Noble Care Center

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 for a census of 91 when: 1. Two over-the-counter (medication that can be obtained without a doctors order) medication bottles were stored in open view on the bedside table of Resident 90, in a multi-resident room; 2. An Emergency Kit (E-kit -a locked and secure box containing an available collection of medications and supplies designed to address immediate needs when the pharmacy is unavailable) was opened and a medication was used without the proper documentation per facility policy; and, 3. An opened and used multi-dose vial of Heparin (an injectable medication given to prevent blood clots) was not dated with an opened or use by date per standards of practice. These failures may pose unsafe medication use in the facility. Findings: 1. During a concurrent observation and interview, on [DATE], at 12:20 PM, in Resident 90's room with Licensed Nurse (LN) 1, LN 1 confirmed Resident 90 had one bottle of Fish oil…

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 residents receiving pureed chicken and pureed noodles received the appropriate nutritive content as prescribed by a physician when serving sizes were smaller than ordered for the 14 residents receiving a Pureed (soft, pudding-like consistency) diet, and the 10 residents receiving the pureed meat on the Dysphagia Mechanical diet (texture- modified diet designed to make foods easier to chew and swallow). This failure had the potential of leading to malnutrition and weight loss for the 14 residents receiving a Pureed diet, and the 10 residents receiving the pureed meat on the Dysphagia Mechanical diet. Findings: During an observation of the lunch meal on 3/12/25, at 11:42 a.m., the service utensils were noted for the various foods. The pureed sweet and sour chicken was noted to have a green handled scoop (equivalent to 2 2/3 ounces {unit of measurement}) in the pan, which was the only scoop used during the lunch meal service. The pureed noodles also had a green handled scoop (2 2/3 ounces) placed 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 provide food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 87 residents who ate facility prepared meals when: 1. Two food labels were unreadable, two labels did not include the year, and several bottles of seasoning did not have a use by date; 2. Dry storage walls were not smooth and cleanable, floor of the dry storage was uneven, the refrigerator door appeared discolored, and the kitchen floor had missing and cracked tiles; 3. One container of baking powder was left open and unsealed; 4. Dry storage floor was discolored and sticky, oven doors, microwave, and toaster had food residue on surfaces, and the shelf under the dishwashing machine appeared discolored and rough to the touch; 5. Two containers of sugar and flour were stored directly on kitchen floor, as well as a box of juices in the emergency food closet; 6. Kitchen had worn food preparation equipment such as a rusty strainer, one pot had 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 interview and record review, the facility's Quality Assessment Performance Improvement (QAPI, a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes) committee failed to develop and implement action plans, for a problem identified in June 2024, when three of eight sampled employee files (Certified Nurse Assistant (CNA) 1, CNA 2, and Licensed Nurse (LN) 8) did not contain background checks until 22-24 months after their hire dates. These failures had the potential to expose residents to physical and psychosocial harm. Findings: During an interview and record review on 3/11/25, at 12:09 PM, CNA 1's employee file was reviewed with the Director of Staff Development (DSD). The DSD confirmed Certified Nurse Assistant (CNA) 1 was hired on 4/26/23, and the background check (a screening for a history of fraud, abuse, and criminal offenses) in her file was completed on 2/11/25. The DSD confirmed the background check was not completed until 22 months after the hire date. The DSD stated the importance 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 one of twenty sampled residents (Resident 39) had their rights related to treatment choices known and protected when, a copy of Resident 39's Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) was not available in the medical record. This failure had the potential to result in Resident 39's preferences for treatment to not be followed. Findings: A review of Resident 39's admission RECORD, indicated that Resident 39 was admitted to the facility in the fall of 2023 with diagnoses that included Alzheimer's (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), and cognitive communication deficit (communication problem that stems from difficulties with thinking and processing information). A review of Resident 39's medical record titled, Physician Orders for Life-Sustaining Treatment [POLST - a form that contains…

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 resubmit the Pre-admission Screening and Resident Review (PASRR - a required assessment for individuals with mental illness, intellectual or developmental disabilities, or related conditions, so that a determination of need, appropriate setting, and a set of recommendations for services to be included in the individual's plan of care is provided) for one of twenty sampled residents (Resident 71) when, Resident 71's PASRR was not submitted by the facility on the 31st day after admission to the facility. This failure had the potential for Resident 71 to not receive the necessary services to meet their mental and psychosocial (the link between social factors and individual thought and behavior) needs. Findings: A review of Resident 71's admission RECORD, indicated that Resident 71 was admitted to the facility in early 2024 with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought). A review of Resident 71's medical record, from the transferring hospital, titled,…

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 baseline care plan within 48 hours of admission as required to address resident-specific care needs for one of twenty sampled residents (Resident 249) when, Resident 249's admission document identified a communication need that was not addressed on his baseline care plan. This failure had the potential for Resident 249 to not receive person-centered care. Findings: A review of Resident 249's admission RECORD indicated that Resident 249 was admitted in 2/28/25 with diagnoses which included dementia (a decline in memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily living). A review of Resident 249's Social Services Assessment-Admission/Re-Admission, dated 3/5/25, indicated that Resident 249's primary language was [NAME], and further indicated that Resident 249 could not communicate in English. During an observation on 3/12/25, at 12:29 p.m., of Resident 249 in his room, Resident 249…

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

Based on interview and record review the facility failed to develop and implement a resident-specific care plan intervention for 1 of 20 sampled residents (Resident 66) when, Resident 66 had no care plan addressing his anticoagulant care needs. This failure placed Resident 66 at risk for a decline in their health and well-being. Findings: A review of Resident 66's admission RECORD indicated that Resident 66 was admitted to the facility with diagnoses which included amputation of both legs below the knees (surgical procedure to remove the lower legs below the knees when they were severely damaged or diseased), and amputation of fingers on right and left hand due to frostbite (surgical procedures to remove fingers of both hands when they were severely damaged due to frostbite (injury caused by freezing of the skin and underlying tissue)). A review of Resident 66's Physician Order Summary, indicated, .Apixaban Oral Tablet [anticoagulant (medication used to prevent or reduce blood clots)] 5 MG [unit of measure] .Give 1 tablet by mouth two times a day for treat and prevent blood clot…

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 conduct an IDT (Interdisciplinary Team: group of healthcare professionals from various disciplines that works together to develop and implement individualized resident care plans) meetings for one of twenty sampled residents (Resident 31), when Resident 31 ' s quarterly IDT care conferences were not conducted as scheduled for April 2024 and October 2024. This failure had potential to result in Resident 31's changing care needs not being accurately reflected in the care plan and the current care interventions not being readily available to implement and evaluate for their effectiveness and relevance. Findings: Review of Resident 31's admission RECORD indicated Resident 31 was admitted to the facility with multiple diagnoses including diabetes (abnormal blood sugar levels) and hyperlipidemia (elevated levels of lipids (fats) in the blood). During a concurrent interview and record review on 3/13/25, at 10 a.m., Resident 31's electronic medical record (EHR) was reviewed with the Social Services Director (SSD). The SSD stated…

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

Based on observation, interview, and record review, the facility failed to ensure adequate treatment and services were provided for one of twenty sampled residents (Resident 96) when Resident 96's STAT order (should be prioritized first as it is needed urgently) left hand x-ray was delayed and the delay in the order being carried out was not reported to the physician in a timely manner. This failure placed Resident 96's at risk of worsening and prolonged pain while awaiting for diagnosis of the left hand injury. Findings: A review of Resident 96's medical record titled, admission RECORD, indicated that Resident 96 was admitted to the facility in early 2025 with diagnoses that included encephalopathy (a disturbance of brain function) and cognitive communication deficit (communication problem that stems from difficulties with thinking and processing information). During an observation and interview on 3/11/25, at 11:36 a.m., with Resident 96, Resident 96 was noted to have bruising on the back part of his left hand. Resident 96 stated that he got the bruising from somewhere but does…

