Fulton Gardens Post Acute, LLC

Based on interview and record review, the facility failed to ensure long term antibiotic use was clinically justified for safe use with monitoring and a nursing plan of care for 1 out of 29 sampled residents (Resident 56), when Resident 56 was prescribed doxycycline (an antibiotic, a medication used to treat infection) with full dosing regimen for over one year.This failed practice could contribute to unsafe antibiotic use, risk of developing resistance bugs (when antibiotic no longer can kill or suppress the bug), and ineffective use with side effects.Findings:A review of Resident 56's clinical record titled, admission RECORD, indicated Resident 56's diagnosis included diabetes (blood sugar disease), kidney disease, obesity (excessive body fat), and history of knee surgery with an infection. Review of the Resident 56's medical record titled, Medication Administration Record, (MAR, a record that indicates physician orders, medications administered and/or held) dated 4/26, the record indicated Resident 56 was on an ongoing antibiotic called doxycycline as follows: .Doxycycline .…

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

Based on observation, interview, and record review, the facility failed to provide a homelike environment for five of five residents (Resident 4, Resident 5, Resident 6, and Resident 7, and Resident 8) when,Resident 4 displayed episodes of aggression, and repeated yelling throughout the day and night and Resident 4 behavior care plans were not person centered, and staff were not able to address it; and, Multiple residents including Resident 5, Resident 6, Resident 7, and Resident 8 were negatively affected by Resident 4's continuous yelling and had reported to staff their frustration and lack of sleep and/or rest.This deficient practice had the potential to negatively affect the psychosocial (the mental, emotional, social, and spiritual effects of a disease) and physical well-being of the facility's residents. Findings:Review of Resident 4's admission RECORD, indicated, Resident 4 was originally admitted to the facility in the fall of 2023 with a diagnosis including but not limited to cerebrovascular disease (condition that affect blood flow to your brain), vascular dementia…

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 two sampled residents (Resident 3) right to be free from physical abuse and neglect (failure to provide goods and services necessary to avoid physical harm or mental anguish) when, 1. Resident 3, with a diagnosis of paraplegia (inability to feel or move your legs, making it impossible to stand or walk) was placed in Resident 4's room as his roommate even though Resident 4 had a history of aggressive behavior towards staff and other residents. Subsequently, on 5/27/25, Resident 3 called repeatedly for staff assistance due to Resident 4 coming over to his side of the room and at approximately 2:20 a.m., Resident 4 walked over to Resident 3's side of the room, pulled his room curtain, grabbed Resident 3's call light and tossed it off the bed, grabbed his throat, and began choking him. 2. The facility failed to implement measures that would ensure residents in the facility were safe from Resident 4 by constructing an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement appropriate safety measures to ensure a safe environment free of accidents or hazards and prevent elopement (form of unsupervised wandering that leads to the resident leaving the facility) for two of two residents (Resident 1 and Resident 2) when, 1. Resident 1 had a documented history of substance use disorder (SUD, a disease that affects a person's brain and behavior and leads to an inability to control the use of a legal or illegal drug or medicine and can refer to the use of illegal substances, such as marijuana, methamphetamine and the misuse of legal substances such as alcohol or prescription medications) and was homeless, and there was not a plan in place to address Resident 1's risk of exit seeking or eloping behavior, nor was Resident 1 advised of the risk of leaving the facility early, and subsequently Resident 1 eloped from the facility in the early morning hours of 7/8/25, with his PICC (peripherally inserted central…

