Northgate Postacute Care

Based on observation, interview, and record review, the facility failed to properly dispose of used fentanyl patches (potent opioid medication used to pain management). This failure had the potential to result in drug diversion, inaccurate medication accountability and unsafe medication management.Findings:During a concurrent observation and interview on 8/20/2025 at 11:36 a.m. with Licensed Vocational Nurse (LVN 2), in the east wing hallway, the medication cart had nine opened and used fentanyl patches stored in a plastic cup. LVN 2 stated the fentanyl patches needed to be disposed of by the Director of Nursing (DON).During an interview on 8/20/2025 at 12:39 p.m. with the DON, the DON stated used fentanyl patches should not have been stored in the medication cart and should have been brought to the DON for proper disposal.During an interview on 8/21/2025 at 3:43 p.m. with the Pharmacist (Pharm), the Pharm stated used fentanyl patches should be cut up and placed into a disposal bin that was filled with liquid to ensure it was unable to be reused. The Pharm further stated fentanyl…

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 safely store and label drugs in accordance with acceptable standards of practice when:1. One medication cart was left unlocked and unattended. This failure had the potential to result in residents and staff obtaining unauthorized access to medications and supplies that could lead to adverse effects.2. An open bottle of Senna syrup (laxative medication used to stimulate a bowel movement), stored in the medication cart did not have an expiration date. This failure had the potential to result in Senna syrup having a reduced effectiveness, potential bacterial contamination and unpredictable side effects.Findings:1.During an observation on 8/20/2025 at 8:27 a.m. in the hallway of the west wing between room [ROOM NUMBER] and room [ROOM NUMBER], Licensed Vocational Nurse (LVN 1) was standing next to the medication cart and walked away into room [ROOM NUMBER]. The medication cart was left unlocked and unattended.During a concurrent observation and…

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

This REQUIREMENT is NOT MET as evidenced by the following:Based on observation, interview, and record review, the facility failed to ensure garbage was properly disposed of when trash was observed on the ground and in an unsecured garbage dumpster, creating an unsanitary environment with the potential to attract pests.Findings:During an observation on 8/20/2025 at 7:41 a.m. in the facility's garbage storage area, one trash dumpster was observed with both lids unsecured and open due to overflowing garbage. Multiple bags and boxes of trash were also observed on the ground in the garbage storage area.During an interview on 8/20/2025 at 11:20 a.m. with Certified Dietary Manager (CDM), CDM stated leaving trash unsecured and on the ground was unacceptable because it attracts pests and rodents to the facility.During a review of the facility's policy and procedure (P&P) titled, Garbage and Trash, dated 2023, the P&P indicated, Adequate, clean, vermin-proof areas must be provided for storage of garbage and rubbish.all food waste must be placed in sealed leak-proof, non-absorbent, tightly…

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 hospice services met professional standards for one of 15 sampled residents (Resident 36) when:1. The Hospice Registered Nurse (HRN) left Resident 36 exposed to the public for approximately 22 minutes, with no clothes from the waist to the feet.2. The Hospice Registered Nurse's (HRN) conduct was unprofessional towards Resident 36.These failures had the potential to cause physical and psychosocial harm to Resident 36.Findings:1.During a review of Resident 36's admission Record, dated 8/23/2025, the admission record indicated Resident 36 was admitted to the facility on [DATE] with a diagnoses of dislocation of internal left hip prosthesis (a condition where surgically implanted left hip comes out of place) and Huntington's disease (a condition in which nerve cells in the brain break down over time). During a review of Resident 36's Patient Billing/Care Level Change, document dated 8/4/2025, the document indicated, Resident 36 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 identify the need to place one of 15 sampled residents (Resident 37) on Enhance Barrier Precautions (EBP-infection control strategy used to prevent spread of bacteria), while having multiple open wounds. This failure had the potential to result in the spread of dangerous multidrug-resistant organisms (MDROs) among the residents and staff.Findings:During a review of Resident 37's admission Record, dated 8/21/2025, the admission record indicated Resident 37 was admitted to the facility on [DATE] with diagnosis of complete traumatic amputation (surgical removal) of the left midfoot.During a concurrent observation and interview on 8/18/2025 at 4:08 p.m. with Resident 37, in Resident 37's room, Personal Protective Equipment (PPE, specialized clothing and equipment to protect infectious agents) and EBP signage were not posted outside of Resident 37's room. Resident 37 had a white kerlix (woven gauze used for absorbing fluids), bandage on 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, the facility failed to maintain equipment in a safe and operating condition when:One of the laundry machine was covered in rust and was broken.The bed locks for Resident 36 were not working. These failures had the potential to affect the resident's health and safety. Findings:1.During a concurrent observation and interview on 8/19/2025 at 2:05 p.m. with the Housekeeping Staff (HSK) and the Maintenance Director (MDR), in the laundry room, two laundry machines were observed. One of the laundry machine was broken and covered with rust. The MDR confirmed one of the laundry machines was broken. The HSK stated the broken laundry machine had been broken for quite some time, and it delayed the laundry process for the residents. During an interview on 8/21/2025 at 2:53 p.m. and at 4:59 p.m., with the MDR, the MDR stated the broken laundry machine should be repaired as soon as it is found to be broken, to better serve the residents and for the safety of the staff. MDR…