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 safe environment for 1 of 20 sampled residents (Resident 65) when, Resident 65's footboard (part of the bed frame located at the foot of the bed) was broken and splintered. This failure had the potential to cause harm to Resident 65. Findings: During a concurrent observation and interview on 3/11/25, at 11:53 AM, in Resident 65's room, it was observed that Resident 65 had a broken footboard that had exposed splinters and sharp edges on the side that faced Resident 65. Upon further observation it was noted that there was a thick black tape placed around the broken part of the footboard; however, it did not cover the sharp and splintered part facing Resident 65. Resident 65 stated it had been taped for a while, but could not recall who taped it, or when it was taped. Resident 65 further stated she could hurt herself on it and the footboard should be fixed. During a concurrent observation and interview on 3/11/25, at 12:24 PM, in Resident 65's room, Licensed Nurse (LN) 1 confirmed the footboard was…

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

Based on interview and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs for two of twenty sampled residents (Resident 66 and Resident 300) when: 1. Resident 66's antibiotic (a medication that kills germs) doses were not documented accurately in the medical record; and, 2. Resident 300's nicotine patch (a nicotine medicated patch worn on the skin to help reduce cravings of cigarettes) was not available for use for 6 days. These failures had the potential for Resident 66's infection (invasion and growth of germs in the body) to not be fully treated, resulting in a decline of his health and well-being and, resulted in Resident 300 feeling anxious without the nicotine patch and did not allow Resident 300 to achieve his highest practicable physical, mental, and psychosocial well-being. Findings: 1. A review of Resident 66's admission RECORD indicated that Resident 66 was admitted to the facility in 2025 with diagnoses which included Methicillin Resistant Staphylococcus Aureus Infection (MRSA, presence of germs in the body that do 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 interview and record review, the facility failed to ensure one of six sampled patients (Patient 68) was free from unnecessary medication when Patient 68 was receiving antidepressant medication with no monitoring for side effects or behavior manifestations of depression and the pharmacist's recommendation for a review of the medication use was not acknowledged by the physician in a timely manner. These failures had the potential for Patient 68 to receive unnecessary medication and the potential for medication side effects to go unnoticed, negatively impacting Patient 68's health and well - being. Findings: A review of Patient 68's admission RECORD, indicated, she was admitted to the facility in early 2024, with diagnoses which included depression. A review of Patient 68's Order Details, dated 6/12/24, indicated, .Selegiline HCL [hydrochloride] [medication prescribed to treat depression] .one time a day for m/b [manifested behavior] verbalization of sadness related to DEPRESSION . A review of an online document, accessed on 3/21/25, published by the National Library of…

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

Based on interview and record review, the facility failed to ensure safe monitoring and assessment of blood pressure (BP-the force of your blood pushing against the walls of your arteries as your heart pumps blood and was measured as two numbers: systolic (when the heart beats) and diastolic (when the heart rests between beats)) and heart rate (HR-frequency of your heart beats per minute) for medications to treat high (hypertension (HTN)) and low (hypotension) BP for 1 of 20 sampled residents (Resident 35) when: 1. Resident 35's physician's prescribed hold parameters (a set of numbers that guide the nursing staff when to not give medication for safety reasons) for midodrine (medication used to treat low BP) was not followed; 2. Resident 35's physician's prescribed hold parameters for labetalol (a medication used to treat HTN) were not followed; 3. Resident 35's BP and HR readings used to determine hold parameters for administering BP medications were used for more than one dose of medication at different times on the same day for both midodrine and labetalol; and, 4. Licensed Nurses…

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 standardized recipes were utilized for food preparation to ensure foods were prepared by methods that conserve nutritive value and flavor when vegetables were placed into the steam table approximately three hours before meal service, and measurement tools were not used during meal preparation for the 87 residents receiving kitchen prepared meals. These deficient practices placed residents at an increased risk for nutritional impairment. Findings: During an observation on 3/12/25, at 8:29 a.m., [NAME] 1 (CK 1) added a green scoop of butter to vegetables in a pot on the stove. The [NAME] was unsure of the amount in the scoop. During an observation on 3/12/25, at 8:32 a.m., CK 1 set a pot of water on stove to make noodles and added an unmeasured amount of oil. During an observation on 3/12/25, at 9 a.m., CK 1 transferred vegetables from the steamer to a steam table pan and added a handful of salt, a plastic spoon of black pepper, 3 spoonfuls of garlic powder, and an unmeasured amount of butter. After…

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 that the alternative meal option of a grilled cheese sandwich had a similar protein content to the main entrée for the 87 residents receiving kitchen prepared meals. This had the potential of leading to inadequate protein intake/malnutrition for those residents choosing the sandwich in place of the main entrée. Findings: During an observation of the facility menu posted outside of the kitchen on 3/11/25, at 10:50 a.m., the alternative choices menu was observed. The choices on the Spring 2025 menu included a Grilled Cheese Sandwich without any additional items listed. Review of a facility provided recipe titled, Grilled Two-Cheese Sandwich, indicated that each sandwich was made with 2 ounces [unit of measurement] of cheese, the equivalent of 2 ounces of protein or 14 grams [unit of measurement] of protein. Review of the Cook's Spreadsheet for the lunch meal served on 3/12/25, indicated that the serving size for the Sweet and Sour Chicken was ½ cup (4 ounces) for the small portion, and ¾ cup (6 ounces)…

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 the confidentiality of 1 of 20 sampled residents (Resident 31) when portions of Resident 31's medical records were discovered in Resident 98's medical record during a closed record review (examining a residents medical records after their care has concluded (for example; discharge, death). This failure had the potential for exposure of Resident 31's private and confidential information to unauthorized individuals. Findings: During a closed record review of Resident 98's paper medical record file on 3/14/25, at 8:12 a.m., Resident 98's paper medical record file contained paper medical record documents belonging to Resident 31. During an interview and concurrent record review on 3/14/25, at 9:05 a.m., Resident 98's paper medical record file was reviewed with the Medical Records Clerk (MR). The MR confirmed that there were medical record documents in Resident 98's medical record file that belonged to Resident 31. The MR stated that the risk of placing another resident's records in the wrong file was a violation 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 practice appropriate infection prevention and control measures for a census of 91 when: 1. Licensed Nurse (LN) 1 did not clean, sanitize, and disinfect the glucometer (a device that measures blood sugar levels) per manufacturer's guidelines; and 2. A partially full urinal was sitting on the bedside table with Resident 300's water. These failures had the potential to spread infection and cause health problems to the residents for a census of 91. Findings: 1. During a concurrent observation and interview on 3/11/25, at 12:24 PM, in front of room [ROOM NUMBER], LN 1 was observed cleaning a glucometer after use. LN 1 took one (name brand pre-moistened disinfectant wipe) and cleansed the glucometer for a few seconds and then placed the glucometer on a tray on her medication cart. LN 1 stated she cleaned the glucometer for approximately 15 seconds and could not remember how long the recommended wet-contact time was (how long a disinfectant…