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 professional standards of quality care for one out of four sampled residents (Resident 1) when, Resident 1's prescribed medications were left unattended at her bedside, and a diagnostic test ordered to determine the cause of her illness was not completed in a timely manner. These failures had the potential for harm to Resident 1 and other residents who could gain access to her medications and to cause a delay in Resident 1's medical treatment. Findings: A review of Resident 1's admission RECORD, indicated she was admitted to the facility with diagnoses which included type 2 diabetes mellitus (chronic disease that affects blood sugar levels) and hypertension (high blood pressure). During a concurrent observation and interview on 2/18/25, at 10:50 AM, Resident 1 was observed sitting up in bed with her tray table in front of her. Resident 1 stated she had been coughing so much that she could not take her morning medications. Resident 1 pointed to a plastic cup containing two capsules and six tablets 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 menu and recipes were followed during the lunch meal preparation on 1/8/25, for 94 residents who received food prepared in the facility kitchen when: 1. The recipe for Asian Cucumber Salad was not followed; 2. The recipe for Asian [NAME] was not followed; and, 3. The Asian smooth sauce was not prepared. These failures had the potential to affect the flavor of the food, with the potential for inadequate food intake, and could negatively affect the residents' dining experience. Findings: 1. Review of the facility document titled, Winter Menu, for Wednesday 1/8/25 indicated, .Beef & Broccoli Asian [NAME] Rice Asian Cucumber Salad Pot Sticker Glazed Apricots . During a concurrent observation and interview on 1/8/25, at 10:26 AM, with the Dietary Service Supervisor (DSS) during lunch preparation, the DSS stated the facility had eight cucumbers available, which were not enough to make 100 servings of Asian Cucumber Salad as listed on the menu. The DSS cut and peeled approximately eight cucumbers, then…

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 was prepared and served to meet the needs of 94 residents who received food from the kitchen during the lunch meal on 1/8/25 when: 1. Residents on regular portion diet received less than the required amount; 2. 12 Residents with orders for chopped and easy to chew, soft bite-sized, and minced and moist textured diets did not receive the correct amount of Beef and Broccoli; 3. Residents on a pureed diet received the incorrect portion of Asian Beef and Broccoli, and did not receive Potstickers; 4. Three Residents on a large portion diet did not receive the correct amount of Asian Beef and Broccoli and Asian [NAME] Rice; 5. Residents with orders for Consistent Carbohydrate Diet (CCHO-helps manage blood sugar levels) received the incorrect portion size of Asian [NAME] Rice; and, 6. 14 Residents requiring fortified (added calories) diet did not receive the added items to increase calories. These failures had the potential to result in residents not receiving adequate nutrients, which could lead to…

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Based on observation, interview, and record review, the facility failed to provide safe food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 94 residents who ate facility prepared meals when: 1. Stove and oven contained grease, build-up of food particles, and white, black, and brown colored grimy areas; 2. Over-ripe and spoiled produce was available for use in the walk-in refrigerator; 3. Food was stored in the refrigerator beyond the use by date (UBD) and food marked on the box Keep Frozen was stored in the refrigerator; 4. Food was not stored and maintained at the proper temperatures in the walk-in refrigerator and walk-in freezer; 5. Food was not stored and maintained at the proper temperatures at the East Station refrigerator designated as Unit Refrigerator/Resident Outside Food and freezer temperatures were not monitored; 6. Unit Refrigerator/Freezer located at the [NAME] Station was not clean and was broken with missing parts. Resident food inside the refrigerator was not…

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

Based on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 104, when: 1. Licensed Nurse (LN) 1 did not wear the required personal protective equipment (PPE -gown, gloves, eye protection, and/or facemasks used to prevent the spread of germs) for Resident 72 on Enhanced Barrier Precautions (EBP - infection control intervention to reduce transmission of resistant germs through gown and glove use during high-contact resident care activities) while providing gastrostomy tube (G-tube - a feeding tube that was surgically inserted into the resident's stomach to allow access for food, fluids, and medications) care; 2. A sterile wound dressing was stored open in a treatment cart; 3. Resident 89's room did not have an EBP sign posted, and the PPE supplies were not available outside the door to the room; and, 4. LN 9 did not wear the appropriate PPE when accessing a peripherally inserted central catheter (PICC- a tube inserted into a vein and guided into a large vein above the heart, used to…

