes), hydrochlorothiazide (used to increase urination), hydrocodone (used for pain control). 2. Resident 170 received four medications more than one hour after the scheduled administrations time: furosemide (to reduce fluid retention), methadone (for pain control), spironolactone (used to increase urination), intravenous vancomycin (an antibiotic given directly into the bloodstream through a tube inserted into a vein). The failure to ensure nurses administered medications within one hour of the scheduled administration time had the potential to result in medications being less…

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 5. A review of Resident 97's face sheet, undated, indicated Resident 97 was admitted in 2019, with diagnoses of chronic kidney disease, diabetes mellitus (the body's inadequate production of the hormone insulin results in high blood sugar levels causing excessive urination and damage to body organs), and dementia (a chronic progressive disease marked by memory loss, personality changes and impaired reasoning). A review of Resident 97's Prescription Order, dated [DATE], indicated three units of Novolog U-100 Insulin, (an insulin preparation with a concentration of 100 Units per milliliter) was to be injected before meals, three times a day at 6:45 a.m., 11:45 a.m., and 4:45 p.m. The Order indicted the medication was needed for treatment of Resident 97's diabetes mellitus. A review of Resident 97's Minimum Data Set (MDS, a resident assessment tool used to guide care), dated [DATE], indicated Resident 97 had an active diagnosis of diabetes mellitus and had received daily injections of insulin in the seven-day…

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 use proper food handling techniques when in the kitchen during tray line, the hair for two dietary staff was not completely restrained with a hairnet. This failure had the potential to result in foodborne illness. Findings: During an observation on 7/27/22, at 12:08 p.m., in the kitchen, Dietary Aide 1 (DA 1) was in the tray line, plating food for lunch, with a hairnet only covering the back portion of her hair, leaving the top and front portion of her hair uncovered. During a concurrent observation and interview on 7/27/22, at 12:10 p.m., with Dietary Aide 2 (DA 2), in the kitchen, DA 2 was plating food with a hairnet covering only the crown of her head. DA 2 stated it was important to have a hairnet covering the entire head of hair so that no hair could drop into the food, which would be unsanitary. During an interview on 7/27/22, at 12:13 p.m., with the Dietary Manager (DM), in the kitchen, the DM stated dietary staff must wear hairnets to cover the entire head of hair, so that hair did not fall into…

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 infection control policies and procedures were followed when: 1. One employee did not perform hand hygiene per protocol when doffing and donning gloves when providing direct care for one (Resident 56) of 35 sampled residents. 2. One employee did not wear appropriate Personal Protective Equipment (PPE, protective items or garments worn to protect the body or clothing from hazards that can cause injury) as required in the area for persons under investigation for infection with COVID (yellow zone) when caring for one (Resident 92) of 35 sampled residents. 3. Facility nurses did not date and initial the newly changed dressing of Resident 157's percutaneous line (a needle is inserted into a vein and a tube threaded through the needle and into the vein until reaching a high blood flow area in the trunk of the body). 4. Three medication carts had white particulates on top of the carts. 5. Nursing staff had not disinfected or cleaned a medication tray used to distribute medications between two residents. 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 assist one (Resident 38) of 35 sampled residents with bathing according to her preferences. This failure had the potential to result in emotional distress and decreased self-esteem from not receiving showers for two years. Findings: During a review of Resident 38's admission Record, undated, the admission Record indicated that Resident 38 was re-admitted to the facility in November 2020 with a diagnosis of morbid obesity. During a review of Resident 38's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 4/27/2022, section G indicated Resident 21 needed limited assistance from one person for transfer between surfaces and bathing and was independent in locomotion with use of either a wheelchair or walker. The MDS indicated Resident 38 had unimpaired thinking and remembering skills. The MDS Annual assessment dated [DATE], indicated it was very important to Resident 38 to choose whether to have a tub bath, shower, or…

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 notify the physician for two weeks when one (Resident 13) of 35 sampled residents developed a wound on the buttock. The failure to notify the physician resulted in delay of treatment and had the potential to result in delayed healing and exacerbation of the wound. Findings: During a record review of Resident 13's admission Record, the record indicated Resident 13 was admitted to the facility in 2017. A review of Resident 13's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 7/18/22, indicated he had a diagnosis of dementia (a chronic progressive disease marked by memory loss, personality changes and impaired reasoning). The MDS indicated Resident 13 had highly impaired vision, moderate difficulty hearing, unclear speech, was sometimes able to understand others, and was usually able to make himself understood. The MDS indicated Resident 13 required extensive physical assistance from one person for bed mobility and locomotion, and total assistance from one person for personal hygiene…