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 for one of two residents on antibiotics (Resident 90) in a sample of 20 based on facility policy and national standards when: 1. McGeer Criteria (a set of guidelines for identifying infections in long-term care facilities) was not followed for prescribing antibiotics as indicated in the facility policy and procedure for Resident 90; and, 2. An antibiotic time-out (an active reassessment of an antibiotic prescription 48-72 hours after the medication's first dose) for Resident 90 was done within 24 hours and did not follow the facility's policy and procedure of the ASP; and, 3. The facility did not order a diagnostic urine Culture (a test to find germs, such as bacteria, that can cause an infection) and Sensitivity ([C&S]- a sensitivity test checks to see what kind of medicine such as an antibiotic that will work best to treat an infection) test 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 interview, and record review, the facility failed to develop a care plan for one of two sampled residents (Resident 1) when Resident 1's care needs for alcohol withdrawal and elopement prevention were not addressed on admission. This deficient practice resulted in Resident 1 ' s elopement from the facility on 12/6/24 and 12/13/24. Findings: Review of Resident 1 ' s admission RECORD, indicated Resident 1 was admitted to the facility from Acute Hospital 1 on 12/4/24 with diagnoses including but not limited to alcohol use with intoxication, discitis (an inflammation of the intervertebral discs, convulsion (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles), and chronic obstructive pulmonary disease (a chronic lung disease that causes breathing problems and restricted airflow). Review of Resident 1 ' s Physician Progress Note from Acute Hospital 1 dated 11/27/24, indicated Resident 1 was admitted to the hospital for generalized pain. Resident 1 had…

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 reviews, the facility failed to provide a copy of medical records to Resident 1 within 2 days after a written request was made by Resident 1 on 11/14/24. This failure delayed Resident 1's right to obtain his medical records in a timely manner. Findings: During a review of Resident 1's, admission Record, dated 5/5/23, the admission record indicated that Resident 1 was his own Responsible Party (person responsible for making health care decisions). During an interview on 11/19/24 at 9:55 a.m. with Social Services (SS), the SS stated Resident 1 called on 11/4/24 to ask for a copy of his discharge paperwork. The SS informed Resident 1 he would need to fill out a medical records request form and send it back to the facility. The SS stated the medical records request form was sent to Resident 1 on 11/4/24. During an interview on 11/19/24 at 10:17 a.m. with Medical Records (MR), the MR stated she received a fax number from SS to send Resident 1's discharge paperwork to. The MR stated there was a protocol in place for medical record requests. The MR stated…

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

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of two sampled residents (Resident 1) when a medication used to control pain was not ordered and delivered. This failure had the potential for Resident 1 to experience nerve pain. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility in the winter of 2024, with diagnosis of, but not limited to, Type 2 Diabetic Mellitus (DM) (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), acute and chronic respiratory failure with hypoxia (condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide). During a review of Resident 1's Order Summary Report dated 10/23/2024, the Order Summary Report indicated that Gabapentin (a medication used for nerve pain, which can be caused by different conditions, including diabetes and shingles) Oral Capsule 100 MG (Gabapentin) was ordered for Resident 1 on 5/02/24 with the following…

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 the office of the local Long-Term Care (LTC) Ombudsman (OMB, an official advocate who represents the interests of the residents residing in a LTC facility) a copy of the Notice of Transfer/ Discharge for Resident 1 prior to Resident 1's discharge from the facility. This failure placed Resident 1 at risk of not receiving the necessary protections and support of the LTC Ombudsman office. Findings: A review of Resident 1's clinical document titled, admission RECORD, indicated Resident 1 was admitted to the facility in May of 2024. A review of Resident 1's clinical document titled, NOTICE OF TRANSFER/DISCHARGE, indicated .Notification Date: 6/21/24 .Effective Date: 6/27/24 .Transfer/Discharge to .Shelter for the Homeless .This notice is to inform you that transfer/discharge is necessary for the following reason .The transfer or discharge is appropriate because your health has improved sufficiently .If you intend to file an appeal of this…

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 that one of five sampled residents' (Resident 1) smoking safety evaluation records were completed in a timely manner. This deficient practice had the potential to cause inaccurate documentation in Resident 1's clinical record and had the potential to cause injury from smoking. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in June of 2024, with a diagnosis of, but not limited to, personal history of nicotine dependence (an addiction to tobacco products caused by the drug nicotine) and toxic effect of tobacco cigarette. During an observation on 7/11/24, at 4:05 p.m., in the designated smoking area, Resident 1 was observed smoking without a smoking apron. During a review of Resident 1's undated Smoking Safety Evaluation record, the effective date of the evaluation record was listed as 6/26/24 at 3 pm. The signed date was listed as 7/12/24 at 3:16 pm. During a concurrent interview and record review on 7/24/24, at 3:51 p.m., with the Medical Records…

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

Based on interview and record review, the facility failed to protect one of three sampled resident's (Resident 1) right to be free from physical abuse by facility staff, when Resident 1 was grabbed and was hit in the face by Certified Nursing Assistant (CNA) 1. This failure resulted in Resident 1 crying and sustaining bleeding and discoloration to her lip. Findings: During a review of Resident 1's admission Record, dated September 2023, the admission Record indicated Resident 1's diagnoses included Dementia, (an impairment of brain function including loss of memory and judgment); and Alzheimer's disease, (the most common cause of dementia -a gradual decline in memory, thinking, behavior, and social skills which causes the brain to shrink and brain cells to eventually die). During a review of Resident 1's clinical record, Progress Notes, dated 5/8/24 at 9:55 p.m., the note indicated, .Resident noted lip bleeding, first aid rendered . During a review of Resident 1's clinical record, IDT-Interdisciplinary Post Event Note [IDT-an interdisciplinary team consists of staff from different…

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

Based on interview and record review the facility failed to develop a comprehensive care plan for two of seven sampled residents (Resident 1 and Resident 6) when Resident 1 and Resident 6 were involved in resident-to-resident altercations and post incident care plans were not developed. These failures had the potential for Resident 1 and Resident 6 to not receive adequate care and to have unmet psychosocial needs. Findings: A review of Resident 1's admission RECORD, indicated she was admitted to the facility in 2024, with diagnoses which included bipolar disorder (a mental health condition that causes changes in a person mood, energy, and ability to function). A review of Resident 1's Progress Notes, dated 4/26/24 at 6:29 AM, indicated, . had an altercation with another Resident .claimed [Resident name] threatened to kill her . A review of Resident 6's admission RECORD indicated she was admitted to the facility in 2023 with diagnoses which included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 6's Progress Notes,…

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 professional standards of care were provided for one of seven sampled residents (Resident 7) when Resident 7 sustained a cervical (neck) fracture on 4/8/24 and her medical provider was not informed until 4/26/24. This failure resulted in a delay of treatment, and placed Resident 7 at risk of improper healing and worsening of her injury. Findings: A review of Resident 7's admission RECORD, indicated she was admitted to the facility in 2019 with diagnoses which included epilepsy (a brain condition that causes recurring seizures) and Alzheimer's disease (a progressive disease that affects the parts of the brain that control thought, memory and language). A review of Resident 7's Progress Notes, dated 4/8/2024, at 11:18 AM, indicated, .Back from ED [emergency department] .due to a fall this morning .Assisted resident back to bed, check for any alteration in skin integrity but none noted .with new order of Cefdinir [an antibiotic medication used to treat an infection] .Noted and carried out . The note included results…