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

Based on interview and record review, the facility failed to ensure the Antibiotic Stewardship Program (ASP- a federally mandated program with goals of monitoring, optimizing antibiotic use, and reducing misuse of antibiotics) was followed based on facility policy and national standards for a resident census of 104 when: 1. McGeer Criteria (a set of guidelines for identifying infections in long-term care facilities) was not followed for prescribing antibiotic(s) for Resident 31; and, 2. Antibiotic outcomes (the result of antibiotic use for the infection) were not measured. During a concurrent interview and record review on 1/9/25, at 3:17 PM, with the Infection Preventionist (IP), an ASP spreadsheet titled, ANTIBIOTIC/INFECTION SURVEILLANCE, dated 12/24, was reviewed. The IP stated the spreadsheet was maintained by adding residents' names and information to the document when residents were prescribed antibiotics. The IP further stated McGeer Criteria was used for infection surveillance (the systematic collection, analysis [detailed examination of the elements of something], 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 1 of 22 sampled residents (Resident 74) was treated with dignity and respect, when Certified Nursing Assistant (CNA) 3 and CNA 5 were speaking a foreign language over Resident 74 while providing care. This failure had the potential to impact Resident 74's self-esteem and quality of life. Findings: During an observation on 1/7/25, at 10:12 AM, CNA 3 and CNA 5, were observed on opposite sides of Resident 74's bed, providing Activities of Daily Living (ADL) care. While providing this care, CNA 3 and CNA 5 were observed speaking a foreign language over Resident 74 to each other. The conversation could be heard from outside of Resident 74's bedroom door. During a joint interview on 1/7/25, at 10:15 AM, with CNA 3 and CNA 5, CNA 3 stated CNA 5 was explaining something personal in their native language. CNA 5 stated the conversation had to do with something about her family and not Resident 74. CNA 5 stated they were only allowed to speak a foreign language in the break room. During an interview on 1/7/25, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents who were permitted to self-administer medications (Resident 16 and Resident 60) had their medications stored in a safe manner, when expired and nonexpired medications were accessible to residents at their bedside and the facility failed to follow their self-medication administration Policy and Procedure (P&P). This failure had the potential for a medication overdose for Resident 16, Resident 60, and other residents in the facility, and low efficacy (decrease in effectiveness of medication) of Resident 16's expired medications. Findings: 1. Review of Resident 16's clinical record titled, admission RECORD, indicated Resident 16's diagnoses included diabetes mellitus (inability of the body to regulate blood sugar), hypertension (high blood pressure), and hypothyroidism (inability of the body to secrete enough thyroid hormone). During a concurrent observation and interview on 1/7/25, at 4:07 p.m., with…

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

Based on interview, and record review, the facility failed to implement an individualized care plan intervention for 1 of 22 sampled residents (Resident 44) when Resident 44 had recommendations from a PASRR level II screening (identifies additional resources needed for residents with mental illness, intellectual or development disabilities) which were not incorporated into Resident 44's plan of care. This failure had the potential for Resident 44 to not receive recommended services to support health and well-being. Findings: A review of Resident 44's admission RECORD, indicated Resident 44 was admitted to the facility in 2023. Resident 44's admission diagnoses included dementia (a general term for loss of memory, language, problem- solving and other thinking abilities that are severe enough to interfere with daily life), and schizophrenia (a serious mental disorder in which a person interprets reality abnormally). During a record review of Resident 44's facility Electronic Medical Record (EMR- a digital version of a resident's medical history including diagnoses, medications, tests,…

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 of 22 sampled residents (Resident 12) received the appropriate range of motion (ROM - the distance and direction a joint can move) services to increase range of motion and/or to prevent further decrease in range of motion. This failure could have resulted in Resident 1's ability to use his right hand to his fullest capacity and could have led to a decrease in quality of life. Findings: Review of Resident 12's clinical record titled, admission RECORD, indicated Resident 12's diagnoses included a history of stroke (oxygen was deprived from the brain for a time that resulted in brain damage) and aphasia (a language disorder that made it difficult to understand or express language). A review of Resident 12's clinical record titled, Emergency Documentation - MD [Medical Doctor], dated 8/26/19, at 1:23 p.m., by Physician (PHYS) 1, indicated Resident 12 had a history of aphasia following cerebral infarction (also known as an ischemic stroke, occurs when blood flow to the brain is blocked, causing brain…

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 protection from potentially hazardous items, when three shaving razors were left on the counter unattended in a shared bathroom of four unsampled residents (Resident 58, Resident 55, Resident 87, Resident 41). This failure placed the facility's residents at risk for an injury in the case of accidental access to sharp items. Findings: During an observation on 1/7/25, at 10:20 AM, in a resident bathroom, there were three shaving razors on the counter. The bathroom was shared by four residents. During a concurrent observation and interview on 1/7/25, at 10:21 AM, with Licensed Nurse (LN) 8, LN 8 confirmed the razors were left on the counter and accessible. LN 8 stated these placed residents at risk of injury and infection, especially if a confused resident was able to access the razors. During an interview on 1/9/25, at 3:40 PM, with the Director of Staff Development (DSD), the DSD stated razors were sharp objects and should not be left unattended on a shared bathroom counter. They should be disposed of…