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 handrail was secured to the wall. This failure had the potential to result in residents utilizing an unstable handrail that could subsequently cause a sudden fall and serious injuries.Findings:During an observation on 8/18/2025 at 4:43 p.m. in the east wing hallway, one handrail on the wall between room [ROOM NUMBER] and 10 had a crack along the seam of the handrail and was not firmly secured to the wall.During a concurrent observation and interview on 8/18/2025 at 5:42 p.m. with the Maintenance Director (MDR) in the east wing hallway, the MDR tugged on the handrail between room [ROOM NUMBER] and 10 and the handrail separated from the wall. MDR stated the handrail should have been secured to the wall and it needed to be reenforced.During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, dated January 2018, the P&P indicated, The maintenance department is responsible for maintaining the buildings,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to notify one of two sampled residents (Resident 1) of their responsibilities as a resident when Resident 1 ' s daily rate for room and board increased twice (on 1/1/24 and 1/1/25) with no advanced written notice and required a security deposit with no advanced written notice. These failures caused financial hardship to Resident 1 who stated, It ' s really ruined my life, and stated she felt poor. Finding: During an observation on 2/5/25 at 9:57 a.m., a sign posted in the facility hallway indicated the private pay daily rate was $525 for a two-bed room. During an electronic medical record review on 2/5/25 at 11:42 a.m., Resident 1 ' s face sheet indicated she was admitted [DATE], payor information indicated Private Pay, and Resident 1 ' s power of attorney for healthcare was Family Member (FM) 4. Review of Resident 1 ' s Minimum Data Set (an assessment tool) dated 12/8/24 indicated a BIMS score of 13 (Brief Interview for Mental Status, 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 maintain signed admission agreements for three of five sampled residents (Residents 1, 2, and 3), and failed to give one of five sampled residents (Resident 1) a copy of the admission agreement. This failure resulted in Resident 1 having no documentation of what daily room rate or security deposit she had agreed to pay on admission, and had the potential to result in Resident 2 or 3 having no document for reference when they need information about the terms of their admission. Finding: During an electronic medical record review on 2/5/25 at 11:42 a.m., Resident 1 ' s face sheet indicated she was admitted [DATE], payor information indicated Private Pay, and Resident 1 ' s power of attorney for healthcare was Family Member (FM) 2. Review of Resident 1 ' s Minimum Data Set (an assessment tool) dated 12/8/24 indicated a BIMS score of 13 (Brief Interview for Mental Status, a score of 13 to 15 indicates no cognitive impairment). During an interview on 2/5/25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Thoroughly investigate an allegation of misappropriation of property per policy, 2. Implement the plan to protect other residents from theft, 3. Maintain a theft and loss log, and 4. Incorporate reported incidents of misappropriation of property into the facility quality assurance and performance improvement (QAPI) program for two of two residents (Resident 1 and Resident 2) with reports of missing debit cards and money missing from their bank accounts. These failures put vulnerable residents at risk of misappropriation of property. Findings: 1. On 1/22/25, the Department received a report from the facility that the police had informed the facility staff that Resident 1's family had reported Resident 1 had lost some money and an investigation was started. During a record review and concurrent interview on 2/6/25 at 12:20 p.m., Administrator verified an untitled, undated document kept in the investigation file for Resident 1's reported lost money…

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 physician visits for one resident (Resident 1)of three sampled residents timely. This failure had the potential to delay detection of declining health and the provision of care. Findings: A review of Resident 1's admission record indicated admission to the facility on 2/14/15 with a diagnosis of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or paralysis on one side of the body) following cerebral infarction (condition where blood flow to the brain is interrupted, causing brain tissue to die) affecting left dominant side. A review of Resident 1's Minimum Data Set (MDS-a federally mandated assessment tool), dated 2/19/25 indicated a Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation and judgement status of the resident) score of 13, which indicated no cognitive (related to processes of thinking and reasoning) impairment. During an interview on 3/3/25, at 10:23 A.M., Resident 1stated…

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 maintain documentation and present evidence of its ongoing Quality Assessment and Performance Improvement (QAPI) program implementation and activities. Findings: During an interview on 1/9/25 at 10:15 A.M., Unlicensed Staff B stated she did not know what the Quality Committee or QAPI was. She stated she did not know if there were any current quality improvement projects. During an interview on 1/9/25 at 10:20 A.M., Unlicensed Staff A and Unlicensed Staff C stated they did not know what the Quality Committee or QAPI was. The stated they did not know of any current quality improvement projects. During an interview with Administrator on 1/9/25, at 11:45 a.m., she stated she could not find a binder for the QAPI Committee. At 11:50 a.m., she provided a QAPI binder for review and stated the only documentation it contained was dated 12/2024. She stated there was no other documentation available. She stated the QAPI was supposed to meet monthly. She stated she did not know what the current QAPI was and if there were any performance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to prevent the infestation of roaches when: 1. Live and dead cockroaches were observed in the pantry and food preparation areas in the kitchen where residents ' food was stored and prepared; 2. Pest technician recommendations for the control of the roaches were not followed; and, 3. The bedroom of two residents (Resident 1 and Resident 2), had roaches crawling in and around their beds causing Resident 1 to stop eating the food from the facility. These failures created an environment for harboring of pests and the potential for contamination of the food prepared and served. Findings: 1. During a kitchen observation on 11/27/24 at 10:08 a.m., a brown winged insect was seen climbing along an electrical cord, up and onto a shelf next to the ice machine and the coffee maker, and directly across from the refrigerator in the kitchen pantry. Insect bait traps were seen in the kitchen pantry and around…