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 residents were free from verbal and physical abuse for 2 of 5 sampled residents (Resident 3 and Resident 5), when Resident 3 hit resident 5 on her face and shoulder after Resident 5 shouted and cursed at him to stop staring at her. This failure resulted in physical pain for Resident 5 and the altercation had the potential to diminish the psychosocial well-being of both residents. Findings: According to Resident 3 ' s ' admission Record ' the facility admitted him in 2023 with multiple diagnoses that included head trauma and communication deficit. According to the most recent Brief Interview for Mental Status (BIMS, a tool used to test memory and recall) contained in his quartely assessment, he scored 10 out of 15 which indicated he had moderate cognitive impairment. A review of Resident 3 ' s ' .Post Event Note ' dated 5/6/24 indicated the event date was on 5/3/24 at 6:35 p.m. when, A female resident [Resident 5] shouted at (name of Resident 3) to stop looking at her while he was passing by . 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents' (Resident 1) needs were accommodated promptly, when Resident 1's call light was not within his reach. This failure had the potential of Resident 1's needs not being met and to cause psychosocial and/or physical harm for Resident 1 when unable to contact staff when needed. Findings: Review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in 2022 with multiple diagnoses including myocardial infarction (heart attack, usually occurs due to blockage of blood flow to the heart muscle), respiratory failure (inability to breathe normally), weakness, and history of falling. Review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 2/7/24 indicated Resident 1 needed assistance with daily living activities. Review of Resident 1's fall risk assessment dated [DATE], indicated Resident 1 was at high…

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 have an adequate system for periodically reconciling controlled drugs (substances that have an accepted medical use and have a potential for abuse and may also lead to physical or psychological dependence), and properly administering medications to meet the needs of the residents for a census 93 when: 1.The facility did not clarify midodrine (medication for hypotension) order parameters and administer midodrine to Residents 45 and 199; and, 2. The facility did not have an adequate system for the Director of Nursing (DON) to accurately periodically reconcile controlled drugs received from the pharmacy by nursing staff to prevent drug diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber). These failures had the potential for Residents 45 and 199 to be inadequately treated for hypotension, and drug diversion of controlled medications after nursing staff received…

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

Based on observation, interview, and record review, the facility failed to meet food storage and food service standards when: 1. The walk-in freezer door was left open and ice build-up was found at the bottom of the door. 2. Various dry food items were not labeled with the use by date, 3. Various opened spices were not labeled with an open date, 4. Bowls of ready to eat green salads were not covered appropriately, 5. Fruits were not washed prior to peeling, 6a. Dishwasher temperature and the sanitizer readings were not done as scheduled; and, 6b. The red bucket sanitizer readings were not completed as scheduled. These deficient practices had the potential of leading to food-borne illness for the 90 out of 93 residents eating facility prepared foods. Findings: 1. During the initial kitchen tour on 2/20/24, at 8:47 a.m., with [NAME] 1 in the walk-in refrigerator where the walk-in freezer was located, the freezer door was open and ice build-up at the bottom of the door was found. [NAME] 1 tried to close the freezer door but it would not latch on. [NAME] 1 stated she had to push hard 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 coordinate assessments with the Preadmission Screening and Resident Review (PASARR, a federal requirement to screen all potential nursing home residents for mental illness and intellectual disability, to help ensure that individuals are not inappropriately placed in a nursing home, and to ensure they receive any specialized services that are required) Program for 3 of 21 sampled residents (Resident 13, Resident 41, and Resident 56) when: 1. Resident 13's PASARR Level II recommendations were not implemented, 2. Resident 41's PASARR level I did not include her mental illness diagnosis of schizoaffective disorder (a mental health disorder characterized by abnormal thought processes and an unstable mood); and, 3. The facility did not initiate PASARR level I re-screening when Resident 56 received a mental illness diagnosis of bipolar disorder (a mental health condition that causes changes in a person mood, energy, and ability to function). These failures had the potential for Resident 13, Resident 41, and Resident 56 to not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Consultant Pharmacist (CP) failed to identify and report to the facility an irregularity related to: 1. Resident 18 was administered valproic acid (suspension for seizure) with no resident diagnosis of seizure, therapy duplication for valproic acid suspension and Depakote DR tablet (antiseizure medications also used to treat mood disorders), a gradual dose reduction (GDR- stepwise tapering of a dose to determine if symptoms, conditions or risks can be managed by a lower dose or if the dose or the medication can be discontinued) was not attempted for Depakote DR tablets, follow up on Resident 18's triglyceride (a type of fat found in blood) critical levels, Zyprexa (antipsychotic medication that alternates brain chemistry to help reduce psychotic symptoms), and nortriptyline were administered unnecessarily; and, 2. Resident 41 was administered Zoloft and bupropion (medications to treat depression) unnecessarily and therapy duplication for Zoloft and Lexapro (medication to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure two out of three residents (Resident 18 and Resident 41) were free from unnecessary psychotropic (drugs that affect brain activities associated with mental processes and behavior) medications when: 1. Resident 18 was administered Zyprexa (antipsychotic medication that alternates brain chemistry to help reduce psychotic symptoms), nortriptyline (medication used to treat depression), and valproic acid suspension/Depakote Delayed Release (DR)tablet (an antiseizure medication also used to treat mood disorders) and the facility did not implement resident specific non-pharmacological interventions. Resident 18 was administered valproic acid with no resident diagnosis of seizure, a consent was not obtained for Resident 18's administration of Zyprexa 10mg (milligram- unit of measure) dose and Zyprexa 10mg was administered unnecessarily, no monitoring of TSH (thyroid stimulating hormone- levels can indicate if thyroid disease present)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the facility medication error rate did not exceed five percent or greater when observation of 25 opportunities during the medication pass resulted in four errors. The calculated medication error rate was 16%. This failure resulted in: 1. Placing Resident 1 at risk of constipation and nicotine withdrawal when Licensed Nurse (LN) 20 did not administer nicotine patch (patch to help quit smoking) and Miralax (medication for constipation). 2. Placing Resident 202 at risk of low levels of magnesium and folic acid when LN 20 did not administer magnesium and folic acid. Findings: 1. During a review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history), the AR indicated, Resident 1 was admitted to the facility on [DATE]. During an observation on 2/20/24 at 8:38 a.m. in Resident 1's room, LN 20 administered aspirin chewable 81mg (milligram- unit of measure) tablet, docusate…

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 all medications used in the facility were properly labeled and discarded after the expiration date or discontinued date when: 1. In the [NAME] Wing medication cart, Resident 64's discontinued hydrocodone/acetaminophen (medication used to treat pain) 5-325 mg (milligrams- unit of measure); Resident 16's two latanoprost (medication for high blood pressure in the eyes) bottles, one expired and one with no open or expiration dates; Resident 21's two expired latanoprost bottles; Resident 78's two expired latanoprost and two expired Rhopressa (medication for high blood pressure in the eyes) 0.02% ophthalmic bottles; Resident 33's Lantus (medication for high blood glucose) pen with no open or expiration date; Resident 247's Lantus and Humalog (medication for high blood glucose) pens with no open or expiration dates; Resident 10's two Novolog (medication for high blood glucose) pens with no open or expiration dates, were found not separated from medications that were in use for facility residents. 2. 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 interview and record review, the facility failed to provide sufficient oversight of the daily food service operations for 90 residents who received food from the kitchen out of a census of 93 when the facility did not employ a full-time Registered Dietitian (RD) or a Certified Dietary Manager/Supervisor (CDS). This failure resulted in inadequate supervision of the dietary department and had the potential for unsafe food practices and food-borne illness for residents who received facility-prepared foods. Findings: During an interview on 2/20/24, at 8:32 a.m. with two Dietary Aides (DA) and a [NAME] in the kitchen, the DA 1 stated the dietary department did not have a CDS for the last two weeks and the RD was not in the building. [NAME] 1 stated she was not the supervisor and did not give orders. During the initial tour of the kitchen on 2/20/24, at 8:47 a.m. with [NAME] 1 and DA 1, multiple issues were identified regarding providing and serving nutritive food (Cross-Reference F804); ensuring food was stored, prepared, and served in a safe and sanitary manner (Cross-Reference…