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

Based on observation, interview, and record review, the facility failed to ensure safe pharmaceutical services for a census of 104 when: 1. The emergency kit (E-kit, a box containing emergency medications for faster and easy access when needed) for oral medications was opened and resealed on 1/2/25 and had not been replaced as of 1/7/25; and, 2. Narcotic medication use was not accurately documented in the Medication Administration Record (MAR- a record of the residents' medications and treatments) when removed from the Controlled Drug Record (CDR- a paper record that kept track of narcotic opioid medication [medications used to treat pain that cause drowsiness, dull the senses, and are prone to abuse] use for accountability) sheet for Resident 73. The failure of an opened e-kit not being replaced could result in the unavailability of the medication when needed and unsafe storage of emergency drugs. The failure of not accurately documenting narcotic medications in the MAR could result in unsafe pain medication use and a risk for drug diversion. Findings: 1. During a concurrent…

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

Based on interview, and record review, the facility failed to ensure 1 of 22 sampled residents (Resident 31) was free from unnecessary medications when, Resident 31 continued receiving an antibiotic for a urinary tract infection (UTI- an infection in any part of the urinary system) without having met established McGeer Criteria (a set of guidelines for identifying infections in long-term care facilities) for continued use of the antibiotic as specified in the facility's Antibiotic Stewardship Program (ASP- a federally mandated program with goals of monitoring, optimizing antibiotic use, and reducing misuse of antibiotics). This failure had the potential to result in unnecessary antibiotic side effects (an undesired effect from a medication) for Resident 31 and had the potential to result in the development of multi-drug resistant organisms (MDRO- germs that have developed the ability to survive antibiotics that were previously used to kill them; decreasing antibiotic resistance [when antibiotics become ineffective against infection]). Findings: Review of Resident 31's SBAR…

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 medication storage for a census of 104 when: The refrigerator in the Medication Storage Room containing liquid controlled substances (a drug or chemical that is regulated by the government in terms of its manufacture, possession, and use) was unlocked. This failure increased the risk of drug diversion. Findings: During an observation and concurrent interview on 1/7/25, at 3:10 p.m., with Licensed Nurse (LN) 5 in the [NAME] Unit Medication Storage Room, the medication refrigerator in the Medication Storage Room containing liquid narcotic (medications used to treat pain that cause drowsiness, dull the senses, and are prone to abuse) medications and an e-kit (emergency kit, a box containing emergency medications for faster and easy access when needed) was unlocked. LN 5 stated that the refrigerator should have been locked, and quickly locked the refrigerator. LN 5 stated the risk was that someone who was not supposed to have access to the medications could open the refrigerator. During an interview…

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 closed garbage (dumpster) bin. This failure had the potential to lead to insect and rodent infestation. Findings: During a concurrent observation and interview on 1/7/25, at 8:56 AM, with the Dietary Service Supervisor (DSS) in the area where the garbage bins were kept outside, the lids of the bins were not in place. The dumpsters were noted to open. The DSS stated the garbage dumpsters should be kept closed in order to avoid pests. A review of a facility policy titled, Adequate Sewage Disposal and Plumbing, dated 2019, indicated, .Sanitary garbage disposal. Improperly disposed of garbage is an excellent source of unsanitary practices and unpleasant odors. The real dangers are: Harboring place for vermin, flies, rodents, and cockroaches .To prevent this, follow these easy practices: a. Provide garbage containers that are .Are in adequate supply to hold all garbage between collections. b. Lids must be tight fitting .Secure garbage tightly .

Based on interview, and record review, the facility failed to maintain the confidentiality of 1 of 22 sampled residents (Resident 19), when portions of Resident 19's medical records were discovered in Resident 001's medical record. This failure had the potential for exposure of Resident 19's private and confidential information to unauthorized individuals. Findings: During a concurrent interview and record review on 1/13/25, at 4:20 p.m., with the Director of Medical Records (DMR), the DMR confirmed that Resident 19's Preadmission Screening and Resident Review, (PASSR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) PASSR negative level 1 (the initial assessment did not show any signs of a serious mental illness or intellectual disability), and PASSR negative level 2 (Indicates the individual does not meet the criteria for having a condition requiring specialized services based on the comprehensive Level 2 assessment), forms were found in Resident…