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 three residents (Resident 1) was invited to participate in quarterly care conferences (interdisciplinary meetings to review and revise residents care plans). This failure deprived Resident 1 from providing input into the care and services provided to him at the facility. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE], with a primary diagnosis of generalized anxiety disorder. A review of Resident 1's clinical record on 4/26/24, at 1 p.m., indicated no evidence Resident 1 was invited or participated in his quarterly care conferences for the past 12 months. During an interview on 4/26/24, at 2 p.m., Resident 1 stated he had not been invited to participate in quarterly care conferences. Resident 1 stated he had the right to attend his care conferences. During an interview on 4/26/24, at 3 p.m., the Director of Nursing (DON) was asked for documentary evidence Resident 1 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 ensure one of three residents (Resident 1) was seen by a physician at least every 60 days. This failure had the potential for Resident 1 not to receive medical care. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE], with a primary diagnosis of generalized anxiety disorder. A review of Resident 1's clinical record on 4/26/24, at 1 p.m., indicated only two physician Progress Notes in the past 12 months: One dated 3/25/24, and another dated 4/22/24. During a concurrent interview, the Director of Nursing (DON) was asked to provide evidence Resident 1 was seen by a physician at least every 60 days in the past 12 months, and requested the respective Progress Notes. The DON reviewed Resident 1's clinical record and provided only three additional physician Progress Notes, dated 5/9/23, 10/18/23 and 4/9/24. The DON stated Resident 1 refused physician visits. The DON was asked for evidence Resident 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of three residents (Resident 1) when Resident 1 did not receive Restorative Nursing Services (RNS-range of motion and other physical exercises to promote safety and independence, provided by Restorative Nursing Assistants (RNAs)) according to physician orders. This failure placed Resident 1 at risk of not achieving her highest practical physical well-being. Findings: A review of Resident 1 ' s facesheet indicated she was admitted to the facility on [DATE] with a primary diagnosis of dementia. A review of Resident 1 ' s Discharge Notice indicated she was discharged from the facility on 10/10/23. During an interview on 11/6/23, at 4:24 p.m., Resident 1 ' s family stated Resident 1 did not receive RNS during her stay at the facility. A review of Resident 1 ' s clinical record indicated eight physician orders for RNS, as follows: 5/13/22: RNA to provide resistance ROM…

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 three residents (Resident 1) received physician visits at least every 60 days after admission when Resident 1 did not receive a physician visit for a period of 152 consecutive days during her stay at the facility. This failure had the potential to deprive Resident 1 of physician care. Findings: A review of Resident 1 ' s facesheet indicated she was admitted to the facility on [DATE] with a primary diagnosis of dementia. A review of Resident 1 ' s Discharge Notice indicated she was discharged from the facility on 10/10/23. A review of Resident 1 ' s clinical record indicated monthly physician visits except during the months of June, July, August, and September 2022. A review of Resident 1 ' s physician progress notes indicated Resident 1 had a physician visit on 5/20/22 and the next one on 10/6/22, comprising a period of 152 days without a physician visit. During an interview on 12/14/23, at 11:15 a.m., the Director of Nursing (DON) and…

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

Based on interview and record review, the facility did not provide discharge notices to the Long-Term-Care Ombudsman (A representative that assists residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences), as required by the Federal regulations. For three of four sampled residents (Resident 10, Resident 11 & Resident 12), the facility was unable to provide documentation of discharge notices sent to the Ombudsman, but the Ombudsman office indicated the facility had discharged 13 residents in recent months and only provided discharge notices for 4 of them. In addition, some of the discharged notices included incomplete documentation. This finding had the potential to result in unsafe discharges and inability for the Ombudsman to advocate for the residents in case of inappropriate discharges, which ultimately could have caused harm to the residents. Findings: During a phone interview on 8/22/23 at 10:13 a.m., the office of the Long-Term-Care Ombudsman indicated they had not received discharge notices from the facility…

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 RNA (A Certified Nursing Assistant [CNA] with special training, skills and knowledge that provides therapeutic or rehabilitative services to residents under the direct supervision of a licensed professional) therapy services to three of three sampled residents (Resident 5, Resident 6 and Resident 7) that had physician orders for these services. This could have resulted in inability for the residents to restore their functional body movements, be able to walk and become independent. Findings: Record review indicated Resident 5 was admitted to the facility on [DATE] with medical diagnoses including Fracture of Right Lower Leg (A break in one or both bones below the knee and above the ankle, of the right foot), and Laceration (A deep cut or tear of the skin or flesh) of Right Hand, according to the facility Face Sheet (Facility demographic). Record review of Resident 5's MDS (Minimum Data Sheet-An assessment tool) dated 8/15/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility did not have sufficient staff to meet the care needs of three of four sampled residents (Resident 7, Resident 8 & Resident 9) when they were not provided with activities of daily living (ADLs-Activities related to personal care such as bathing and toileting) as required, and call lights were not answered promptly. During the morning shifts of 9/17/23 and 9/18/23, only two Certified Nursing Assistant (CNAs) were assigned to provide ADL services to all 40 residents of the facility, an assignment of about 20 residents per CNA. In addition, staffing shortages occurred in all shifts. These findings had the potential to result in harm to the residents involved, inability for staff to respond to medical emergencies, and lack of health services provided to the residents of the facility. Findings: Resident 7 Record review indicated Resident 7 was admitted to the facility on [DATE] with medical diagnoses including Cirrhosis of the Liver (A condition in which the liver is…