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 implement infection control practices for a census of 93 residents when: 1. The facility failed to implement their water management program for monitoring legionella's disease (an illness caused by bacteria which grow in moist areas) and other water borne illnesses when the processes for water treatment were not documented since August 2023. This failure had the potential to allow for water borne illnesses. 2. Licensed Nurse (LN) 20, 24, and 28 failed to appropriately disinfect (to clean and make free of disease-causing organisms) shared glucometers before and after resident care, according to manufacturer's specifications. This failure had the potential to spread infection to other residents. Findings: 1. During an interview on 2/23/24, at 9:15 a.m., with the DOM (Director of Maintenace), he stated their water management program had no evidence it was done after August 2023. During an interview on, 2/23/24, at 10 a.m., the Administrator stated there was no documentation of a water management program being…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure resident preferences regarding life sustaining treatment were accurately reflected in the electronic health record (EHR) for 1 of 21 sampled residents (Resident 48) when Resident 48's code status order (an order whether or not to perform resuscitation in an emergency) in the EHR did not match the code status listed on the Physician Orders for Life-Sustaining Treatment (POLST- care directives during life threatening situations). This failure had the potential risk of Resident 48's wishes for life sustaining treatment to not be followed. Findings: A review of Resident 48's POLST, dated [DATE], indicated, .Attempt Resuscitation/CPR [cardiopulmonary resuscitation, lifesaving technique used when a person is not breathing, or their heart has stopped] .Full Treatment . A review of Resident 48's physician order dated [DATE], indicated, .DNR [do not resuscitate], COMFORT TX [treatment] . A review of Resident 48's Progress Notes, dated…

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

Based on interview, and record review, the facility failed to ensure 2 of 3 sampled residents (Resident 47 and Resident 84) were provided timely and specific notification of how their discharge from Medicare Part A skilled services (specialized services provided in a skilled nursing facility) would affect their continued stay at the facility when the Skilled Nursing Facility Advanced Beneficiary Notice of Non - coverage (SNF ABN, a form which lists the items or services that Medicare may not pay for, the reason why, and the estimated cost to the resident) was not provided prior to their Medicare A services end date. This failure had the potential for Resident 47 and Resident 84 to be unaware of their potential liability for payment of services not covered under Medicare A and their rights to appeal the decision. Findings: A review of Resident 47's admission RECORD, indicated, she was admitted to the facility in September of 2023. During a concurrent observation and record review on 2/22/24, at 4:50 PM, the Assistant Business Office Manager (ABOM) confirmed Resident 47's SNF ABN…

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

Based on interview, and record review, the facility failed to ensure an allegation of verbal abuse was reported for 1 of 21 sampled residents (Resident 33) when licensed nurse (LN) 1 did not report to facility administration about Resident 33's allegation of verbal abuse. This failure resulted in a delay of an investigation of the alleged abuse and had a potential to affect Resident 33's psychological well-being. Findings: During an interview 2/20/24, at 11:48 a.m., with Resident 33, Resident 33 stated that Resident 63 banged on the door of his room and called him the 'N word [a derogatory word], a few nights ago and the staff did not do anything. During a review of Resident's 33 record on 2/18/24, at 7 a.m., signed by LN 1 indicated, [Resident 63] had banged on [Resident's 33] door and said FU [a derogatory word] to him. During an interview on 2/20/24, at 4 p.m., the Operations Manager stated he had not been informed of the allegation of verbal abuse of Resident 33 by Resident 63. During an interview on 2/21/24, at 11 a.m., with the Director of Nursing (DON), the DON stated 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 interview, and record review, the facility failed to develop and implement a resident specific care plan (provides direction on the type of nursing care the resident may need based on their health, medication, mental, and or psychosocial needs) for 2 of 21 sampled residents (Resident 90 and Resident 197) when: 1. Resident 90 did not have a care plan developed for the dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) services she was receiving; and, 2. Resident 197 did not have a care plan developed for the hospice (specialized in end-of-life care for all residents with an advanced, life-limiting illness) services she was receiving. These failures placed Resident 90 and Resident 197 at risk to not have appropriate, consistent, and individualized care to meet their needs. Findings: 1. During a review of Resident 90's admission RECORD, indicated Resident 90 was admitted to the facility in early 2024 with diagnoses which included end stage renal disease (the last stage of long-term kidney disease when 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 interview, and record review, the facility failed to consistently complete quarterly Interdisciplinary Team (IDT, care team consisting of different disciplines who assess and coordinate care), care plan conferences (a meeting which provides opportunities for the resident's and/or their representative, and each discipline to revise the residents care plans) for 2 of 21 sampled residents (Resident 13 and Resident 41). These failures had the potential for unmet care needs for Resident 13 and Resident 41. Findings: a. A review of Resident 13's admission RECORD, indicated, she was admitted to the facility in September of 2022. A review of Resident 13's clinical document titled, .IDT-Care Conference Summary ., dated 9/29/22, indicated, .Meeting Type .Initial/admission .Meeting Date and Time 09/29/2022 14:00 [2 PM] . A review of Resident 13's clinical document titled, IDT- Care Conference Summary, dated 12/7/23, indicated, .Meeting Type .Quarterly .Meeting Date and Time 12/07/2023 13:45 [ 1:45 PM] . A review of Resident 13's electronic health record (EHR) showed no documentation…

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 treatment in accordance with current professional standards for 1 of 5 sampled residents (Resident 18) when Resident 18 received duplicate medication therapy with the administration of valproic acid suspension (medication for seizure that is also used for mood disorders) for seizures with no diagnosis for seizures, and was also administered Depakote (antiseizure medication also used to treat mood disorders) DR (delayed release) tablets. This failure resulted in unnecessary psychotropic medications (medication that alternates brain chemistry to help reduce mood disorder symptoms) for Resident 18, which increased the potential for medical interactions, adverse reactions, and unidentified risks associated with the use of psychotropic medications including but not limited to sedation, respiratory depression, constipation, anxiety, agitation, memory loss, and death. Findings: During a concurrent interview and record review on 2/22/24, at 9:37 a.m., with Licensed Nurse (LN) 26, Resident 18's undated admission Record, was…

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

Based on observation, interview, and record review, the facility failed to ensure pureed food (pudding-like texture that is smooth and blended) was prepared in a manner that preserved the nutritional value for thirteen residents who received pureed food from the kitchen when, [NAME] 2 did not follow the recipe for pureed pasta. This failure had the potential to decrease the nutritive value of the pureed food being served. Findings: During an observation of the dinner preparation on 2/21/24, at 3:45 p.m., with [NAME] 2, [NAME] 2 stated she was going to prepare pureed pasta. [NAME] 2 took out a pan of pasta from the steamer and added sauce and melted butter. She then filled the pitcher with pasta and poured the pasta into the blender. She filled half of the pitcher with water from the faucet and poured the water into the blender with the pasta and turned on the blender. [NAME] 2 confirmed she used water to liquify the pasta. [NAME] 2 stated she used water since the pasta had butter. During a review of the facility's undated document titled, RECIPE: PUREED STARCH (RICE, PASTA,…

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 trash was properly disposed of for a census of 93, when the facility's dumpster lids were left open. This failure had the potential to attract unwanted pests. Findings: During a concurrent observation and interview on 2/22/24, at 8:51 a.m., with the Director of Staff Development (DSD) in the dumpster area located behind the kitchen; there were two dumpsters with both lids left open and one of the dumpsters was overfilled with boxes preventing the lid from closing. The DSD confirmed the lids had been left open and should have been closed to prevent infections, contamination, and from attracting pests. During a review of the facility's undated procedure titled, MISCELLANEOUS AREAS indicated, .Garbage and trash cans must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed . According to the USDA Food Section 2022 Section 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (B)…

