Orchards At Tulare

Based on observation, interview, and record review, the facility failed to ensure two of 16 sampled residents (Resident 32 and Resident 73), personal belongings were replaced within a timely manner once the items were reported loss. These failures resulted in Resident 32 and Resident 73 lost items not being replaced During an interview on 5/6/25 at 10:33 a.m. with Resident 73, Resident 73 stated his watch had been missing since December 2024. Resident 73 stated he had reported his missing watch to the social worker. Resident 73 was told by the social worker that the facility will replace the missing watch. Resident 73 stated he was upset that his watch had been missing, and the facility had not replaced the watch. During a review of Resident 73's admission Record, (AR) dated 5/7/25, the AR indicated Resident 73's admission date was 9/9/24. During a review of Resident 73's Minimum Data Set, (MDS - a federally mandated resident assessment tool) dated 3/14/25, the MDS indicated Resident 73 had a (Brief Interview for Mental Status - an assessment tool used by facilities to screen and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Significant Change in Status MDS Assessment (MDS-a federally mandated resident assessment tool; SCSA- a comprehensive assessment completed within 14 days of the identification of a status change) was completed for one of one sampled resident (Resident 68) when Resident 68 had a major decline in two or more MDS areas as evidenced by unplanned significant weight loss and the development of a new wound. This failure had the potential for Resident 68 to have unmet care needs. Findings: During a concurrent interview and record review on 05/08/25 at 11:14 a.m. with MDS Coordinator (MDSC), MDSC reviewed Resident 68's electronic health record (EHR). MDSC stated she should have completed a significant change of status MDS at the same time she had completed a quarterly MDS on 2/26/25 as Resident 68 had major decline in two MDS care areas which were significant weight loss not on prescribed weight-loss regimen and a new wound that triggered on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS-a federally mandated resident assessment tool) Matrix was accurate and up to date for three of eight sampled residents (Resident 1, Resident 23 and Resident 68). This failure resulted in the documentation of an inaccurate assessment and an inaccurate quarterly MDS for Resident 68. Findings: During a review of the facility's Resident Matrix, (RM) dated 5/5/25, the RM indicated, Resident 1 listed anticoagulant (medication used to help prevent blood clots from forming or growing) and Resident 23 listed antibiotic. During an interview on 5/5/25 at 10:16 a.m. with Resident 1, Resident 1 stated he is not currently taking any anticoagulant medications. Resident 1 stated he stopped taking anticoagulant medications this past January. During a review of Resident 1's admission Record (AR), dated 5/7/25, the AR indicated Resident 1's initial admission date was 11/22/24. During a review of Resident 1's MDS 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide quality care to one of one sampled resident (Resident 25) when: 1. Resident 25 had a chocking episode that was not immediately identified and addressed by nursing staff who were present in the dining room at the time of occurance. 2. A comprehensive (complete) assessment was not completed for Resident 25 after a chocking episode and delegation (assigning a task) of monitoring Resident 25 for safety was given to nonnursing staff position titled Hospitality Aid (HA). 3. Education was not provided to a family member who routinely fed Resident 25 who was on aspiration precautions (preventive measures taken to reduce the risk of accidental inhalation of food, liquid, or other substances into the lungs) to ensure swallow strategies, as assessed by a Speech Therapist (ST), was implemented. 4. Resident 25's thickened liquids (to help individuals with swallowing difficulties based on individualized assessment) order was not followed. These…

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

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Pain Management, for one of one sampled resident (Resident 77) when Resident 77's pain was not controlled consistently. This failure had the potential for Resident 77's pain not to be correctly managed. Findings: During an interview on 5/7/25 at 1:50 p.m. with Resident 77, Resident 77 stated two weeks ago the nurse told her she needed to take a different medication and not her regular pain medication. Resident 77 stated she felt horrible for hours going without her pain medication. During a review of Resident 77's Physician Order (PO) dated 4/21/25, the PO indicated, Oxycodone HCL [narcotic medication for acute pain 0- no pain, 1-3 mild pain, 4-6 moderate pain interfering with daily activities, 7-9 severe pain, difficult to tolerate or manage, 10 worst pain possible]oral tablet 5 mg [milligram], give 1 tablet by mouth every 4 hours as needed for moderate pain 4-6. During a review of Resident 77's PO, dated 4/21/25, the PO indicated, Acetaminophen Tablet 325 mg…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accurate documentation and accountability for the destruction of controlled substances, the facility did not ensure controlled substances were destroyed in the presence of a licensed pharmacist, and destruction was appropriately documented with a nurse and a pharmacist signatures. This failure had the potential to result in diversion or mismanagement of controlled medications. Findings: During an observation on 5/7/25 at 8:38 a.m. in the Director of Nursing (DON) office, there was a locked cabinet used to store medications to be destroyed. During a concurrent interview and record review on 5/7/25 at 8:38 a.m. with the Assistant Director of Nursing (ADON), The facility Controlled Medication Destruction Log (MDL), dated 03/25 and 04/25 were reviewed. The MDL indicated, entries had not been dated and signed without a pharmacist involvement. ADON stated she was unable to clarify the following entries: had been dated and signed without pharmacist involvement. The MDL indicated the following: On 3/6/25 RX #…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 twenty eight opportunities for medication administration were performed without error, resulting in an 11% medication error rate. These failures had the potential for: 1. Resident 46, ineffective medication delivery. 2. Resident 46, omissions are inconsistent with manufacturer instructions for use. 3. Resident 34, to rotate injection sites as required. Findings: 1. During a review of the manufacturer's instructions for Combivent Respimat(inhaler for breathing difficulties) indicated, The patient should exhale fully, place lips around the mouthpiece, then inhale slowly and deeply while pressing the inhaler button. After inhalation, the patient should hold their breath for 10 seconds or as long as comfortable. During an observation on 5/6/25 at 9 a.m. in Resident 46's room during a medication pass, a Respiratory Therapist (RT) was observed administering Combivent Respimat to Resident 46. Resident 46 was not instructed to exhale fully prior to inhalation and hold their breath following the dose.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. Follow the planned menu for finger foods diet for one of one sample resident (Resident 18) during lunch trayline (a system of food preparation). 2. Ensure the allotted fluid from dietary was followed as ordered pertaining to a fluid restriction for one of one sample resident (Resident 32). These failures had the potential for Resident 18 to have loss of independence and dignity, and Resident 32 to not have adequate hydration. Findings: 1. During an observation on 5/6/25 at 12:03 p.m. in the kitchen during lunch trayline observation, Resident 18's meal tray card indicated finger foods. A whole piece of chocolate cake was served onto Resident 18's lunch meal tray and placed on the meal delivery cart for distribution. Per the therapeutic diet spreadsheet Chocolate cake cut into smaller pieces was the planned menu for finger foods. During an interview on 05/06/25 at 12:03 p.m. with Registered Dietitian (RD), RD was asked to check if the…