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 medically related social services to 5 of 5 sampled residents wanting to be discharged (Resident 1, Resident 2, Resident 3, Resident 4 & Resident 5). These residents were not provided with assistance in finding placements for discharge, and three of them stated not having State identification cards (IDs) or medical insurance cards. These findings had the potential to cause harm, stress, and frustration to the residents involved. Findings: Record review of an e-mail sent to the Surveyor by Witness XX on 8/23/23 at 10:19 a.m., indicated Resident 1, Resident 2, Resident 3, Resident 4 & Resident 5 were awaiting discharge and felt like they were not being helped by the facility with discharge planning (The process of identifying and preparing for a resident's anticipated health care needs after they leave the skilled nursing facility). Record review of an e-mail sent to the previous Social Services Director (Social Services Director J) on 5/25/23 at 10:42 a.m., by Witness YY, a person not from the facility, who 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 ensure that one of five sampled residents (Resident 6) was treated with dignity and respect, when her request to send a check to her sister for $5000.00 was not honored, her DPOA (Direct Power of Attorney- A legal document that authorizes someone else to handle certain matters, such as finances or health care, on another person's behalf) did not receive regular statements of Resident 6's trust account with the facility, and Resident 6 was not provided with requested petty cash from her trust account immediately upon request. This finding had the potential to result in frustration, sadness, depression, and anxiety for Resident 6. Findings: Record review indicated Resident 6 was admitted to the facility on [DATE] with medical diagnoses including Intervertebral Disc Degeneration (A condition characterized by the breakdown (degeneration) of one or more of the discs that separate the bones of the spine (vertebrae), causing pain in the back or neck 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 replace or reimburse one of two sampled residents (Resident 5) for items that were lost during his stay at the facility, after having notified Administration about it. In addition, the facility policy on theft and misappropriation of property was extremely limiting and did not protect residents for personal property losses over $100.00. This finding had the potential to result in feelings of frustration, abuse, and sadness to Resident 5 and other potential residents. Findings: Record review indicated Resident 5 was admitted to the facility on [DATE] with medical diagnoses including Fracture of Right Lower Leg (A break in one or both bones below the knee and above the ankle, of the right foot), and Laceration (A deep cut or tear of the skin or flesh) of Right Hand, according to the facility Face Sheet (Facility demographic). Record review of Resident 5's MDS (Minimum Data Sheet-An assessment tool) dated 8/15/23 indicated his BIMS (Brief Interview 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 a safe and orderly discharge for one of five sampled residents (Resident 3) when they began the process of a facility-initiated-discharge and provided a 30-day discharge notice to Resident 3 without a discharge plan or having arranged placement (Appropriate and safe housing that meets the resident's needs) for him. This finding had the potential to result in an unsafe, inappropriate discharge which could have caused harm to Resident 3. Findings: Record review indicated Resident 3 was admitted to the facility on [DATE] with medical diagnoses including Fracture of Lumbar Vertebra (Broken bone of the spine in the region of the lower back), and Osteoarthritis (A condition in which the cartilage that cushions the ends of bones in the joints gradually deteriorates), according to the facility Face Sheet (Facility demographic). Record review of Resident 1's MDS (Minimum Data Set-An assessment tool) dated 8/24/23 indicated his BIMS (Brief Interview 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 maintain an infection control & prevention program to prevent the spread of COVID-19 when: 1) No designated screener was available in the front lobby to screen staff and visitors for COVID-19 prior to entry to the building, staff and visitors were not properly screened before entry to the building, and equipment was not cleaned and disinfected between use. The screening logs were not reviewed by Infection Preventionist (IP) after completion. 2) Laundry staff stored the dirty apron near the clean linen and resident's clothing in the clean section of the Laundry room. Dirty linen barrel was stored a foot away from the clean linen barrel. 3) No annual Infection Control Prevention training to the staff. 4) Oxygen tubing and humidifier bottles were not labeled with the date they were changed, and a nebulizer mask was not changed for months. These failures had the potential to contribute to an outbreak, or further spread the COVID-19 virus,…

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 maintain the laundry equipment in a safe operating condition when one of two washing machines had water leakage that created a rusted area about a foot in length on the ground and in the corner of the washing machine. This failure had the potential to result in injury to the staff and residents. Findings: During a concurrent observation and interview on 9/23/21 at 12:21 p.m., in the Laundry room, one of the two washing machines had leakage and rust in the lower corner and with a foot long rust on the ground. The Housekeeping Supervisor (HS) touched the rusted ground and noted water leakage. HS stated that he would fix it. HS stated the leakage started 2 days ago. During a concurrent observation and interview on 9/24/2021 at 11:35 a.m., in the Laundry room, HS stated that there was no more water leakage. HS stated that the washing machine was turned off, not operating. During an interview on 9/24/2021 at 11:37 a.m. the Maintenance Supervisor (MS) stated that the washing machine would not operate until he fixed the leakage. MS…

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 implement the facility's transfer and discharge Policy and Procedure for non-payment notice or follow Federal regulations. Letters of eviction notice were sent to Resident 25, Resident 29, Resident 22, Resident 5 and to a family of Resident 14. This failure resulted in anguish, fear and emotional stress to the residents and family involved. Findings: During an interview on 9/21/21 at 3 p.m., in Resident 25's room, Resident 25 stated that the previous Administrator (PREV ADM) together with the Social Worker (SW) walked into his room when he was lying on his bed. Resident 25 stated that PREV ADM handed him a letter dated 4/23/2021, indicated that he owned facility for non-payment of $22,788.00. Resident 25 stated that the PREV ADM told him that he had a lot of money and asked how he was going to handle this non-payment, or he would be evicted. Resident 25 stated that he was startled when the PREV ADM approached him. Resident 25 stated that he called his family immediately that day and told them that he will be evicted if 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.