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 inform residents and/or their representatives of the nature and implications of any proposed binding arbitration agreement (a contract between two or more parties that requires them to resolve disputes before an arbitrator, neutral third party, rather than the court system) when the agreements and the right to rescind within 30 days, were not clearly explained to 2 out of 3 sampled residents (Resident 4 and Resident 298). This failure resulted in Resident 4 and Resident 298 or their responsible party (RP) signing the binding arbitration agreement without fully understanding that they were giving up their right to litigation in a court proceeding should a dispute arise and that they had the right to revoke the agreement within 30 days of signing. Findings: During an interview on 2/22/24, at 8:26 AM, the Director of Business Development and Admissions (DBDA) stated the arbitration agreement was reviewed with residents and/or their responsible parties as the last part of their admission packet. The DBDA further stated 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 interview, and record review, the facility failed to ensure hospice services (specializes in end-of-life care for all residents with an advanced, life-limiting illness) were coordinated for one of six residents receiving hospice (Resident 197)when, 1. The facility did not secure a written agreement describing the responsibilities between the hospice agency and the facility prior to initiating care for Resident 197; and, 2. The hospice agency's nurse progress notes and visit information were not in Resident 197's hospice clinical record. These failures had the potential for Resident 197 to not receive proper and appropriate hospice care and services from the facility and the hospice agency; and had the potential for Resident 197's medical record to have insufficient information to reflect the condition, care, and services provided. Findings: 1. A review of Resident 197's admission RECORD indicated Resident 197 was admitted to the facility in 2024 with a diagnosis of end stage renal disease (the last stage of long-term kidney disease when the kidneys can no longer support 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 interview, and record review, the facility failed to provide emergency electrical power on 1/10/24 when the electricity went out and failed to ensure the generator (machine for converting mechanical energy into electricity) safety checks were completed per the facility's policy and procedure (P&P). These failures resulted in the facility being without emergency electrical power for 15-20 minutes and could have resulted in harm to 94 residents who reside at the facility. Findings: During a concurrent interview and record review on 1/23/24, at 9:53 AM, with the Maintenance Director (MD), the generator maintenance logs were reviewed. MD stated there was a major power outage at the facility and the surrounding area on 1/10/24 due to a car accident down the street. MD further stated that during the power outage, the facility's generator failed to automatically turn on for approximately 15-20 minutes. MD explained he was unsure why the generator failed to automatically turn on when the facility's power went out. MD stated he did not have records of the weekly generator checks…

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 their policy and procedure on abuse prevention when one of three sampled staff members' employee files (Staff 1) did not contain a background check. This failure allowed for an incomplete employee file and exposed residents of the facility to a staff member who was working and interacting with the vulnerable population without a criminal history background check on file at the facility. Findings: During a review of Staff 1's employee file, a background check was not located. Staff 1 had been employed in the facility since 4/21/21. During an interview on 11/2/23, at 12:15 p.m., with the Administrator, the Administrator confirmed, a copy of Staff 1's background check could not be located. During a review of the facility's policy and procedure titled, Abuse, Neglect and Exploitation undated, indicated, The components of the facility abuse prohibition plan are discussed herein: Screening, A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriate resident property…

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

Based on observation and interview the facility failed to ensure a clean, comfortable, and homelike environment for three out three rooms sampled (Room A, Room B, and Room C) when: 1. Room A, occupied by three residents, had a broken light fixture, a broken foot board, a broken bedside cabinet, a broken closet door handle, and a broken bathroom window screen. Room A had three soiled divider curtains between the three beds. Room A had red stains on the floor and glass sliding door, the ceiling vent had an accumulation of dust and spider webs, and bed 3 had dried brown stains on the bed frame. 2. Room B, occupied by three residents, had three soiled divider curtains between the three beds. Room B had black grime on the floor behind the bathroom and entry doors. 3. Room C, occupied by three residents, had two broken closet storage drawer handles, and broken tiles under bed 3. These failures resulted in the facility residents not being provided a clean, comfortable, and homelike environment with the potential to negatively impact residents' physical and psychosocial wellbeing. Findings:…

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 adequate infection prevention and control measures were practiced for a census of 91 when: 1. Isolation precautions (measures taken to prevent the spread of germs/infections from one person to another) signs were not posted outside COVID positive residents' rooms and isolation precautions were not taken for all COVID positive residents, 2. A staff member did not wear an N95 (type of mask that offers the highest level of respiratory protection) mask in the Alzheimer's Care Unit (ACU) where the facility had COVID positive residents, and staff did not change facemasks after exiting the ACU unit and before entering the non-COVID unit, and 3. Staff were not fit tested (done to ensure a good fit for N95 masks) for N95's. These failures had the potential to spread COVID-19 infection among residents, staff, and visitors that could cause serious illness and/or even death. Findings: 1. During an interview on 9/5/23 at 3:29 p.m., the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two residents (Resident 2 and Resident 3) were free from physical abuse from Resident 1. This failure resulted in Resident 2 being slapped in the face and Resident 3 was hit on the arm. Findings: A review of Resident 1's face sheet, indicated she had diagnoses which included dementia (loss of memory and judgement), and schizoaffective disorder (a combination of schizophrenia and a mood disorder, which includes hallucinations and delusions). Resident 1 has wandering and aggressive behaviors, such as hitting and yelling at staff. A review of the document titled, S (Situation), B (Background), A (Assessment), R (Recommendation), (SBAR-framework for communication between members of the healthcare team about a patient's condition), indicated, On 7/3/23 at 2:30 p.m., Resident 3 (room [ROOM NUMBER]A) wandered into room [ROOM NUMBER]. Resident 1 (room [ROOM NUMBER]B) walked up to Resident 3 and punched him in the arm. Afterwhich, Resident 1 wandered…

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 a qualified Dietary Services Manager (DSM) was employed in the absence of a full-time Registered Dietitian (DC) for 94 residents who received food from the kitchen. This failure had the potential for the residents' nutritional needs not to be met; and dietary staff were not supervised by a qualified person. Findings: During the initial kitchen tour on 1/10/23, at 8:23 a.m., with the DSM, the tour revealed unsanitary ovens, clean food preparation equipment stored in an unsanitary environment, loose food debris on shelving and kitchen floors, grime on the floor, and a pipe in the walk-in refrigerator with tape wrapped around it, dripping water into a metal container above where food was stored. (Cross-reference F812). During an interview on 1/11/23, at 9:40 a.m., with the DSM, when asked to see her qualifications for DSM, the DSM stated, I'm not certified. I'm going to start this month . It takes one year to complete . During an interview on 1/11/23, at 9:44 a.m., with the DC, The DC stated, I have been…

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 four of 35 sampled residents (Resident 71, Resident 91, Resident 54, and Resident 13) rights related to treatment choices were known and protected when: 1. There was no evidence an Advance Directive (legal documentation consistent with a person's medical preference when they were no longer able to make decisions for themselves) was discussed and/or offered to Resident 71, Resident 91, and Resident 54; and, 2. Resident 13's code status order (to provide or not provide life saving measures in the event of an emergency) in the electronic medical record did not match the code status listed on the POLST (Physician Orders for Life Sustaining Treatment: care directives during life threatening situations), and nursing staff were unaware of how to proceed when a discrepancy was identified. These failures had the potential to result in not determining and/or honoring the residents' wishes related to the provision of medical treatment and health care…