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

Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) who received hospice care (end of life care) had care coordinated between the facility and the hospice agency, when the facility requested a medication review recommended on 12/10/24 for Resident 2, and did not follow up on the outcome of the review. This failure resulted Resident 2's medication review not available in Resident 2's clinical record and had the potential for not providing quality care to a terminally ill resident (Resident 2). Findings: A review of Resident 2's clinical record titled, admission RECORD, indicated Resident 2 was admitted to the facility with diagnoses which included, palliative care (comfort measures) and alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills). A review of Resident 2's hospice care plan initiated on 7/14/24 indicated, .On HOSPICE CARE .Facility staff and Hospice Staff are coordinating together for resident's centered care and communicating together to promote comfort, privacy and dignity…

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 care and services according to professional standards of practice and the comprehensive care plan for one of three sampled residents (Resident 1) when a physician ordered pain medication (Tramadol-used to relieve moderate to moderately severe pain) did not arrive from the pharmacy until three days after Resident 1's admission to the facility, and the medication was not administered from the E-kit (an emergency supply of medication) even though it was available. These failures put Resident 1 at risk for increased, uncontrolled pain and had the potential to affect her psychosocial wellbeing. Findings: A review or Resident 1's medication administration record (MAR), dated 10/2024, indicated Start date 10/1/24 .Tramadol .50 mg [unit of measure] give one tablet every 12 hours as needed for pain .Monitor level of pain (0-10 scale): Document pain level as follows: 0=None .1-3=Mild Pain .4-6=Moderate Pain .7-10=Severe Pain . A review of Resident 1's…

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

Based on interview and record review, the facility failed to ensure necessary services were provided for two of three sampled residents (Resident 1 and Resident 2) when Resident 1 went one week (6/19/24-6/26/24) without receiving a shower and Resident 2 did not have a shower for six days. These failures placed Resident 1 and Resident 2 at risk for poor hygiene, poor skin integrity, increased risk of infection, and self-isolation. Findings: a. Review of Resident 1's admission record indicated Resident 1 was admitted with diagnosis of generalized weakness and difficulty walking. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 6/12/24, in section GG (functional abilities and goals) and section E (ability to shower/bathe self) indicated Resident 1 needed partial to moderate assistance with bathing and other Activities of Daily Living (ADL's). During an interview with Resident 1 on 7/2/24, at 2:26 PM, Resident 1 stated, Sometimes they only do showers once a week. They keep saying they have too many people to shower. Resident 1 also stated, Sometimes I'll get a…

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

Based on observation, interview, and record review, the facility did not ensure a safe environment for 6 out of 29 sampled residents (Resident 1, Resident 6, Resident 83, Resident 43, Resident 101, and Resident 462) when: 1. Resident 1, Resident 6, Resident 83, and Resident 43's smoking paraphernalia were not stored correctly, 2. Resident 43 was smoking in the designated smoking area with an oxygen tank; and, 3. Resident 101 and Resident 462's fall care plan interventions for landing mats at the bedside were not implemented. These failures had the potential to result in avoidable injuries for Resident 1, Resident 6, Resident 83, Resident 43, Resident 101, Resident 462, and the potential to affect all residents' safety in the facility. Findings: 1a. During a concurrent observation and interview on 12/12/23, at 9:54 AM, in the [NAME] Hallway, Resident 1 was observed with a lighter and cigarette on his wheelchair. Resident 1 stated he got his lighter from somebody out there and pointed in the direction of the smoking area. Resident 1 further stated he was an assisted smoker and was not…

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

Based on observation, interview, and record review, the facility failed to ensure the correct measuring scoops were used when [NAME] 1 did not measure the small portion diets correctly for 8 residents who received small portions. This failure resulted in plating unknown quantites of lunch items including starch with a potential to negatively impact the residents' nutritional status. Findings: During an observation in the kitchen on 12/14/23, at 11:50 AM, [NAME] 1 was observed serving small portions without using the appropriate scoops. During an interview with [NAME] 1 on 12/14/23, at 12:38 PM, [NAME] 1 confirmed she did not use the appropriate scoops to measure the small portions and she should have. During an interview with the Certified Dietary Manager (CDM) on 12/24/23, at 12:46 PM, the CDM stated they should measure the small portions. The CDM explained it was important to make sure the residents were getting the correct nourishment. During an interview with the Registered Dietitian (RD) on 12/14/23, at 1:54 PM, the RD stated portion sizes were important due to nutrition…