Based on observation, interview and record review, the facility failed to ensure their full-time Infection Preventionist (IP-The person designated by the facility to be responsible for the infection prevention and control program), was able to perform her IP role when she was assigned to work on the floor and provide direct patient care. This failure had the potential to result in breaks in infection control, which could have resulted in spread of COVID-19 and other pathogens among residents and staff at the facility. Findings: During a concurrent observation and interview on 9/20/21 at 11:55 a.m., Licensed Staff B, who was the facility appointed Infection Preventionist, was observed working on the floor, passing medications. Licensed Staff B confirmed she was the assigned nurse for Resident 191. Licensed Staff B was subsequently observed working on the floor, passing medications, every day from 9/20/21 to 9/24/21 for morning shift. This was confirmed by daily nursing staffing assignments provided by the facility. During an interview on 9/22/21 at 2:32 p.m., Licensed Staff B 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 food safety was maintained when: 1. A spoiled lettuce and potato were stored in the kitchen refrigerator and dry storage with other produce in good condition, and; 2. Undated and unlabeled perishable food items were left in a resident's room (Resident 12) at room temperature, for a prolonged period of time. These findings had the potential to result in food borne illness to Resident 12, and other residents at the facility. Findings: 1. During the initial kitchen observation on 09/20/21 at 10:10 a.m., with the Dietary Manger present, a spoiled lettuce was found stored with other lettuce in good condition in the kitchen refrigerator. The lettuce was dark in color, mushy, and dark brown liquid was coming out of it. The Dietary Manager confirmed the observation and removed it from storage. During an observation on 9/20/21 at 10:21 a.m., inside a container in the dry storage, a spoiled potato was found stored with other potatoes in good…

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

Based on observation, interview and record review, the facility failed to record the Covid-19 nasal swab test results of unvaccinated staff and visitors. This failure had a potential to result in spread of Covid-19 virus to residents and staff. Findings: During a concurrent observation and interview on 9/23/2021 at 10:25 a.m., the Infection Preventionist (IP) demonstrated how to use the Covid 19 test performed to staff and visitors. IP stated that she would perform Covid 19 test to visitors and staff who were not vaccinated prior to entry to the facility. IP stated that after she performed the Covid-19 test, she would record the result. IP stated that she recorded the result in the computer. IP could not locate any record keeping in the computer. IP could not provide any evidence of record keeping of the Covid-19 test for the unvaccinated staff and visitors. A review of the Policy & Procedures title Surveillance for Infections release date 1/2018 revealed that The Infection Preventionist (IP) will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other…

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 a safe, comfortable and homelike environment when: 1. The facility failed to ensure the only soap dispenser in a staff restroom was functional, and; 2. A large area of peeling paint was observed right next to Resident 20's bed. These findings had the potential to result in spread of infections, and discomfort and harm to Resident 20. Findings: 1. During an observation on 9/20/21 at 10:30 a.m., in one of the facility staff restrooms, the only soap dispenser was missing the cover, and was not functional. While it did seem to contain soap, no soap could be obtained from it. Staff assistance was required from Licensed Nurse B, who showed Surveyor how to obtain soap from the broken soap dispenser, however, there were no instructions for other visitors or staff to guide them on how to obtain soap from it. During an interview on 9/22/21 at 2:56 p.m., Maintenance/Housekeeping Supervisor stated the soap dispenser was broken two days prior to the observation on 9/20/21, and while parts were brought to fix it,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure MDS (Minimum Data Set-A federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) assessments were accurate and complete within the required timeframes for two of eight sampled residents (Resident 33 and Resident 191). This had the potential to result in inability for the facility to identify residents' preferences, goals of care, functional and health status, and strengths and needs. Findings: Resident 33 was admitted to the facility on [DATE] with medical diagnoses including Diabetes Mellitus, according to the facility Face Sheet (Facility Demographic). Resident 33's MDS dated [DATE], indicated she had a urinary catheter (A tube placed in the body to drain and collect urine from the bladder), under the section, Bowel & Bladder. This document indicated it was completed by MDS Nurse. During review of Resident 33's medical records on 9/21/21 at 11:24 a.m., including physician orders 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 ensure a registry staff (Unlicensed Staff D) was provided necessary information to care for a non-English speaking resident (Resident 32), when she was not informed this resident had a communication tool available. This had the potential to result in inability for Resident 32 to communicate with staff, which could have caused feelings of frustration and helplessness for Resident 32. Findings: Resident 32 was admitted to the facility on [DATE] with medical diagnoses including Parkinson's Disease (A progressive nervous system disorder that affects movement), according to the facility Face Sheet (Facility demographic). The Face Sheet also indicated Resident 32's primary language was Chinese. During a concurrent observation and interview on 9/21/21 at 9:46 a.m., Resident 32 was observed in bed, and could not be interviewed, and she did not seem to understand English. The assigned Certified Nursing Assistant, Unlicensed Staff D, who was in the…