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 complete three quarterly care conferences (a meeting which provides opportunities for the residents and/or their representative, and each professional discipline to revise the residents' care plans) for one of 35 sampled residents (Resident 23). These failures had the potential for unmet care needs for Resident 23. Findings: A review of Resident 23's admission Record indicated Resident 23 was admitted to the facility in 2015 with diagnoses which 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 depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During an interview on 1/11/23, at 8:47 a.m., Resident 23's representative (RR) stated no recent care plan conferences were held for Resident 23. The RR further stated it was a concern to not be involved in Resident 23's plan of care. During an interview on 1/13/23, at 11:38 a.m., Social Services (SS) stated the purpose of 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 failed to ensure two of 35 sampled residents (Resident 147 and Resident 395) received adequate supervision to prevent an avoidable accident when: 1. A safe environment was not provided for Resident 147; and, 2. A smoking assessment and smoking care plan were not completed for Resident 395. These failures had the potential to result in an avoidable injury to Resident 147 and Resident 395. Findings: 1. A review of Resident 147's admission Record (a document that contains clinical and demographic data) indicated Resident 147 was admitted to the facility in early 2023 with diagnoses which included multiple rib fractures on his right side and altered mental status (changes in cognition-process of acquiring knowledge and understanding, mood, and/or behavior). A review of Resident 147's clinical document titled, Fall Risk Evaluation ., dated 1/11/23, indicated, Fall Risk Evaluation 17 .If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls . A review of Resident 147's care plan…

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 evaluate acceptable parameters of nutritional status for two of thirty-five sampled residents (Resident 27 and Resident 71) when Resident 27 and Resident 71 were not weighed at least weekly. This failure had the potential for weight loss or weight gain to go undetected which could result in a delay of treatment/interventions and have a negative effect on the health of Resident 27 and Resident 71. Findings: During an interview on 1/13/23, at 8:46 a.m., Restorative Nurse Aide (RNA) 1 explained weekly weights were done on all new admissions until the dietician decided the resident could change to monthly weights. RNA 1 stated weekly weeks were scheduled for Monday each week; and RNA 1 was the only staff member who did the weight measurements. RNA 1 stated she did not always work on Mondays, and if she did not work, the weights were not completed by another staff. RNA 1 confirmed she did not obtain missed weights when she returned to work. RNA 1 explained…

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 respiratory care was provided in accordance with professional standards of practice for a census of 96 when: 1. An Oxygen in use sign was not posted outside of the room for Resident 399, 2. The oxygen flow rate was not followed per physician order for Resident 399 and Resident 3, 3a. Resident 399's oxygen tubing was not dated when last changed; 3b. Resident 3's oxygen tubing was not dated and the oxygen humidifier bottle was empty without a date when changed; and, 3c. Resident 14, Resident 40, and Resident 42's oxygen tubing and/or nebulizer masks were not changed per facility policy. These failures had the potential to result in negative impacts on the residents' health and safety including risks for ineffective oxygen therapy, and respiratory distress. Findings: 1. A review of Resident 399's admission Record indicated Resident 399 was admitted to the facility with diagnoses which included asthma (a respiratory condition in which…

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 handling, use, and disposition with census of 96 when: 1. There was a discrepancy between the Controlled Drug Record (CDR, an accountability record for opioid use) removal and the respective Medication Administration Record (MAR, referred to as a drug chart that serves as a legal record of the drugs administered to a resident) documentation for three residents (Resident 17, Resident 72, and Resident 349). 2. Hazardous medications (medications that may pose harm to individuals handling them based on manufacturer and government guidelines) stored in the facility's [NAME] side medication cart, were not tagged in the MAR as hazardous for nursing staff to wear gloves when handling during administration or dispensing. 3. Disposition of the discontinued non-narcotic medications did not have signatures of the two licensed staff; and the disposal container was wide open and accessible in the facility's main medication room.…

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 carry out a doctor's order for blood thinner medications (a type of medication that prevents blood clot harming the resident) and notify the medical doctor of recurrent missed antibiotic use for one of 96 residents (Resident 88) when: 1. Resident 88's order for enoxaparin (or Lovenox, a blood thinner in the form of a shot or injection) and Resident 88's order for warfarin (a blood thinner given by tablet) for treatment of blood clot, was not carried out as ordered; and, 2. Resident 88's intravenous (or IV- into the vein) antibiotics called daptomycin and ceftaroline (antibiotics used to treat serious blood and wound infection) were not consistently documented in the Medication Administration Record (or MAR- a legal document that lists the medications prescribed and given) as given and the medical doctor was not notified of recurrent missed antibiotic use. These failures resulted in Resident 88 missing warfarin for two days and enoxaparin for five days, and the potential Resident 88 would experience severe complications…

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 96 when: 1. Undated and expired medications (spoiled medications that no longer should be used) were stored in the refrigerator in the main medication room (a locked room for storage of medications and supplies). 2. Expired and unlabeled medication stored in the [NAME] side medication cart (a mobile cart containing medications used on daily basis for administration to residents). 3. Expired and unlabeled medications and supplies were stored in two out of two treatment carts (a mobile cart containing medication and supplies for wound and skin diseases). 4. Emergency Kits (Ekit- a sealed box with supply of medications for emergency use) in the refrigerator were marked with expiration dates of 10/2022 and 12/2022 and the Ekit for antibiotic medications were not exchanged for over 2 months after multiple use. These failures may pose unsafe medication use in the facility. Findings: 1. During an inspection of the refrigerator located in the facility's main medication…

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 food safety requirements when: 1. Refrigerated food items were stored in an area that contained a pipe wrapped in tape with a liquid dripping from it into a metal tray in the vicinity of stored food, and contained a brownish slimy fluid with residue; 2. Clean cooking equipment was stored on a surface containing food debris and other unidentifiable debris, and cooking utensils were in containers that had dust and food debris on the outside and on the inside; 3. Kitchen ovens contained loose food debris and burnt in food debris; 4. The kitchen did not have air gaps (a break in the plumbing to prevent unsanitary water from flowing back into the sink) in the food preparation sink and the dishwasher; 5. Kitchen floors contained visible dirt, food products and build up; and, 6. Refrigerator and freezer temperature logs were not kept up to date. Findings: 1. During a concurrent observation and interview with the Dietary Services Manager (DSM) on 1/10/23, at 8:23 a.m., in the kitchen, the walk 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 maintain infection prevention and control practices for a census of 96 residents when: 1. The laundry services staff did not seperate clean and soiled items in the laundry area, and a ceiling vent fan was dirty and filled with lint; 2. Resident 71 was found with his indwelling urinary catheter (a tube inserted into the bladder to drain or collect urine) bag in contact with the floor; and, 3. Resident 88's peripherally inserted central catheter (PICC, a type of long catheter that is inserted through a peripheral vein, often in the arm, passed through to larger veins near the heart and used to give fluids, nutrition, drugs, or other treatments) line dressing was not changed at least weekly. These failures increased the risk of infectious diseases for residents in the facility. Findings: 1. During a concurrent observation and interview on 1/11/23, at 12:56 p.m., with the Housekeeping/ Laundry Supervisor (HS) in the dirty side of the laundry services area, HS confirmed there were six black trash bags of clean…

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 two of thirty-five sampled residents (Resident 4 and Resident 5) were treated with dignity, respect, and in a manner which promoted independence during dining when staff stood over Resident 4 and Resident 5 while assisting them to eat. This failure had the potential to negatively affect Resident 4 and Resident 5's quality of life during mealtime, with a potential for decreased social interaction and loss of appetite. Findings: During an observation on 01/12/23, at 1:14 p.m., in the Memory Care Unit dining room, Certified Nursing Assistant (CNA) 1 stood over Resident 5 while feeding them lunch at a table where several other people were seated. During an interview on 01/12/23, at 1:30 p.m., CNA 1 stated Resident 5 required maximum assistance with meals (unable to independently use utensils to eat food). CNA 1 acknowledged standing up to feed Resident 5 the lunch meal while Resident 5 was seated in a wheelchair. CNA 1 stated there were not enough chairs for staff to sit on when assisting with meals. CNA 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.