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

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident(Resident 68) beverage and/or liquid preferences were obtained to provide sufficient drinks and liquids the resident prefers to help maintain hydration. Facility's failure to obtain Resident 68's beverage preferences placed Resident 68 at an increased risk for dehydration and delayed wound healing. Findings: During a concurrent observation and interview on 5/7/25 at 11:58 a.m. with Resident 68 in Resident 68's room, Resident 68 stated when she was at home she liked to drink Pepsi, Kool-Aid, and pineapple juice. Resident 68 stated in here they only give her the liquids they have in the kitchen that day. Resident 68 stated no one has come to ask her preferences for liquids. During a review of Resident 68's RD [Registered Dietitian]/IDT [interdisciplinary team] Weight [wt] Variance Meeting [mtg] (Wt Mtg), dated 12/31/24, the Wt Mtg indicated, Wt: 85# (pounds). Wt Change: -23# (21.3%[percent]) x [for] 3 months, po [by mouth] intake: 0-50% [of total meals], Diet: fortified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 system to maintain an accurate and complete medical record (electronic health record/EHR) for one of one sampled residents (Resident 57) when the EHR had not contained documentation that an order for 4 ounces (oz) house nourishment (HN shake) with breakfast was provided to Patient 57. In addition, quantity consumed of HN shake was included in the overall fluid intake from all fluids served for breakfast impeding interdisciplinary team (IDT) ability to identify and assess intake of the planned nutrition intervention. Further, due to a Certified Nursing Assistant (CNA) 1 late entry documentation of fluid intake from the breakfast meal, the EHR contained inaccurate information reflecting Resident 57 consumed fluids from her breakfast meal at 11:03 a.m. This deficient practice had the potential for residents to not receive the ordered nutrition intervention and/or services to support their highest practicable well-being. Findings: During a review of Resident 57's Order Summary (OS), dated 6/11/2024, the…

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

Based on observation, interview, and record review, the facility failed to ensure staff followed infection control practices for one of one sampled residents (Resident 34) during the administration of an injectable medication. This failure had the potential to increase the risk of exposure to blood-borne pathogens. Findings: During a concurrent observation and interview in Resident 34's room on 5/6/25 at 11:09 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 was administering Humalog insulin quick pen (used to treat low blood sugar) to Resident 34 in the left lower abdomen. LVN 2 used her ungloved hand, to uncap and dispose of the contaminated needle tip. LVN 2 stated, I'm not going to lie, I just grabbed it without thinking and threw it out. During a review of the facility's policy and procedure (P&P) titled, Medication Administration -Subcutaneous Insulin, dated 1/2023, the P&P indicated, Put on gloves, engage safety device, and discard syringe and needle in appropriate syringe disposal container.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was administered antipsychotic (Seroquel-use to treat delusional thoughts) medication as ordered by the physician. This failure resulted in Resident 1 not receiving his medication and the potential for adverse side effects. Findings: During a review of Resident 1's Medication Administration Record (MAR) dated 3/25, the MAR indicated, Seroquel XR Oral Tablet Extended Release 24 Hour 50 mg (milligram). Give 1.5 tablet by mouth at bedtime. There was a 9 (indicating other/see nurse notes) documented on the MAR for 3/20, 3/22, 3/23, 3/24, 3/29, and 3/30. During a review of Resident 1's Physicians Order (PO) dated 3/25, the PO indicated Seroquel XR Oral Tablet Extended Release 24 Hour 50 mg. Give 1.5 tablet by mouth at bedtime. During a review of Resident 1's Progress Notes (PN) dated 3/20/25, the PN indicated, Seroquel XR Oral Tablet Extended Release 24 Hour 50 mg. Not available, pending delivery. During a review of Resident 1's PN dated 3/22/25, the PN indicated, Seroquel XR…

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

Based on observation, interview, and record review, the facility failed to follow it's own procedure and procedure (P&P) when two of two sampled Certified Nursing Assistant (CNA 1 and CNA 2) were not wearing their required company-issued identification badge while on duty. This failure had the potential for residents and family members to not be able to identify the staff members. Findings: During a concurrent observation and interview on 3/26/25 at 11:31 a.m. with CNA 1, CNA 1 was not wearing an identification badge. CNA 1 stated she had forgotten her identification badge. During a concurrent observation and interview on 3/26/25 at 11:32 a.m. with CNA 2, CNA 2 was not wearing an identification badge, CNA 2 stated she had left her identification badge in her car. During an interview on 3/26/25 at 12:1 p.m. with Director of Staff Development (DSD), DSD stated it was the facility practice for all staff to wear identification badge when on duty. During a review of the facility P&P titled, Identification Badges, dated 2024, the P&P indicated, 1. All employees are required to wear an…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was administered medication as ordered by the physician. This failure resulted in Resident 1 not receiving her medication and the potential for adverse side effects. Findings: During a review of Resident 1's Order Recap Report (ORR-physician order) dated 2/1/25-2/28/25, the ORR indicated, Rosuvastatin Calcium Tablet 20 mg (milligrams-unit of measurement) give 1 tablet by mouth at bedtime for hyperlipidemia (elevated fat in the blood) .start date 11/16/24. During a review of Resident 1's Medication Administration Record (MAR) dated 2/25, the MAR indicated, Rosuvastatin Calcium 20 mg give 1 tablet by mouth at bedtime. There was a 9 (indicating other/see nurse notes) documented on the MAR for 2/2, 2/6, 2/11-2/13, 2/19-2/21 and 2/27-2/28. During a review of Resident 1's Progress Notes (PN) dated 2/2/25, the PN indicated, Emar -Administration Note.Rosuvastatin Calcium.pending delivery. During a review of Resident 1's PN dated 2/6/25, the PN indicated, Emar -Administration…

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

Based on interview and record review, the facility failed to maintain confidentiality of medical records for one of three sampled residents (Resident 1) when a screen shot (a digital image that captures the exact content displayed on a computer or mobile device screen at a specific moment) of Resident 1's medical record was taken and shared by a text message. This failure resulted in Resident 1's personal health information to be viewed by others who was not be involved in Resident 1's care. Findings: During a review of a complaint received from an anonymous complainant, a screen shot was included. The screen shot contained Resident's 1 picture and medical information which included Resident 1's birthdate, age, allergies, code status, and gender. Anonymous complainant indicated the screen shot of Resident 1's medical records was taken and shared by a staff member working at the facility. During a concurrent interview and record review on 1/16/25 at 1 p.m. with Administrator and Director of Nurses (DON), Administrator and DON reviewed the screen shot and confirmed the screen shot…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 twelve sampled residents (Resident 8) was referred to the dermatologist as ordered by the physician. This failure had the potential to result in a delay of treatment. Findings: During a review of Resident 8's Progress Note (PN), dated 11/26/24 at 1:54 p.m., the PN indicated, (Doctor name) in to see resident on 11/25/24.Dermatology consult ordered. During a review of Resident 8's Order Details (OD), dated 11/26/24, the OD indicated, May see dermatologist for generalized rash. During a concurrent interview and record review on 12/11/24 at 12:06 p.m. (16 days after the order was received) with Licensed Vocational Nurse/Infection Preventionist (LVN/IP) 1, LVN/IP 1 reviewed Resident 8's clinical record. LVN/IP 1 was unable to provide documentation Resident 8 was referred to the dermatologist. LVN/IP 1 stated the referral process had not been started. During an interview on 1/10/25 at 9:45 a.m. with Social Service Director (SSD), SSD stated when a referral was ordered by the physician the nurses were to place it 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 interview and record review, the facility failed to implement its policy and procedure (P&P) when an outbreak was not reported to California Department of Public Health (CDPH-state health department) when two of twelve sampled residents (Resident 3 and Resident 4) were diagnosed with scabies (a contagious skin disease marked by itching and small raised red spots, caused by the itch mite). This failure resulted in the CDPH being unaware of the outbreak. Findings: During a review of Resident 3' s Wound Physician Consultation Note (completed by Physician 1) (WPCN), dated 12/9/24, the WPCN indicated, The patient with rash on chest.Treatment.Better now, continue scabies treatment. During a review of Resident 4' s Wound Physician Consultation Note (completed by Physician 1) (WPCN), dated 12/9/24, the WPCN indicated, The patient with rash on back/chest/arm.Treatment.continue scabies treatment. During an interview on 12/11/24 at 11:22 a.m. with LVN/IP 1, LVN/IP 1 stated on 12/4 Resident 4 and Resident 3 were the first residents presented with a rash and were treated for scabies.…