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

Based on observation, interview and record review, the facility failed to maintain an effective system of accounting and accurate reconciliation of a controlled medication for one resident (Resident 10). This failure resulted in the unaccounted 3 ml lacking from the bottle of Morphine sulfate (opiate pain medication) of Resident 10. Findings: During a concurrent observation and interview on 9/21/21 at 11:55AM, the Medication Cart at the East Hall containing the 30-ml container for Morphine sulfate of Resident 10 indicated 8ml remaining medication in the container. Licensed Nurse B who was looking at the narcotic count sheet of Resident 10 stated the 30-ml container of Morphine sulfate should have 11 ml remaining. When asked why was there a descripancy in the remaining amount, Licensed Nurse B could not explain why the bottle was approximately 3 ml short. During an interview on 9/21/21 at 12:15pm, when asked why the Morphine sulfate bottle of Resident 10 was short 3 ml, the DON could not explain the discrepancy but stated she will find out. During a follow-up interview on 9/21/21 at…

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

Based on observation, interview and record review, the facility failed to ensure medication error rate did not exceed 5% when two medication errors were noted among 29 medication administration observations. This failure resulted in a medication error rate of 6.9%. The failure also had the potential to cause adverse consequencies such as hypoglycemia (low blood sugar), upset stomach or diarrhea to Resident 36, and prevent the delivery of the correct dose of medication that could result to inadequate control of asthma and other respiratory disorder symptoms to Resident 12. Findings: 1. During an observation of medication administration on 9/21/21 at 8:18am, Licensed Nurse A administered one tablet of Metformin HCl (is an anti-diabetic medication that lowers blood sugar levels) 500mg to Resident 36. Resident 36 took the medication along with 5 other medications with a glass of juice and water. During an interview on 9/21/21 at 10:26am, when asked if she had breakfast earlier, Resident 36 stated she has not had breakfast. During an interview on 9/21/21 at 10:27am, Staff C 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 one of eight sampled residents' (Resident 12) dietary orders were followed, when staff failed to provide her with a standing order for coffee during her lunch meal. This had the potential to result in frustration and despair to Resident 12. Findings: Resident 12 was admitted to the facility on [DATE] with medical diagnoses including Chronic Obstructive Pulmonary Disease (A group of diseases that cause airflow blockage and breathing-related problems), according to the facility Face Sheet (Facility Demographic). Resident 12's MDS (Minimum Data Set-An assessment tool) dated 9/03/21 indicated her BIMS (Brief Interview of Mental Status-A cognition assessment) was 15, which indicated her cognition was intact. Resident 12's 9/20/21 lunch tray card indicated, Standing Orders: 8 fl oz Coffee 4 fl oz Fruit Juice 4 fl oz Milk whole. During dining observation on 9/20/21 at 12:44 p.m., Resident 12 did not receive the coffee in her standing order…

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

Based on observation, interview and record review, the facility failed to protect residents' rights when: 1. Four of six sampled residents (Resident 21, Resident 36, Resident 9 and Resident 27) complained of being called Momma and Poppa by facility staff; 2. Five of six sampled residents (Resident 21, Resident 36, Resident 9, Resident 27 and Resident 195) stated having heard facility staff speaking a language other than English in resident care areas; 3. Three of five sampled residents (Resident 1, Resident 36 and Resident 27) stated they had observed staff using personal cell phones during work hours, and; 4. Facility staff was observed not wearing identifying name badges, while other staff was observed wearing name badges which did not include their position or title. These failures had the potential to cause feelings of helplessness, disrespect and frustration to the residents of the facility. Findings: 1) During a Resident Council meeting on 01/28/20 at 11 a.m., in the facility's dining room, four of six residents (Resident 21, Resident 36, Resident 9 and Resident 27) 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, the facility failed provide complete and timely discharge notices to the Ombudsman for three of fifteen sampled residents (Resident 33, Resident 8, & Resident 10) when: 1) One discharge notice provided to the Ombudsman did not include the address of the receiving facility, and; 2) Two discharge notices for planned discharges were provided to the Ombudsman after the residents had been discharged from the facility. These failures could have resulted in lack of protection for residents from being inappropriately discharged and lack of advocacy services for the residents of the facility. Findings: 1) Resident 8 was admitted to the facility on [DATE], with medical diagnoses including Vascular Disorder of Intestine (A condition in which there is a decrease in intestinal blood flow) and Mood Disorder (A group of conditions characterized by a serious change in mood which cause disruption to life activities), according to the facility Face Sheet (Facility Demographic). A Nurse's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure pain was managed within acceptable standards of care for one of seven sampled residents (Resident 30) when: 1) The facility did not ensure Resident 30's pain level was assessed and reassessed to ensure pain management was effective; and, 2) The facility did to ensure PRN (as needed) pain medication was administered to Resident 30, who had a documented pain level of 6 out of 10 on multiple occasions. These failures may have resulted in suffering and distress to resident 30, who passed away on 01/27/20, at the facility. Findings: Resident 30 was admitted to the facility on [DATE], with medical diagnoses including Malignant Neoplasm of the Colon (Colon Cancer) and Heart Failure, according to the facility Face Sheet (Facility Demographic). A physician's order, dated 12/19/19, indicated, Morphine Sulfate (Concentrate) (A narcotic used to relieve moderate to severe long-term pain) Solution 20 MG/ML Give 0.25 ml by mouth every 1 hour as…