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

Based on observation, interview, and record review, the facility failed to ensure one of 29 sampled residents (Resident 105), was treated with dignity and respect when: 1. Certified Nursing Assistant (CNA) 2 did not knock on Resident 105's door prior to entering his room; and, 2. CNA 2 was not seated when assisting Resident 105 with his breakfast meal. These failures resulted in Resident 105 not being treated with dignity and respect and had the potential to negatively affect Resident 105's feeling of self-worth. Findings: A review of Resident 105's admission Record indicated Resident 105 was admitted to the facility with diagnoses which included vascular dementia (problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage from impaired blood flow to your brain) and blindness. 1. During an observation outside of Resident 105's room on 12/13/23, at 07:55 AM, CNA 2 was observed entering the room without knocking and setting down Resident 105's breakfast tray. During an interview in Resident 105's room with CNA 2, on 12/13/23, at 8:18 AM,…

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.

2. A review of Resident 61's admission RECORD indicated Resident 61 was admitted to the facility in 2022 with diagnoses which included, acute and chronic respiratory failure (disease that can cause shortness of breath, anxiety, and confusion), muscle weakness, and polyneuropathy (nerve disease that causes a decreased ability to move and feel). During an observation on 12/12/23, at 8:46 AM, Resident 61 was observed lying in bed with no call light visible. When asked to demonstrate call light use, Resident 63 attempted to reach his call light multiple times without success. During an observation and interview on 12/12/23, at 9:03 AM, the Director of Staff Development (DSD) confirmed Resident 61's call light was not in reach. The DSD obtained Resident 61's call light from underneath his pillow behind his left shoulder. The DSD stated the call light should be in reach for Resident 61 to obtain assistance when he needed it. The DSD further stated if Resident 61 could not reach his call light he could potentially fall or have unmet needs. A review of Resident 61's care plan, initiated…

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 1 out of 29 sampled residents (Resident 63) rights related to treatment preferences were known and documented in their physician orders and care plans when: Resident 63's cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure) status order and care plan did not match the CPR preferences listed on her Physician Order for Life Sustaining Treatment (POLST, a written medical order from a physician specifying the types of treatment an individual wants to receive during a serious illness). This failure had the potential risk for Resident 63's preferences regarding emergency treatment to not be followed. Findings: A review of Resident 63's admission RECORD, indicated Resident 63 was admitted to the facility in July of 2023 with diagnoses which included chronic obstructive pulmonary disease (COPD, long term lung disease that causes shortness of breath and cough). A review of Resident 63's POLST, signed by the physician on [DATE],…

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 1 of 29 sampled residents' (Resident 1) Pre-admission Screening Resident Review (PASSR, a screening tool used to evaluate an individual who may have a mental disorder or intellectual disabilities) was updated when Resident 1 received an additional diagnosis, other schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), on 2/3/23. This failure had the potential to result in Resident 1 not receiving additional mental health services. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in early 2021 with diagnoses which included bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs (mania or manic episodes) to lows (depression or depressive episode) and other schizophrenia. A record review of Resident 1's clinical document titled, Preadmission Screening and Resident Review (PASRR ) Level 1 Screening Document, dated 3/3/21,…

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 of 14 residents (Resident 46) receiving oxygen in the facility, received oxygen consistent with professional standards of care when Resident 46 had an oxygen concentrator that was not free of dust and debris. This failure had the potential to result in respiratory illness and infection in Resident 46. Findings: During a concurrent observation and interview with licensed nurse (LN) 4 on 12/12/23, at 11:08 AM, in Resident 46's room, Resident 46's oxygen concentrator filter was noted to have a large amount of dust and debris. LN 4 confirmed there was a large amount of dust and debris. LN 4 explained the filter should not be dusty. LN 4 further explained the dust and debris could cause upper respiratory infections and cough. During an interview with the Director of Nursing (DON) on 12/15/23, at 10:03 AM, the DON stated it was important to keep the oxygen concentrator free of dust and debris due to infection control and the risk for additional respiratory issues. A review of an undated oxygen concentrator…