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

Based on interview and record review, the facility failed to ensure physician orders were implemented for one of two sampled residents (Resident 1). This failure had the potential for Resident 1's injuries to worsen. Findings: During a review of Resident 1's Order Summary Report (OSR) dated 12/1/24, the OSR indicated, Cleanse sutures to back of head with NS (normal saline), pat dry and leave open to air. Every day shift.start date.11/28/24.monitor discoloration to chest for s/s (signs and symptoms) of worsening and notify MD (doctor of medicine) of changes.start date 11/27/24.monitor discoloration to right breast for s/s of worsening and notify MD of changes every shift for 14 days.start date 11/27/24.monitor discoloration to right under breast for s/s of worsening and notify MD of changes every shift for 14 days.start date 11/27/24.monitor discoloration to right upper arm for worsening and notify MD of changes every shift for 14 days.start date 11/27/24.monitor for pain before, during and after treatment to head. Every day shift.start date 11/28/24.monitor sutures on right side…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two sampled resident's (Resident 1) fall assessment was accurate. This failure had the potential for staff to be unaware of Resident 1's fall risk. Findings: During a review of Resident 1's admission Record (AR) , dated 12/3/24, the AR indicated, Resident 1 was admitted on [DATE] with diagnosis including Dementia (the loss of thinking, remembering, and reasoning that interferes with a person's daily life and activities). During a review of Resident 1's Cognitive Patterns (CP) dated 11/13/24, the CP indicated, BIMS (Brief Interview for Mental Status).04 (indicating severe cognitive impairment). During a review of Resident1's S (Situation) B (Background) A (Appearance) R (Review and Notify) dated 11/24/24 at 7:20 p.m., the SBAR indicated, Falls.Resident complain to pain to head and right shoulder.send resident out to hospital. During a review of Resident 1's FRE dated 11/24/24 at 8:01 p.m. (completed after the fall), the FRE indicated, Fall…

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

Based on observation, interview, and record review, the facility failed to follow its own policy and procedure for one for four sampled residents (Resident 1), when Resident 1 was not immediately assessed, and Attending Physician (AP) was not notified of Resident 1 ' s discoloration (bruise) to left inner corner eye, discoloration to right eyebrow, discoloration to bilateral upper extremities (region of the body that includes arm, forearm, and hand), discoloration to the back of left thigh. This failure resulted in a delay in treatment for Resident 1. Findings: During a concurrent observation and interview on 10/24/24 at 12:20 p.m. with Resident1, Resident 1 was in her room, sitting in a chair eating lunch. Resident 1's left outer eye was noted with red/purple/black discoloration measuring approximately 2.5 centimeters (cm) and left inner eye with red discoloration measuring approximately 1 cm. Resident 1 only smiled when spoken to. During an interview on 10/24/24 at 12:52 p.m. with Director of Nurses (DON), DON stated on 10/21/24 at approximately 5 p.m. Licensed Vocational Nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 discharge instructions were discussed with the responsible party (RP) of one of three sampled residents (Resident 1) when Resident 1 was discharged home. This failure resulted in the RP of Resident 1 being unaware of how to care for Resident 1 and Resident 1 being admitted to the hospital. Findings: During a review of the Progress Notes (PN), dated 10/18/24 at 8:03 p.m., the PN indicated, At 1125 resident discharges home to family.admitted for short term rehabilitation; PT (Physcial Therapy)/OT (Occupational Therapy), ST (Speech Therapy) and wound care. Past medical hx (history) of hemiplegia (condition that causes severe weakness in the muscles on one side of the body, often affecting the arm, leg, and face) % [sic] hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), muscle weakness, contracture of muscle, and pressure ulcer (injury to the skin and underlying tissue…

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

Based on observation, interview, and record review, the facility failed to ensure the therapeutic menu was followed for three of five sampled residents (Resident 4, Resident 5, and Resident 6). This failure had the potential for unmet nutritional needs. Findings: During a review of the Fall Menu (FM) dated 9/18/24, the FM indicated, Chicken cacciatore, sauce, pasta with garlic and herbs, broccoli and cauliflower, parsley sprig, Italian green salad, dressing, cranberry crunch square and milk were to be served for lunch. 1. During a review of Resident 4 ' s Diet Card (DC), (undated), the DC indicated, Diet order: Regular Texture. During a concurrent observation and interview on 10/15/24 at 12:23 p.m. in Resident 4 ' s room, Resident 4 ' s lunch tray was at bedside. On the lunch tray there was a plate that contained pasta, cauliflower and mechanical soft (a texture-modified diet that limits foods that are difficult to chew or swallow) chicken cacciatore. There was a dessert and salad on the side. Resident 4 stated the kitchen ran out of regular texture chicken cacciatore entrée and…

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

Based on interview and record review, the facility failed to follow physician orders when the physician was not notified of elevated blood sugars for one of three sampled residents (Resident 1) . This failure had the potential for Resident 1 to experience complications. Findings: During a review of Resident 1 ' s Order Summary Report (OSR), dated 10/1/24, the OSR indicated, Fingerstick Blood Sugar Monitoring three times a day notify MD (physician) if blood sugar is above 300 or below 70mg/dl (milligrams/deciliter-unit of measurement).order date 9/25/24. During a review of Resident 1 ' s Medication Administration Record (MAR), dated 10/2024, the MAR indicated, 10/1 BS (blood sugar) 0800 (8 a.m.) 349 10/2 BS 0800 349 10/3 BS 0800 339 10/4 BS 0800 350, 1100 (11 am) 312, 1600 (4 p.m.) 355 10/5 BS 0800 326, 1100 348 10/6 BS 0800 329, 1600 (4 pm) 333 10/7 BS 0800 349, 1600 303 10/8 BS 0800 302 10/9 BS 1600 302 10/10 BS 1100 347 10/11 BS 1600 409 10/12 BS 1100 343 10/13 BS 0800 347, 1100 338 10/14 BS 0800 347 10/15 BS 0800 329 10/16 BS 0800 349, 1600 344. During a concurrent interview and…

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

Based on observation, interview, and record review, the facility failed to ensure medications were properly stored. This failure resulted in unidentified pills being in the bottom of the medication carts. Findings: During a concurrent observation and interview on 10/15/24 at 3:03 p.m. with Licensed Vocational Nurse (LVN) 1, medication cart 2 was observed. In drawers three and four there were several loose pills laying in the bottom of the drawers. LVN 1 stated the pills should not be loose in the bottom of the cart. During a concurrent observation and interview on 10/15/24 at 3:07 p.m. with Assistant Director of Nursing (ADON), ADON was unable to identify the loose pills and stated medications were not supposed to be loose in the drawers of the medication carts. During a concurrent observation and interview on 10/15/24 at 3:15 p.m. with LVN 2, medication cart 3 was observed. There were several loose pills laying in the bottom of drawers two and three. LVN 2 stated the pills should not be loose in the bottom of the drawers. During a review of the facility policy and procedure (P&P)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a care plan for one of four sampled residents (Resident 1) when the hospital medical records were not requested after Resident 1 was re-admitted from the hospital. This failure resulted in the facility being unaware of Resident 1 ' s weight bearing status and the need for a follow up appointment, placing Resident 1 at risk for re-injury and a delay in care. Findings: During an observation on 10/17/24 at 10:35 a.m. in the hallway, Resident 1 was ambulating with a four wheeled walker. During a review of Resident 1 ' s Progress Notes (PN), dated 10/4/24 at 11:05 a.m., the PN indicated, Date of Incident: 10/3/24.Unwitnessed fall.CNA (certified nursing assistant) was notified that resident fell on the floor.resident was noted to be on the floor trying to get herself back up.IDT (Interdisciplinary Team-a collaborative approach to patient care that involves multiple health professionals working together to provide comprehensive care) met and determined that resident while ambulating too fast with her…