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 update a comprehensive nutrition care plan that described services to be furnished for one (Resident 17) of 35 sampled residents. The failure to have a care plan which described Resident 17's current services and interventions for the nutritional needs associated with use of a gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach) had the potential to result in weight loss, malnutrition, and complications such as pneumonia. Findings: During a review of Resident 17's undated admission Record, the admission Record indicated Resident 17 was admitted to the facility in 2021. The admission Record indicated Resident 17 had difficulty swallowing, was on a tube feeding via gastrostomy tube, was unable to speak, and was unable to move himself in bed due to contractures (arm and leg are tight and prevent stretching of the limbs) from a cerebral infarction (damage to the brain, from interruption of the blood supply). During a review of the quarterly Minimum Data Set (MDS, an…

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

Based on observation, interview, and record review the facility failed to ensure one (Resident 21) of 35 residents received grooming assistance. This failure resulted in Resident 21 feeling uncomfortable due to long fingernails with black material under the nail tips and had the potential to result in scratches and infection. Findings: During a review of Resident 21's admission Record, the admission Record indicated that Resident 21 was admitted to the facility in January 2022. During a review of Resident 21's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 4/21/2022, the MDS indicated Resident 21 had a diagnosis of dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities), but was able to understand others and be understood. The MDS indicated Resident 21 needed extensive assistance from one person for personal hygiene and grooming. During a concurrent observation and interview on 7/25/22, at 10:40 a.m., Resident 21 had thickened fingernails extending beyond the end of his fingertips with…

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

Based on observation, interview, and record review the facility failed to ensure one (Resident 173) of 35 residents received toenail care assistance according to the Resident's preferences. This failure had the potential to result in decreased self-esteem, decreased ability to wear shoes comfortably, and be scratched by the long toenails. Findings: During a review of Resident 173's admission Record, undated, the admission Record indicated Resident 173 was admitted to the facility in January 2022 with a diagnosis of paraplegia. During a review of Resident 173's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 7/8/2022, the MDS indicated Resident 173 was able to understand and be understood and had unimpaired thinking and remembering skills. The MDS indicated Resident 173 was totally dependent on one person for personal hygiene and grooming. During a concurrent observation and interview on 7/25/22, at 11:56 a.m., in Resident 173's room. Resident 173's bare left foot had toenails which extended beyond the ends of the toes by one quarter inch. Resident 173…

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 respond to a pharmacist's medication regimen review recommendation for one (Resident 136) of 35 residents for more than 30 days. The failure to respond to the recommendation for a gradual dose reduction of the medication aripiprazole (a psychotropic medication, a medication that affects brain activities associated with mental processes and behaviors) had the potential to result in adverse side effects from continued use for Resident 136 such as stroke, seizures, and suicide. Findings: During a review of Resident 136's face sheet dated 7/29/2022 the record indicated that Resident 136 was admitted to the facility on [DATE] with a diagnosis of dementia (a chronic progressive disease marked by memory loss, personality changes and impaired reasoning). During a review of Resident 136's Physician Order Report for 6/29/22 to 7/29/22, the Physician Order Report indicated an order, start date 6/17/2022 for daily administration of 15 milligrams (mg) 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 interview and record review, the facility failed to accurately document entries for two of two sampled residents (Resident 106 and Resident 128) on the Skilled Nursing Facility Advanced Beneficiary Notice (ABN). This failure resulted in incomplete and inaccurate records. Findings: During a record review of Resident 106's undated Face Sheet, the Face Sheet indicated Resident 106 was admitted to the facility in 2017. During a record review of Resident 106's NOMNC, the NOMNC indicated the last day of Medicare part A coverage was 4/15/22. During a record review of Resident 128's undated Face Sheet, the Face Sheet indicated Resident 128 was admitted to the facility in 2015. During a record review of Resident 128's NOMNC, the NOMNC indicated the last day of Medicare part A coverage was 5/24/22. A review of the SNF ABN form (form CMS-10055, 2018) indicated, Signing below means that you've received and understand this notice During a concurrent interview and record review with the Social Service Coordinator (SSC) 1 on 7/28/22, at 10:06 a.m., the SNF ABN notices for Resident 106 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.