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

Based on observation, interview, and record review, the facility failed to ensure safe medication handling for a census of 99 when: 1. Facility did not ensure safe storage and handling of hazardous medications (drugs that pose short-or long-term harm upon exposure to human via skin or inhalation); and, 2.Facility did not ensure prescription medication delivery receipts were signed and accounted for by a licensed nurse (LN). These failures could contribute to unsafe medication handling and possible drug diversion (illegal or abuse of prescription drugs). Findings: 1a. During a medication administration observation for Resident 66, in the East station of the facility with LN 5 on 12/12/23, at 4:44 p.m., LN 5 poured Valproic acid (or Depakote- a medicine to control seizures) in a medicine cup with bare hands for administration via G-tube (or Gastrotomy tube- a tube inserted through the belly that delivers nutrition and medication directly to the stomach). During a review of Resident 66's medical record titled, Medication Administration Record, (or MAR- listed medications and times 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 a high dose of Ergocalciferol [Vitamin D product; helps the body absorb calcium and phosphorous (vital minerals) for healthy bones and used in the treatment of diseases caused by a hormonal imbalance like hypoparathyroidism (a hormone that regulated mineral absorption)] was reassessed for continued use in 1 out of 5 residents (Resident 95) sampled for unnecessary medications. This failure could result in unsafe medication use, accumulation of medication in the resident's body and adverse effects. Findings: During a review of DailyMed (drug information site by US National Institutes of Health, NIH, which provides trustworthy information about marketed drugs) drug information on Ergocalciferol (a Vitamin D product) 50,000 units (a unit for measuring vitamins), last accessed on 12/19/23, via https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=e58cfb46-f8a7-4327-bbe8-da4d4be2bd1d, the drug information indicated, Therapeutic dosage should be readjusted as soon as there is clinical improvement. Dosage levels must be…

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 antipsychotic medication (drugs used to treat mood and mental health disease) use, diagnosis (medical or mental indication), and monitoring was based on standards of practice in 2 out of 18 residents (Resident 5, Resident 61) when: 1. Resident 5 did not have a specific diagnosis for the use of an antipsychotic medication called Zyprexa (a mind-altering antipsychotic drug); and, 2. Resident 61 was documented as having a diagnosis of schizophrenia for resistive to care as documented in the medical record for use of Risperdal (a mind-altering antipsychotic drug). These failures could result in unsafe medication use and/or treatment of mental health or behavior issues. Findings: 1. During a review of Resident 5's electronic medical record titled, History and Physical, (a comprehensive review of medical conditions) written by Medical Doctor (MD) 1, dated 11/20/23, the record indicated, a medically complex patient, who was admitted with generalized weakness and a history of kidney, heart issues and seizure (a disease…

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 medication administration practices when the medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) for a census of 99 residents. The facility had a total of four errors out of 44 opportunities which resulted in a facility wide medication error rate of 9.09 %. Medication administration observations were conducted at varied times, in random locations throughout the facility. These failures had the potential to result in unsafe medications use and not following the doctor's orders. Findings: 1. During a medication administration observation in the West-2 wing of the facility with Licensed Nurse (LN) 4, on 12/12/23, at 9:05 a.m., LN 4 administered Resident 57's medications. The administered medications included a total of six pills, one eye drop, one inhaler (breathing treatment), and one nasal (nose) spray that were due at 9 a.m. on a daily basis. During a review of Resident 57's medical record titled, Medication Administration Record, (or MAR;…

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 safe medication storage practices for one out of two medication rooms (a locked room for storage of prescription, non-prescription and controlled medications) and two out of four medication carts (mobile cart that stored resident's medication and supplies) with a census of 99 when: 1.Expired (outdated) medications were stored in the medication storage room and medication carts; and, 2.A medication refrigerator located in the facility's [NAME] station was overcrowded and the temperature was 50 degrees upon opening. These unsafe medication storage practices could contribute to medication error and unsafe medication use. Findings: 1 a. During a concurrent observation and interview on [DATE], at 9:50 a.m., in the facility's [NAME] station medication room with Licensed Nurse (LN) 3, a Flu vaccine (a shot to prevent against Flu) bottle was expired on [DATE] while it was stored in the active storage area. LN 3 confirmed the finding 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 food was prepared in accordance with professional standards of food service safety for 90 out of 99 residents receiving food from the kitchen when: 1. Pureed food was taste tested using the same spoon, 2. All food items for the lunch meal on 12/14/23 were not temped (process for taking temperatures of prepared food items using a calibrated kitchen thermometer); and, 3. The food preparation sink did not have an air gap (a break in the plumbing to prevent unsanitary water from flowing back into the sink) located under the food preparation sinks (where fruits, vegetables and other foods are prepared). These failures had the potential to expose 90 residents of a census of 99 to food borne illnesses (illnesses caused by the ingestion of contaminated food or beverages). Findings: 1. During a concurrent observation and interview with [NAME] 1 in the kitchen on 12/14/23, at 11:15 AM, [NAME] 1 was observed preparing the pureed (blended food) food items. [NAME] 1 stated she always taste tested the pureed food…