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

Based on observation, interview and record review, the facility failed to ensure: 1) The pureed (food blended to the consistency of applesauce or milkshake texture) diet recipe was followed for nine residents; and, 2) The therapeutic menu was not followed for a resident on a renal, fortified diet. These failures led to residents receiving meals that did not meet their nutritional needs and further compromised their health status. Findings: 1) On 1/30/20, a review of the facility's Cook's Spreadsheet Winter Menus, dated 1/30/20, indicated .Lunch Regular: Roast Beef Savory Thyme Sauce, Red Beans and Rice, Parslied Carrots, Caesar salad . During an observation and concurrent interview of the lunch meal preparation on 1/30/20 at 12 P.M., the [NAME] (CK N) stated the puree entrée was not the same food as the food used to prepare the regular diet meals. CK N stated pureed ground beef was cooked for the pureed diets instead of roast beef that was on the menu for the regular diets. CK N stated, That's how I do it all the time. The Certified Dietary Manager (CDM) acknowledged CK N did not…

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

Based on observations, interviews, and record reviews, the facility failed to ensure food was prepared in a manner which conserved flavor and nutritive value when: 1) The puree recipe for the roast beef entrée was not followed and did not have flavor; and, 2) Palatable meals were not provided to residents. This failure had the potential to affect the meal intake and nutritional status of nine residents who received a pureed diet and other residents who complained about the palatability of the meals. Findings: A review of the November 2020, December 2020, and January 2020, Resident Council meeting minutes was conducted. The January 2020, meeting minutes indicated the temperature of the food was a high concern for residents. 1) During the confidential Resident Council meeting on 1/28/20 at 11 AM, five of six residents in attendance stated having issues with the food at the facility, and four of the six stated The food has no taste. Resident 9 stated most of the food did not have taste and was overcooked. Resident 195 stated she had been served salt and red meat when her the meal…

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 and sanitary conditions were maintained for food storage, according to standards of practice when: 1) Three serving scoops were found dirty with green and brown crusted substances and stored with clean serving utensils; 2) Sixteen plastic bowls were stored wet underneath a food prep counter; 3) Ten potatoes in a supply box of potatoes had black discoloration, were moist and soft to touch were not discarded; and, 4) The ice machine was not cleaned and maintained, according to manufacturer's instructions. These failures had the potential to cause widespread food-borne illness among all 43 residents who consume food from the kitchen. Findings: 1) On 1/27/20 at 12:30 p.m., during an observation and interview with the DSS in the kitchen, three dirty serving scoops with dry crusted green and brown substances inside, were found stored in a drawer with clean serving utensils. The DSS acknowledged the dirty serving scoops and stated they were not cleaned and stored correctly. According to the 2017, Federal…

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 documentation was accurate and complete when: 1) Pain assessment and reassessment was not documented for one of seven sampled residents (Resident 30); and, 2) Weekly Nursing Progress Notes were inaccurate for one of seven sampled residents (Resident 30). This failure had the potential to result in lack of lack of communication among the health care team, poor quality of care and inadequate pain management, for Resident 30. Findings: Resident 30 was admitted to the facility on [DATE], with medical diagnoses including Malignant Neoplasm of the Colon (Colon Cancer) and Heart Failure, according to the facility Face Sheet (Facility Demographic). 1) Resident 30's Physician orders, dated 12/19/19, indicated, Admit to Hospice Care Hospice Services. Physician orders, dated 12/19/19, also indicated, Monitor and rate pain: Provide non pharmacological intervention prior to administration of pain medication if resident complained of pain .every shift 0-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.