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

Based on interview and record review, the facility failed to ensure the physician was notified of a change of condition when one of four sampled residents (Resident 1) had a rash. This failure had the potential for the rash to worsen. Findings: During a review of the Shower Day Skin Inspection (SDSI), dated 8/5/24, the SDSI indicated, Skin Problem.Yes.Rash.All over body.8/5/24.(Nurse Signature). During a review of the Shower Day Skin Inspection (SDSI), dated 8/8/24, the SDSI indicated, Skin Problem.Yes.Rash.All over body.8/8/24.(Nurse Signature). During a review of Resident 1 ' s Progress Notes (PN), dated 8/13/24 (8 days after the rash was identified) at 6:06 p.m., the PN, documented by Infection Preventionist (IP) indicated, (Physician name) was consulted by this writer regarding her rash to her stomach. During a concurrent interview and record review, on 8/27/24 at 4:21 p.m. with Infection Preventionist (IP), Resident 1 ' s Progress Notes (PN) were reviewed. There was no documentation indicating the physician was notified of Resident 1 ' s rash until 8/13. IP stated she notified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow its policy and procedure for one of three sampled residents (Resident 1) when a laboratory test was not completed. This failure had the potential for the facility to be unaware of health issues for Resident 1. Findings: During a review of Resident 1 ' s Progress Notes (PN), dated 5/22/24 at 11:37 a.m. the PN indicated, IDT (Interdisciplinary Team-a group of health care professionals with various areas of expertise who work together toward the goals of their clients) Risk Management Follow Up.As staff heard loud voices coming from room [Resident 1 and Resident 2 ' s room]. Staff ran to room and saw [Resident 1] was [sic] standing at the end of his bed exchanging voices with other [Resident 2].Staff noticed a skin tear to [Resident 1] ' s right lower eyelid.New Interventions put into place.psych (psychological) eval (evaluation). During a review of Resident 1 ' s Psychiatric F/U (follow up) Note (PFUN), dated 5/22/24, the PFUN indicated, Plan.Will recommend labs [laboratory] (CBC (complete blood count), CMP…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. Follow infection prevention and control practices in accordance with Centers for Disease Control and Prevention (CDC, national health organization) guidelines for 92 of 92 residents residing in the facility. 2. Ensure surveillance for infection were properly conducted, data collected, analyzed, track and trended for 92 of 92 residents residing in the facility. 3. Develop and implement water management policies and procedures to assist the facility in the prevention of Legionella (waterborne bacteria that cause serious lung disease) and /or other opportunistic waterborne pathogens. These failures had the potential to transmit infectious diseases. Findings: 1 a. During a concurrent observation and interview on 4/15/24 at 11:13 a.m. with Certified Nursing Assistant (CNA) 1, in Hallway 1, Resident 72's door had a Contact Precaution (intended to prevent transmission of infectious agents through direct or indirect contact with contaminated objects) sign posted outside the door. CNA 1 stated Resident 72 has…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Physicians provided informed consents for four of four sampled residents (Resident 29, Resident 35, Resident 54, Resident 72, and Resident 143) prior to administration of psychotropic medications (used to treat mental health disorders) and ensure the consent and acknowledgement of the informed consents by the resident or the resident's representative were documented on the Informed Consent Form (ICF). This failure violated patients' rights to be fully informed of their treatment and medications. Findings: During a concurrent interview and record review on 4/16/24, at 2:21 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 29's ICFs, dated 7/24/23, 11/823, and 1/17/24, were reviewed. The ICF, dated 7/24/23, indicated, Latuda (medication to treat a mental health disorder) 20 mg (milligram) one tablet daily for schizophrenia (mental health disorder) manifested by visual hallucinations. The ICF, dated 11/8/23, indicated, Cymbalta (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.

Based on observation, interview, and record review, the facility failed to ensure four of 46 sampled residents (Resident 44, Resident 242, Resident 39, and Resident 4) were assessed and provided with the appropriate call light type to call staff when needed. This failure had the potential for residents' needs not being met. Findings: During an observation on 4/15/24 at 9:25 a.m. in Resident 44's room, Resident 44's call light was on the floor. During an observation on 4/15/24 at 9:28 a.m. in Resident 242's room, Resident 242's call light wire was not attached to the wall and the call light was not in Resident 242's reach. During an observation on 4/15/24 at 9:30 a.m. in Resident 39's room, Resident 39's call light was on the oxygen concentrator (a device that delivers oxygen) and was not in resident's reach. Upon pushing the button, the call light was not working. During a concurrent observation and interview on 4/15/24 at 9:38 a.m. with Director of Maintenance (DM), in Resident 44, Resident 242, and Resident 39's shared room, Resident 44's call light was on the floor, Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility failed to: 1. Ensure 10 of 13 sampled residents (Resident 54, Resident 80, Resident 29, Resident 143, Resident 72, Resident 36, Resident 78, Resident 45, Resident 82, and Resident 24) or residents' representatives were provided information and allowed to formulate advance directives (AD, a written document that tells the health care providers who should speak for you and what medical decisions they should make if you become unable to speak for yourself). This failure had the potential to result in the residents' wishes or health choices to not be honored. 2. Ensure the Physician's Order for Life Sustaining Treatment (POLST-a medical order form that records patient treatment wishes so emergency personnel know what treatments the patient wants in the event of a medical emergency) for two of two sampled residents (Resident 143 and Resident 142) was ordered by the physician prior to having Resident 143 and Resident 142's representatives sign the documents. Findings: 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of two sampled residents (Resident 142 and Resident 143) and/or the resident representative received a summary of the Baseline Care Plan (BCP-the minimum healthcare information necessary to properly care for each resident immediately upon their admission) within 48 hours of admission. This failure had the potential for unmet care needs for Resident 142 and Resident 143. Findings: During a review of Resident 143's admission Record (AR), the AR indicated Resident 143 was admitted on [DATE] with diagnosis including Cerebral Palsy (a group of disorders that affect a person's ability to move and maintain balance and posture) and unsteadiness on her feet. During a concurrent interview and record review on 4/15/24 at 2:33 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 143's BCP, dated 4/14/24 was reviewed. The BCP was not completed. The BCP was not signed, and the resident or resident representative signatures were not obtained indicating…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation of competency and skill performance for six of eight sampled employees (Certified Nursing Assistant [CNA] 5, CNA 7, Restorative Nursing Assistant [RNA] 2, Registered Nurse [RN] 1, Assistant Director of Nursing [ADON], and Infection Preventionist [IP]). This failure had the potential to result in lack of competent and skilled staff. Findings: During a concurrent interview and record review on 4/16/24 at 10:27 a.m. with Director of Staff Development (DSD), no competency evaluations or skills performance checklists were found in CNA 5, CNA 7, or RNA 2's employee personnel records (EPRs). DSD stated CNAs are supposed to shadow another CNA during orientation. DSD stated she does not have any competency assessments for CNAs. During a concurrent interview and record review on 4/16/24 at 10:45 a.m. with DSD, RN 1, ADON, and IP's EPRs were reviewed. There were no competency evaluations or skills performance checklists found in the EPRs. DSD stated the RNs and LVNs would be reviewed by the Director of Nursing…

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

Based on observation, interview, and record review the facility failed to: 1. Ensure opened food items were labeled with an expiration date. 2. Ensure the ice machine expired water filter was replaced per manufacture's guidelines. These failures had the potential to result in decreased palatability (tastiness) and the potential for spread of foodborne illnesses. Findings: 1. During a concurrent observation and interview on 4/16/24 at 8:51 a.m. with Interim Dietary Supervisor (IDS), in the dry food storage area, an opened bag of egg noodles was not labeled with the opened date. IDS stated this is an opened bag of egg noodles and it is not labeled with an opened date. IDS stated it should have an opened date. During a concurrent observation and interview on 4/17/24 at 9:59 a.m. with Registered Dietitian (RD), in the kitchen, the following spices and seasoning containers were opened with no opened and/or no expiration dates: Onion powder-no opened date, no expiration date Lemon pepper-no expiration date Ground cumin-no expiration date Ground nutmeg-no expiration date Light chili…