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 infection control and prevention practices with a census of 99 when: 1. Safe infection control practices were not followed for cleaning and disinfecting a shared glucometer (a device used to measure blood sugar) in-between resident care for Resident 66; and, 2. Staff did not follow hand hygiene (cleaning and sanitizing hand) in-between resident care for Resident 57 and Resident 82, and Resident 72. These failures could pose health safety risks and spread of infection in the facility. Findings: 1. During a medication administration observation with Licensed Nurse (LN) 5 on 12/12/23, at 4:35 PM, in the facility's East hallway, LN 5 gathered the blood sugar measurement supplies plus a glucometer into the Resident 66's room. LN 5 then placed the supplies and glucometer on Resident 66's bed sheet, with gloved hands, LN 5 poked one left middle finger with a lancet (a sharp small needle) and squeezed the finger to get blood. LN 5 then soaked the test strip attached to the glucometer with blood to measure…

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 an accurate, and complete assessment for 1 of 3 sampled residents (Resident 1) when Resident 1's elopement (a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision) risk assessments were not completed accurately. This failure potentially contributed in Resident 1 eloping from the facility on 10/25/23 without the facility's knowledge and was not found for over 24 hours. Findings: The Department received a report from the facility on 10/25/23, at 12:09 a.m., indicating, . [Resident 1] .Date/Time 10/24/23 .left facility around 1704 [5:04 p.m.] without informing staff. Has Dx [diagnosis] Dementia [loss of memory and judgment that results in forgetfulness, limited social skills, and impaired thinking abilities that interferes with daily functioning] Staff searched the .whole building unable to find him . During an interview on 10/25/23, at 3:23 p.m., the Administrator (ADM) stated 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 review, the facility failed to protect one resident's rights (Resident 2) of three sampled residents, to be free from physical abuse when Resident 1 went to Resident 2's room and pushed Resident 2 out of his wheelchair causing Resident 2 to fall. This failure resulted in Resident 1 physically attacking Resident 2, resulting in a fall and a scratch to the left cheek. Findings: A review of an admission Record indicated Resident 1 was admitted to the facility middle 2023 with multiple diagnoses which included psychoactive substance abuse (an impaired capacity to control substance-taking behavior), bipolar disorder (a mental illness that causes extreme mood swings), and anxiety. A review of a Minimum Data Set (MDS, an assessment tool), dated 8/17/23, indicated Resident 1 had no memory problems. A review of an admission Record indicated Resident 2 was admitted to the facility middle 2019 with multiple diagnoses which included psychotic disorder (affects the mind, where…

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

Based on interviews and record review, the facility failed to report an allegation of abuse when one of three sampled residents (Resident 1) alleged she was handled roughly by a Certified Nursing Assistant (CNA) 3 when CNA 3 provided care to the resident. This failure to report and investigate an allegation of abuse had the potential to expose other vulnerable residents in the facility to abuse. Findings: A review of Resident 1's clinical record titled, Face sheet (a record of admission), indicated that Resident 1 was admitted in mid-July of 2023 with diagnoses that included fracture of upper and lower end of right fibula (the outer and usually smaller of the two bones between the knee and the ankle). Resident 1's Minimum Data Sheet (MDS - an assessment tool to help measure health status of patients in nursing homes), dated 7/25/23, indicated that, Resident 1 was non-English speaking and needed an interpreter to communicate with a doctor or healthcare staff. Resident 1 was cognitively intact and needed extensive assistance for bed mobility, transfer, dressing, toilet, and personal…

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.