Based on interview and record review, the facility failed to notify the DEPARTMENT of an incident of abuse, when Licensed Staff overheard one resident (Resident 8) yelling at her roommate, using profane language and did not report the incident to facility administration or the required authorities. This failure resulted in abuse reoccurrence. Findings: A Nurse's Note, dated 01/2/20 at 1:09 a.m., documented by Licensed Staff I, indicated, At 12:30 am, heard resident (Resident 8) throwing profanities to her roommate (Resident 96). Resident noted with aggressive behavior towards roommate. Spoke with the resident together with the other charged nurse (Licensed Staff H) and the cna (Certified Nursing Assistant) assigned, to figure out what's going on. Per resident, she hates her roommate and wants to be transferred somewhere else. There were no Nurse's Notes, regarding this incident, documented by Licensed Staff H, who, according to Licensed Staff I's documentation, was also present. A second Nurse's Note dated 01/26/20 at 10:34 a.m., documented by Licensed Staff I' indicated, 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 inform and communicate the transfer or discharge of Resident 45 to the receiving facility when: 1) The medical doctor (MD) ordered to discharge Resident 45 to detox center. 2) The Licensed Nurse failed to report to the receiving facility of the care that Resident 45 received. Findings: A review of the Policy and Procedure of Transfer or Discharge Documentation, released on January 2018, indicated when a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. Under Process: #4, When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: a) The basis for the transfer or discharge: b) That an appropriate notice was provided to the resident/and or legal representative: c) The date and time of the transfer or discharge: The new…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to implement its policy and procedure on Care Plan-Baseline (a baseline care plan must be developed for each resident within 48 hours of admission to the facility. There are no exceptions to this requirement for holidays, weekends, or night admissions, and the baseline care plan was required to address, at a minimum, the following: Initial goals based on admission orders, Physician orders, Dietary orders, Therapy services, Social services, and Pre-admission Screening and Resident Review (PASARR) recommendations if applicable) for one of three sampled residents, Resident 144, when a baseline care plan was not completed within 48 hours after her admission and a summary provided to her. This failure had the potential to result in adverse events most likely to occur after admission (e.g. falls, medication errors, dietary restrictions). Findings: During a review of the Resident 144's, admission Record, dated 2/3/20, the admission Record indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a resident-centered, comprehensive care plan for constipation, for one of seven sampled residents (Resident 30). This failure had the potential to result in ineffective, incompetent care to Resident 30, who required specific interventions for his disease condition. Findings: Resident 30 was admitted to the facility on [DATE], with medical diagnoses including Malignant Neoplasm of the Colon (Colon Cancer) and Heart Failure, according to the facility Face Sheet (Facility Demographic). A facility document titled, Nursing admission Assessment, dated 12/19/19, indicated Resident 30 had a colostomy (A surgical procedure bringing one end of the large intestine out through the abdominal wall, creating an opening which provides an alternative channel for feces to leave the body) upon admission to the facility. Resident 30's Treatment Records indicated he received colostomy care every day during his stay at the facility, from 12/19/19 until 01/27/20. 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, professional standards of practice were not followed when a Licensed Nurse failed to check a colostomy bag frequently for one of two sampled residents (Resident 30), who was known to remove his colostomy device during periods of confusion. This failure had the potential to result in skin breakdown, dignity issues, discomfort and harm to Resident 30. Findings: Resident 30 was admitted to the facility on [DATE], with medical diagnoses including Malignant Neoplasm of the Colon (Colon Cancer) and Heart Failure, according to the facility Face Sheet (Facility Demographic). Resident 30's MDS (U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes), dated 12/26/19, indicated his BIMS (Brief Interview for Mental Status-a structured evaluation aimed at evaluating aspects of cognition in residents in Medicare or Medicaid certified nursing homes) score was 8, which indicated his cognition was moderately impaired. 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 observations, interviews, and record reviews, the facility failed to implement its policy and procedure on Medication Ordering and Receiving from Pharmacy, for one of eight sampled residents, Resident 195, when a blister pack (Blister pack contains designated sealed compartments, or spaces, for medicines to be taken at particular times of the day) did not indicate the physician had changed the directions for the use of Midodrine HCL (Midodrine Hydrochloride - a medication prescribed to treat low blood pressure caused by certain conditions). This failure had the potential to result in a significant medication error, which may cause adverse consequences to Resident 195. Findings: During a review of Resident 195's Discharge Summary, dated 1/13/20, the Discharge Summary, indicated, Resident 195 had a discharge diagnosis of hypotension (low blood pressure). The list of new medications prescribed to Resident 195 included Midodrine HCL 5 mg tablet 10 mg PO (by mouth) TIDAC (three times a day before meals) for…

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

Based on observation, interview and record review, the facility failed to ensure food and nutrition service's department staff competently carried out kitchen duties in a safe, sanitary manner according to manufacturer's instructions when: 1) A kitchen staff member was unable to verbalize and demonstrate correct techniques related to testing sanitizer buckets; and, 2) A kitchen staff member was unable to demonstrate the correct technique for testing the dishwasher sanitation level. These practices had the potential to expose residents to food-borne illness, due to lack of staff training and monitoring of their duties. Findings: During the initial brief kitchen tour observation on 1/27/20 at 12:30 p.m., an interview was conducted with [NAME] O while cleaning a food prep surface. [NAME] O stated, I used the sanitizer from the red bucket to wipe the surface throughout the day. [NAME] O stated the sanitizer liquid was changed every two hours. [NAME] O was asked to demonstrate how to check for the sanitizer concentration. [NAME] O, took the test strip, dipped it into the red bucket and…

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

Based on observation, interview and record review, the facility failed to ensure the garbage container was completely covered when in used in the kitchen. This failure had the potential to expose the food prepared in the kitchen for residents, and clean dishware, to garbage waste and provide an environment which harbored pests. Findings: During the initial kitchen observation on 1/28/20 at 12:25 PM, the garbage container had a lid with a big hole opening in the center measuring approximately 1-foot x 1-foot. The kitchen staff were in the process of tossing garbage from the soiled trays on the food carts through the center of the garbage lid. On 1/30/20 at 11:20 AM, a Kitchen Staff (Cook O) demonstrated how to disposed of the garbage. [NAME] O rolled the garbage container with the lid that had the big opening in the center, to the outside dumpster, sealed the plastic bag inside the garbage container, and placed it in the dumpster. [NAME] O then placed a new plastic bag inside the garbage container and brought it back to the kitchen. [NAME] O stated the garbage can lid had a hole in…

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 principles were followed when: 1. A clean linen cart was left partially uncovered while not in use, in a facility hallway, and; 2. A cooler, which contained stool and urine specimens, was placed right next to a sink which was used to obtain water for resident consumption. These failures had the potential to cause contamination of facility resources, spread of infections and water-borne illnesses to the residents of the facility. Findings: 1) During an observation on 01/28/20 at 9:43 a.m., a clean linen cart was partially uncovered in one of the facility's hallways. The cart had a dark green covering, with Velcro straps on the sides to keep it closed when not in use. The Velcro straps were unattached, therefore; the covering was partially open, exposing clean linens inside. This was confirmed by Unlicensed Staff E, who stated the cart should be closed all the way. During an interview with the Director of Staff Development (DSD) on 01/30/20 at 2:43 p.m., she stated clean linen carts were…

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.