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

Based on observation, interview, and record review, the facility failed to ensure the Governing Body: 1. Provided oversight to their Infection Prevention and Control Program (IPCP) and the Infection Preventionist (IP-individual responsible for the facility's IPCP and help prevent the transmission of communicable diseases and infections). This failure resulted in the removal of the personal belongings, memorabilia, and clothing for five of five sampled residents (Resident 29, Resident 35, Resident 54, Resident 72, and Resident 80), which could potentially have a negative effect on the residents' well-being. 2. Established water management program as part of the Infection Control Program under the leadership of the Infection Preventionist. This failure had the potential for transmission of water-borne infections. 3. Developed and implemented Quality Assurance and Performance Improvement (QAPI) policies and procedures. This failure had the potential for residents and staff to be placed at risk for harm when the facility did not have QAPI framework to achieve quality care and services…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the Binding Arbitration Agreement in simple, understandable language or language common to the area other than English. This failure had the potential for residents to not fully understand the terms of the agreement and the nature or the possible consequences as a result of the agreement. Findings: During an interview on 4/17/24 at 5:49 p.m. with Business Office Manager (BOM) in the presence of the Administrator, BOM stated most of the arbitration discussion occurs on admission. BOM stated the agreement for entering a binding arbitration was part of the admission packet and, she was obligated to ask the resident or the resident representative. BOM stated she explained to the best of her ability and her knowledge what the binding arbitration meant and what it entailed, or she mailed the Binding Arbitration Agreement (BAA) to the family or resident representative. BOM stated, The facility does not have a language-assistance service. That is something I need to discuss with Corporate or the Administrator. BOM 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 one of eight sampled residents, (Resident 45), when Resident 45's room was not maintained in a clean homelike environment. Findings: During an observation on 4/16/24 at 9:19 a.m. in Resident 45's room, Residents 45's wall and floorboards to the left of resident's bed, had multiple splatters of a brown substance. During a concurrent observation and interview on 4/16/24 at 9:36 a.m. with Director of Nursing (DON) in Resident 45's room, DON stated, No this [Resident 45's room] is not clean or acceptable. DON stated the wall and floorboard next to Resident 45's bed does not look like it's been cleaned in a while. During a review of the facilities policy and procedure (P&P) titled, Resident Rooms and Environment, dated 8/2020, the P&P indicated, The Facility provides residents with a safe, clean, comfortable, and homelike environment . I. Facility Staff aid to create a personalized, homelike atmosphere, paying close attention to the following: A. Cleanliness and order .

Based on observation, interview, and record review, the facility failed to: 1. Provide the necessary care to maintain good grooming and personal hygiene for one of eight sampled residents (Resident 4). This failure resulted Resident 4 having long and dirty fingernails. 2. Ensure one of eight sampled residents (Resident 45) was assisted with oral care. This failure resulted in Resident 45 having dental issues and/or tooth decay. Findings: During a concurrent observation and interview on 4/15/24 at 9:50 a.m. with Certified Nursing Assistant (CNA) 4 in Resident 4's room, Resident 4's fingernails on her left hand were long (passed the fingertips) and had blackish discoloration underneath the fingernails. CNA 4 stated nails should be cleaned every day. Sunday is the day when we do nail care for our residents. During an interview on 4/15/24 at 10:04 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated Resident 4 had long fingernails and there was dirt underneath the fingernails. During a review of the facility's policy and procedure (P&P) titled, Fingernails/Toenails, Care of, 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 observation, interview, and record review, the facility failed to provide two of two sampled residents (Resident 29 and Resident 87) activity choices that met the residents likes and interests in accordance with the residents' assessment and care plan. This failure resulted in Resident 29 and Resident 87's expression of boredom and not meeting the resident's interest to improve their sense of well-being. Findings: During a concurrent observation and interview on 4/16/24 at 9:21 a.m. with Resident 29, in Resident 29's room, Resident 29 was sitting at the edge of the bed looking at the wall. Resident 29 stated, I get bored here, there is nothing to do. There are no magazines, no books, no newspaper for me to read. I love to read. I watch television sometimes, but that's it. I color some. That's all I do. Resident 29 did not have any books, magazines, or newspaper on her nightstand nor on the overbed table. Resident 29 stated,They took away the picture of my mom and my love. I have nothing here. During an interview on 4/17/24 at 2:07 p.m. with Activities Director (AD), AD…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Social Services followed up on the status of the hearing aids for two of two sampled residents (Resident 29 and Resident 36). This failure had the potential to result in poor communication and loss of hearing abilities. Findings: During an interview on 4/16/24 at 9:26 a.m. with Resident 29, Resident 29 stated, I have hearing problems. They checked my ears, but I have not heard from them about my hearing aids. During a concurrent interview and record review on 4/17/24 at 8:35 a.m. with Social Services Director (SSD), Resident 29's Audiogram (a chart that shows the results of a hearing test), dated 1/5/24, was reviewed. The audiogram report indicated, Right and left ear had moderately severe hearing loss. Notes: The patient has hearing loss significant to qualify for hearing aids and is eligible for them under Medical (payment program). We will start the process of obtaining their hearing aids. SSD stated she had no log to trigger which residents needed follow-up. SSD stated she had not made a follow up for Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure weekly wound assessments were done for one of one sampled resident (Resident 39). This failure had the potential to result in the inability to determine the healing progress of current wounds. Findings: During a concurrent interview and record review on 4/18/24 at 11:58 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 39's Skin & Wound Evaluation (SWE), [undated] was reviewed. LVN 1 stated Resident 39 was admitted on [DATE] with a wound on the left hand first and second fingers. LVN 1 stated no weekly wound assessments were done for the past four weeks in March and and there was only a wound assessment done on 4/3/24. During an interview on 4/18/24 at 2:40 p.m. with Director of Nursing (DON), DON stated weekly wound assessments should be done on residents with wounds. Facility policy and procedure related to weekly wound assessments was requested; none was provided.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 68) received treatment for contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in his left hand. This failure had the potential for worsening of Resident 68's contracture. Findings: During an observation on 4/16/24 at 10:55 a.m. in Resident 68's room, Resident 68's left hand had contractures. Resident 68 did not have a physician's ordered rolled-up washcloth in his hand. During a concurrent interview and record review on 4/17/24 at 11: 20 a.m. with Infection Preventionist (IP), Resident 68's Orders, dated 12/29/23 were reviewed. Resident 68's Orders indicated, Cleanse Left hand Contraction with soap and water, gently pat dry and place rolled up washcloth QD [every day]. IP stated the Restorative Nursing Assistants (RNAs) put the rolled-up wash cloths in resident's hands when ordered by the doctor. IP stated Resident 68 should have his left hand cleaned and a rolled-up washcloth placed 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 interview and record review, the facility failed to ensure communication and coordination between the facility and dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working) center was complete with assessments of the dialysis access site (surgically created access) on the Dialysis Communication Form for two of two sampled residents (Resident 39 and Resident 49). This failure had the potential to result in complications due to not properly assessing the dialysis site. Findings: During a concurrent interview and record review on 4/16/24 at 10:50 a.m. with Licensed Vocational Nurse (LVN) 2, the Nurses Dialysis Communication Record (NDCR) for Resident 39, dated 4/11/24 and 4/13/24 was reviewed. The NDCR indicated post-dialysis monitoring was blank on 4/11/24 and 4/13/24. LVN 2 stated these forms were incomplete and should be completed right away once resident was back in facility. During a concurrent interview and record review on 4/17/24 at 3:13 p.m. with LVN 2, NDCR for Resident 49, dated 4/10/24 was reviewed. The NDCR…