Based on observation, interview, and record review, the facility failed to ensure three of thirty five sampled residents (Resident 71, Resident 68, and Resident 79) were provided with reasonable accommodations of needs when; 1. Resident 68 was not provided with a wheelchair; 2. Resident 79 was not provided a tray table to eat meals from; and, 3. Resident 71's call light was not within reach. These failures resulted in Resident 68 and Resident 79's needs not being met, did not provide a homelike environment, removed the possibility for independent functioning, and had the potential to impact their psychosocial well-being. Resident 71 was not able to use the call light when desired which had the potential to result in physical and/or psychosocial harm. Findings: 1. During an interview on 1/10/23, at 11:07 a.m., Resident 68 stated that he borrowed his roommate's wheelchair to go to an appointment today. Resident 68 explained his roommate used his walker while he was using his roommate's wheelchair. Resident 68 stated he asked the therapy department for a wheelchair, but was told there…

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 obtain acknowledgement that the beneficiary notification forms were given to two of three sampled residents (Resident 47 and Resident 59), when the Notice of Medicare Non-Coverage (NOMNC - a form which indicates that Medicare covered services are ending and how to appeal) and the Advanced Beneficiary Notice of Non-coverage (ABN, a form which gave the choice to continue services under private pay if Medicare did not provide payment) was not mailed to the responsible party (RP) of Resident 47 and proof of sending the forms to Resident 59's RP was not obtained. This failure resulted in Resident 47's RP and Resident 59's RP not having the information available on how to appeal the decision, or have knowledge of the costs to continue treatment in the facility. Findings: Review of Resident 47's admission RECORD indicated that Resident 47 was admitted to the facility in late 2020 with diagnosis which included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). No RP was listed on…

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

Based on observation, interview, and record review, the facility failed to ensure resident's rights to file a grievance was honored for a census of 96 residents, when grievance forms were not available for residents to use. This failure had the potential for a grievance to not be addressed and removed the right for a resident to file an anonymous grievance at any given time. Findings: During a concurrent observation and interview on 1/11/23, at 10:56 a.m., the Social Services (SS) stated when residents voice concerns staff would fill out a grievance form and turn it into her. When asked where grievance forms were kept, the SS stated they were located in a box outside of her office and kept at the nurse's station. The SS confirmed the box outside of her office did not contain any grievance forms. The SS stated without forms available, residents would not be able to file an anonymous grievance. During an interview on 1/11/23, at 11 a.m., Licensed Nurse (LN) 5 confirmed there were no grievance forms available at the nurse's station and would obtain a form from social services if one…

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

Based on interview and record review, the facility failed to ensure a mental health diagnosis was accurately reflected in the medical records for one resident (Resident 147) out of 35 sampled residents when: Resident 147 was prescribed a mind-altering medication called quetiapine (also called Seroquel, a medication to treat mental illness) for schizoaffective disorder (a type of mental health with mood swings) and valproic acid (a medication for seizure and mental health) for aggressive behavior, while the documented diagnosis by the Mental Health Doctor (specialist doctor in mental health) was advanced dementia (profound memory loss and/or disorientation) in the medical records. Improperly documented diagnoses may result in unsafe medication use in the facility. Findings: During review of Resident 147's electronic medical record, titled Medication Administration Record (or MAR, a document that listed the prescribed medications given to residents), with date range of 1/1/23- 1/30/23, the following mind-altering medications were prescribed: Quetiapine . Tablet 25 mg (mg is unit 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 adequate treatment and services were provided for one of 35 sampled residents (Resident 64) when Resident 64's elevated blood sugar levels were not reported to the physician in a timely manner. This failure placed Resident 64 at risk for hyperglycemia (blood sugar level higher than the standard range) to be unrecognized and untreated. Findings: Review of Resident 64's admission Record indicated Resident 64 was admitted to the facility in the fall of 2022 with diagnoses which included diabetes mellitus (a condition that results in too much sugar in the blood). During an interview on 1/12/23, at 10:31 a.m., Resident 64 confirmed he took medicine for his diabetes. Resident 64 stated he was always thirsty and was going to the bathroom all the time to void. During an interview on 1/12/23, at 4:18 p.m., licensed nurse (LN) 9 stated he was familiar with Resident 64 and knew the resident was a diabetic. LN 9 stated symptoms of hyperglycemia included being thirsty, fruity breath, and being sweaty. LN 9 further…

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 appropriate care and services for two of two residents (Resident 20 and Resident 86) requiring tube feeding (method of providing nutrients via a tube directly into the stomach or intestine when a person is unable to eat by mouth) when: 1. Resident 20's tube feeding container was not changed as indicated, 2. Resident 86's tube feeding container label did not indicate the time the feeding was started; and, 3. Resident 86's physician order for tube feeding was not followed. These failures had the potential for the residents to have complications related to tube feedings and/or risk for infections. Findings: 1. A review of Resident 20's clinical document titled, admission Record indicated Resident 20 was admitted to the facility in the spring of 2022, with diagnoses which included dysphagia (difficulty swallowing foods or liquids) and presence of a gastrostomy (a tube that is surgically inserted into the resident's stomach to allow access for food, fluids, and medications). During a concurrent observation…

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 kitchen staff accurately measured food portions when 3 residents, Resident 59, Resident 31, and Resident 60 did not receive the amount of food required by their diets. This failure had the potential to result in excessive or reduced caloric intake required by the individual resident, negatively impacting the residents' nutritional status, health and well-being. Findings: During a tray line observation and review of the meal tickets (a card for each tray which indicates diet and portions) on 1/12/23, at 12:50 p.m., Resident 59, Resident 31, and Resident 60's meals were plated and the following was observed: Resident 60's meal ticket indicated, Regular 1 1/2 portions, extra bread. Dietary staff plated 1 slice of chicken, 1 and 1/2 slices of bread, 1 and 1/2 scoops rice, 1 scoop vegetables. The cook acknowledged she used a full scoop and poured out some of the food to measure 1/2 a scoop, rather than using a 1/2 scoop measuring cup. Resident 31's meal ticket indicated, Dysphagia Level 3 [difficulty…

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 their Antibiotic Stewardship Program (a program designed for the safe use of antibiotics) for a census of 96 residents when Resident 87 was prescribed an antibiotic treatment without a proper indication. This failure increased the potential for inappropriate antibiotic therapy resulting in the development of antibiotic resistant bacterial infections in the facility. Findings: A review of Resident 87's admission Record indicated Resident 87 was admitted to the facility in late 2022. Review of Resident 87's Medication Administration Record (MAR) indicated resident took Ciprofloxacin (also known as Cipro, medication used to treat an infection) 500 milligram (mg, a unit of measurement) 1 tablet by mouth two times a day for elevated white blood cells (WBC) for ten days. Further review of the document indicated Resident 87 had completed his antibiotic order on 1/10/23. During a concurrent interview and record review on 1/13/23, at 3:44 p.m., Resident 87's clinical health record was reviewed with the Infection…

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.