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

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 54) was assessed to determine the level of risk for bed entrapment (patient is caught, trapped, or entangled in the spaces in or about the bedrail, mattress or bed frame). This failure had the potential for adverse consequences. Findings: During an observation on 4/15/24 at 12:07 p.m. in Resident 54's room, Resident 54's bed had two quarter bedrails up on both sides of the bed. During a concurrent interview and record review on 4/17/24 at 10:47 a.m. with Licensed Vocational Nurse (LVN) 1 Resident 54's assessment, dated 3/10/24 was reviewed. LVN 1 was unable to provide documentation of a bed entrapment assessment for Resident 54 and stated they did not have it. During an interview on 4/17/24 at 10:54 a.m. with Director of Maintenance (DM), DM stated there were three beds with bed rails, 20 A, 6 B, and 27 B. DM stated he started bed safety check for the beds with bedrails this month. DM was not able to provide the bed safety check for Resident 54 prior to…

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

Based on interview and record review, the facility failed to ensure the physician evaluated and addressed weight loss for one of one resident (Resident 80). This failure had the potential for the resident to not receive proper medical care for weight loss. Findings: During a concurrent interview and record review on 4/16/24 at 10:20 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 80's Situation, Background, Assessment, Recommendation (SBAR-a verbal or written communication tool that helps provide essential, concise information) Communication Form, dated 4/5/24, indicated Resident 80 had a weight loss of seven pounds (lbs.) in one month. Resident 80's weight on 3/4/24 was 113 lbs. and on 4/1/24 Resident 80's weight was 106 lbs. LVN 1 stated the Interdisciplinary Team (IDT- a group of professionals who help people receive the care they need) met and recommended to add House Supplement (high calorie nourishment) at breakfast. LVN 1 stated the IDT team is composed of the Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Services Director (SSD), Medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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: 1. Ensure controlled substances (highly abused drugs) were stored in a locked cabinet. This failure had the potential for controlled substances to be diverted. 2. Ensure expired medications were not stored with active stock of medications. This failure had the potential to expose residents to expired medicaitons with unknown potency and efficacy. 3. Ensure destruction of medications were done in accordance with the facility policy. This failure had the potential for employees to divert discarded medications. 4. Ensure the treatment cabinet with medications in Central Supply Room was locked. This failure had the potential for medications to be accessed by unauthorized users. Findings: 1. During a concurrent observation and interview on 4/17/24 at 10:36 a.m. with Licensed Vocational Nurse (LVN) 3 in Medication Room, the Narcotic Emergency Kit (narcotic scheduled II, III, IV and V which are highly abused drugs) was in cabinet drawer that was not locked. LVN 3 stated the drawer should be locked. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Social Services followed up dental services for three of three sampled residents (Resident 29, Resident 36 and Resident 41). This failure had the potential for unplanned weight loss. Findings: During an interview on 4/16/24 at 9:26 a.m. with Resident 29, Resident 29 stated she had upper dentures and lower partials. Resident 29 stated, I need the upper dentures fixed because they fall off when I eat and when I speak. They are old. Really bad. During a concurrent interview and record review on 4/17/24 at 9:01 a.m. with Social Services Director (SSD), Resident 29's Dental Notes (DN), dated 8/18/23, 12/20/23, and 3/26/24 were reviewed. The DN, dated 8/18/23 indicated, Denture evaluation done. Patient is requesting new full upper denture (FUD). Is worn down. FUD is old and dirty. MO (medical) submitted. The DN, dated 12/20/23 indicated, Full mouth x-rays (FMX). The 3/26/24 DN indicated,MO request submitted. SSD stated she had not followed up on 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 prepare a pureed menu item according to the recipe instructions. This failure had the potential to result in food lacking nutritive value. Findings: During a concurrent observation and interview on 4/17/24 at 10:17 a.m. with [NAME] (CK) 1 in the kitchen, CK 1 poured an unknown amount of thickener (a substance to thicken pureed foods) into a pan of pureed spinach. CK 1 did not have the recipe for the pureed spinach and did not have a measuring cup to measure the thickener. CK 1 stated she knows the recipe and how much thickener is supposed to be added. CK 1 stated she does not use the measuring cup because she can eyeball it. During a concurrent observation and interview on 4/17/24 at 10:18 a.m. with Registered Dietitian (RD) in the kitchen, CK 1 prepared a pureed spinach without measuring the thickener. RD 1 stated, she [CK 1] should be measuring it [thickening agent] out and following the recipe. That is our policy. During a review of the facility's policy and procedure (P&P) titled, Food Preparation,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an effective Quality Assurance and Performance Improvement (QAPI-a data driven and proactive approach to quality improvement) Program as evidenced by: 1. Four members of the nursing staff (Licensed Vocational Nurses [LVN] 6, LVN 7, LVN 8, and Staffing Coordinator [SC]) were not familiar with QAPI and the facility's quality improvement projects. 2. The fall interventions had not been fully monitored and evaluated, data collected, analyzed, tracked, and trended, and outcome of the process had not been fully established. 3. The facility did not have performance indicators to monitor quality of care and services in high risk and problem prone areas like Infection Control and Laundry. These failures had the potential for residents and staff to be placed at risk for harm when the facility did not have a QAPI framework to achieve quality care and services for 92 of 92 residents residing in the facility. Findings: 1. During an interview on 4/18/24 at 3:25 p.m. with LVN 6, LVN 6 stated, I don't know when asked what QAPI…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain and implement an effective antibiotic (fight bacterial infections) stewardship (coordinated effort to measure and improve how antibiotics are prescribed by clinicians and used by patients) program for one of one sampled resident (Resident 4). This failure had the potential to place residents at risk for harm caused by unnecessary use of antibiotics. Findings: During an interview on 4/18/24 at 11:05 a.m. with Infection Preventionist (IP), IP stated Resident 4 was sent to the hospital for evaluation of altered mental status and was diagnosed with sepsis (presence of harmful microorganisms in the blood) related to urinary tract infection (UTI- bacteria invade and grow in the urinary tract [the kidneys, ureters, bladder, and urethra]). IP stated Resident 4 was readmitted to the facility on [DATE] with a Multidrug Resistant Organism (MDRO-a germ that is resistant to many antibiotics) and was placed on Contact Precaution (prevent transmission 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: 1. Administer the pneumococcal vaccine for one of three sampled residents (Resident 80) after consent was obtained. 2. Obtain vaccine refusal consent forms for one of three sampled residents (Resident 72). These failures had the potential to spread infectious diseases Findings: 1. During a concurrent interview and record review on 4/18/24 at 2:02 p.m. with Director of Nursing (DON), Resident 80's Immunization Consent or Declination (IC), dated 1/2/24 and Electronic Health Record (EHR) was reviewed. The IC indicated on 1/2/24 Resident 80's responsible party signed consent for Resident 80 to receive the Pneumococcal (PPSV23) and Pneumococcal (PCV12) vaccines (at admission or at a later date if clinically indicated). Resident 80's EHR indicated no Pneumococcal vaccine had been administered. DON stated Resident 80's consent for the Pneumonia vaccine was signed by the resident representative on 1/2/24, but the vaccine was not administered. DON stated, It [pneumococcal vaccine] should have been given if she [resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the facility was maintained in a safe, clean, homelike environment when: 1. One of two observed bathrooms had a clogged toilet, and two of two observed bathrooms needed sanding and painting. This failure resulted in unsanitary and unsafe conditions for the residents. 2. The kitchen temperature was too hot for three of three kitchen staff (Interim Dietary Supervisor [IDS], Dietary Staff [DS 1 and DS 2]) . This failure had the potential to result in facility kitchen staff experiencing heat-exposure related injuries. Findings: 1. During an observation on 4/15/24 at 11:01 a.m. in the shared bathroom between rooms [ROOM NUMBERS], there was a damp towel on the floor wrapped around the base of the toilet. There was bubbling and peeling paint on the wall next to the toilet. The lower 1/3 of the metal door frame near the toilet was black and orange. There was a plunger next to the toilet. During an observation on 4/15/24 at 11:05 a.m. 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 interview and record review, the facility failed to revise a care plan for one of three sampled residents (Resident 2) when staff placed Resident 2 on the floor to prevent a fall. This failure resulted in staff being unaware of how to care for Resident 2. Findings: During a review of Resident 2's admission Record (AR), dated 3/7/24, the AR indicated, admission Date 12/8/23.Diagnosis.unspecified dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change). During a review of Resident 1's Care Plan (CP), dated 12/24/2023, the CP indicated, [Resident 2] is high risk for falls r/t [related to] confusion, gait/balance problems, poor communication/comprehension, unaware of safety needs.Date initiated: 12/24/23.Interventions.Anticipate and meet the resident's needs.Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.Continuous direct supervision…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician was notified when four of eight sampled residents (Resident 1, Resident 2, Resident 4, and Resident 5) presented with rashes. This failure resulted in a delay of care and the potential for scabies (a contagious skin disease marked by itching and small raised red spots, caused by the itch mite) to spread to other residents, staff, and visitors. Findings: 1a. During a review of Resident 1 ' s Shower Day Skin Inspection (SDSI), dated 1/3/24, the SDSI indicated, Rash: chest, arms, back. The SDSI was signed by Certified Nursing Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 1. During a review of Resident 1 ' s SDSI dated 1/6/24, the SDSI indicated, Rash: see below. The body diagram had a rectangle around the front torso and the right side of the back, with rash documented on the sheet. The SDSI was signed by CNA 2 and LVN 1. During a review of Resident 1 ' s S (Situation) B (Background) A (Appearance) R (Review and Notify) (SBAR-used to notify the Physician of a change of condition), dated 1/9/24,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 its policy and procedure (P&P) when an outbreak was not reported when six of eight sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6) were diagnosed with scabies (a contagious skin disease marked by itching and small raised red spots, caused by the itch mite). This failure resulted in the state health department being unaware of the outbreak. Findings: During a review of Resident 1 ' s Integumentary Assessment Sheet (completed by Physician 1) (IAS), dated 1/11/24, the IAS indicated, Pt [Patient] seen exam bedside with generalized pruritic (severe itching) macule (flat, distinct, discolored area of skin) papule (small, well-defined bump in the skin) rash over trunk and upper extremities with tracking (trail or a path) without burrowing (move underneath by digging or making a hole to hide) with ddx (differential diagnosis) scabies. During a review of Resident 2 ' s IAS (completed by Physician 1), dated 1/11/24, the IAS indicated, Pt seen exam bedside with generalized…

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

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 9) Responsible Party (RP) was provided with Resident 9 ' s medical record when requested. This failure resulted in a delay of the medical record being provided. Findings: During an interview on 2/9/24 at 8:42 a.m., with Family Member (FM) 1, FM 1 stated she was Resident 9's RP and had requested the medical record for Resident 9 several times since November 2023. FM 1 stated, when she requested the medical record the medical record release form was to be e-mailed to her and the facility never sent the e-mail. During an interview, on 2/9/24 at 11:37 a.m., with Medical Records Supervisor (MRS), MRS stated she had heard Resident 9 ' s RP wanted medical records and e-mailed the medical record release form to FM 1 but had never received the completed request back. MRS was unable to provide evidence the medical request form was provided to FM 1. During an interview, on 2/9/24 at 11:52 a.m., with the Social Services Director (SSD), SSD stated Director of Nursing (DON) spoke with FM 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 interview and record review, the facility failed to follow its policy and procedure on Resident-to-Resident Altercations for one of two sampled residents (Resident 1). This failure resulted in Resident 2 hitting Resident 1. Findings: During a review of the facility ' s Self Report of Resident-to-Resident Altercation (SRRRA), dated 1/16/24, the SRRRA indicated, On 1/14/2024 at approximately 5:00 a.m., staff reported that while redirecting (Resident 2) ' s behavior towards (Resident 1), (Resident 2) made contact with (Resident 1) on the face with a closed fist as both CNA (Certified Nursing Assistant 1) and (Resident 1) attempted to exit the room. During a review of Resident 1's Brief Interview for Mental Status (BIMS), dated 9/11/23, the BIMS indicated, BIMS Summary Score 4.Severe cognitive impairment. During a review of Resident 2's Brief Interview for Mental Status (BIMS), dated 8/10/23, the BIMS indicated, BIMS Summary Score 4.Severe cognitive impairment. During an interview on 1/17/24 at 5:22 p.m., with CNA 1, CNA 1 stated she was assigned to Resident 1 and Resident 2…

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

Based on observation, interview, and record review, the facility failed to provide care for one of three sampled residents (Resident 1), when Resident 1 was not immediately assessed, and Attending Physician (AP) was not notified of Resident 1 ' s unwitnessed fall. This failure resulted in a delay in treatment for Resident 1. Findings: During an interview on 12/28/23 at 10:45 a.m. with Director of Nurses (DON), DON stated on 12/24/23 at approximately 2:51 p.m. Licensed Vocational Nurse (LVN 1) had noted discoloration to Resident 1 ' s left inner eye. DON stated upon further investigation, on 12/23/23 during a.m. shift, Hospitality Aid (HA) had found Resident 1 in a sitting position on the floor next to his bed. DON stated Resident 1 ' s AP was not notified of the fall on 12/23/23 and no assessment was completed. During an interview on 12/28/23 at 11:20 a.m. with LVN 1, LVN 1 stated on 12/24/23, Resident 1 ' s left outer eye had purple discoloration. LVN 1 stated Resident 1 may have hit the night stand causing the discoloration to his left eye. During an interview on 12/28/23 at 11:29…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician was notified for one of three sampled residents (Resident 1) when Resident 1 was not administered prescribed medications. This failure had the potential for Resident 1 to have adverse side effects. Findings: During a review of Resident 1 ' s Medication Administration Record (MAR), dated April 2023, the MAR indicated, Clonidine patch (used to treat high blood pressure) weekly.apply one patch transdermally [to the skin] one time a day every Mon [Monday].Spironolactone (used to remove excess fluid).give 1 tablet by mouth one time a day.Venlafaxine (used to treat depression).give 1 tablet by mouth one time a day.Coreg (used to treat high blood pressure).give 1 tablet by mouth two times a day.lasix (used to remove excess fluid).give 1 tablet by mouth two times a day.risperdal (used to improve mood, thoughts and behaviors).give 2 mg [milligrams] by mouth two times a day.Seroquel (used to treat mental health conditions).give 1 tablet by mouth two times a day.Hydralazine (used to treat high blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 plan of care was implemented and/or updated after a fall for two of three sampled residents (Resident 1 and Resident 2). This failure had the potential for the residents to fall again. Findings: 1. During a review of Resident 1 ' s Progress Notes (PN), dated 5/27/22 at 10:20 a.m., the PN indicated, [Resident 1] was on the ground in bathroom in sitting position.IDT [Interdisciplinary Team- members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities] Recommendations.offer toileting after meals. During a review of Resident 1 ' s Care Plan (CP), dated 5/27/22, the CP indicated, On 5.26.2022 [Resident 1] was found sitting on the floor of his bathroom.Date Initiated: 5/27/2022.Interventions.offer toileting after meals. During a concurrent interview and record review, on 12/14/23 at 1:43 p.m., with Director of Nursing (DON), Resident 1 ' s Documentation Survey Report (DSR), dated May 2022 and June 2022, was reviewed. There 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 the medical record was complete for one of three sampled residents (Resident 1). This failure resulted in an incomplete medical record. Findings: 1. During a concurrent interview and record review, on 12/7/23, at 1:22 p.m., with Director of Nursing (DON), Resident 1 ' s Weekly Summary (WS) assessments were reviewed. DON was unable to provide WS documentation for the weeks of 1/8/23-1/14/23, 1/22/23-1/28/23, 1/29/23-2/4/23, 2/5/23-2/11/23, 2/12/23-2/18/23, 3/19/23-3/25/23, 3/26/23-4/1/23 and 4/2/23-4/8/23. DON stated, weekly summaries should have been done by the nurse during the shift it was assigned. 2. During a concurrent interview and record review, on 12/14/23, at 1:43 p.m., with DON, Resident 1 ' s Documentation Survey Report (DSR), dated 2/2023 was reviewed. The DSR indicated, Bathing/Shower days are Monday and Thursday. There was no documentation indicating Resident 1 was provided a shower on 2/2/23. DON stated, when the shower was provided it should have been documented or it was not given. During a review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two sampled staff (Dietary Aide [DA] 1 and Certified Nursing Assistant [CNA] 1) wore their N95 mask (respiratory device designed to achieve a very close facial fit and very efficient filtration of airborne particles) properly. This failure had the potential for residents, staff, and visitors to be at risk for contracting COVID 19. Findings: During a concurrent observation and interview, on 10/11/23, at 5:01 p.m., with Dietary Aide (DA) 1, DA 1 was observed pushing the resident food cart down the hall wearing an N95 mask. The two straps on the N95 were cut, and tied together and then looped around each ear. DA 1 stated, she was wearing the N95 due to a COVID 19 outbreak in the facility but had modified the N95 straps because it hurt her head. During a concurrent observation and interview, on 10/11/23, at 5:03 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 was observed coming out of a resident's room wearing an N95 mask below her nose and the two straps had been cut and tied together and…

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

Based on observation, interview, and record review, the facility failed to follow the therapeutic menu when cornbread was not served as indicated for five of five sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5). This failure had the potential for the residents to have unmet nutritional needs. Findings: During a review of the Summer Menu (SM), dated 6/15/23, the SM indicated, Roast Pork Loin with spiced apples, ranch style beans, southern style green beans, parsley sprig, corn bread 2x2 1/2, margarine, vanilla mousse choc (chocolate) chip garnish, milk were to be served for lunch. During a concurrent observation and interview on 10/5/23 at 12:20 p.m. in the restorative dining room, with Certified Nursing Assistant (CNA) 1, Resident 2, Resident 3, Resident 4, and Resident 5's lunch was observed. None of the residents were served cornbread. CNA 1 stated none of the residents were served cornbread. During a concurrent observation and interview on 10/5/23, at 12:30 p.m. with Resident 1, in the dining room, Resident 1 was served a pork chop, rice, green…

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

Based on interview and record review, the facility failed to ensure Physician's Orders (PO) were implemented for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to have an increase in behavior symptoms. Findings: During a review of Resident 1's S [situation] B [background] A [Appearance] R [Review and Notify] (SBAR-used to notify physician of a change of condition) dated 9/9/23, the SBAR indicated, Other res [resident] accused [Resident 1] of hitting her in the face. During a concurrent interview and record review on 9/13/23 at 11:55 p.m., with Director of Nursing (DON), Resident 1's clinical record was reviewed. The PO dated 9/11/23 was reviewed. The PO indicated, D/C [discontinue] Zyprexa (medication used to treat mental health conditions) [5 mg twice a day].Start Zyprexa 5 mg [milligrams-unit of measurement] po [by mouth] 6 am & 7.5 mg po QHS [at bedtime] . DON was unable to provide evidence of the PO was being implemented. DON stated the PO should have been implemented. During a concurrent interview and record review on 9/13/23 at 12…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary care and services according to the care plan for one of three sampled residents (Resident 1) when Resident 1 was not supervised by staff when walking down the hallways. This failure resulted in Resident 1 being found outside of the facility alone. Findings: During an observation on 8/2/23, at 10:55 a.m., Resident 1 was observed in [Resident 1] ' s room sitting on the bed. During a review of Resident 1 ' s S [Situation] B [Background] A [Appearance] R [Review and Notify] Communication Form (SBAR), dated 8/1/23, the SBAR indicated, Elopement (the act of leaving secretly); found outside of facility. During a review of Resident 1 ' s Elopement Evaluation (EE), dated 7/19/23 at 5:59 p.m., the EE indicated, Does the resident wander.Yes. During a review of Resident 1 ' s Care Plan (CP), dated 2/11/23, the CP indicated, I am at risk for elopement not being able to make good safety decisions.Goal.I will remain safe within my unit thru my next review.Interventions/Tasks.Find something on the unit I…

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

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) was free from abuse when Resident 1 was tied down in her wheelchair with a blanket (draw sheet-a flat sheet used on top of the bed mattress) to prevent her from getting up. This failure had the potential for injury. Findings: During a review of the facility Investigation Report (IR), dated 8/8/23, the IR indicated, On August 3, 2023, at approximately 1830 [6:30 p.m.] hours, it was reported to the assisted director of nursing [ADON] that a staff member loosely tied a blanket around [Resident 1] while she was sitting in her wheelchair. This was witnessed by another staff member. During an interview on 8/7/23 at 10:45 a.m. with Administrator and Director of Nurses (DON), Administrator stated on 8/3/23, Certified Nursing Assistant (CNA) 1 had taken Resident 1 in the dining room in her wheelchair with a blanket [draw sheet] tied around her wheelchair. Administrator stated CNA 2 had witnessed the incident. Administrator stated Resident 1 was a high risk for fall and…

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

Based on observation, interview, and record review, the facility failed to implement one of three sampled residents (Resident 1) Resident to Resident Care Plan (CP). This failure resulted in Resident 1 being left alone without staff supervision for approximately 11 minutes and potential for altercation with other residents. Findings During an interview on 7/24/23 at 1 p.m. with Director of Nurses (DON), DON stated on 7/21/23, Resident 1 was involved in a physical altercation with Resident 2. DON stated, Resident 1 was placed on 1 to 1 supervision (one staff to one resident direct observation) to prevent further altercation. During a concurrent observation and interview on 7/24/23 at 2:09 p.m. with Certified Nursing Assistant (CNA) 1 in Resident 1's room, Resident 1 was lying in bed with her eyes closed. A black steel folding chair was noted next to Resident 1's bed. CNA 1 stated the chair was for the assigned 1 to 1 for Resident 1. CNA 1 stated the assigned 1 to 1 should not have left Resident 1 in her room by herself. CNA 1 excused herself from Resident 1's room to find the…

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

Based on observation, interview, and record review, the facility failed to ensure an item on the menu was prepared and served to 34 of 34 residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 8, Resident 9, Resident 12, Resident 13, Resident 16, Resident 18, Resident 21, Resident 23, Resident 24, Resident 26, Resident 28, Resident 29, Resident 32, Resident 34, Resident 35, Resident 37, Resident 39, Resident 40, Resident 41, Resident 42, Resident 44, Resident 45, Resident 51, Resident 52, Resident 55, Resident 58, Resident 59, Resident 60, and Resident 61) on a therapeutic diet. This failure had the potential to alter texture and nutritional value for these residents. Findings: During a review of the lunch menu, dated 5/25/21, the menu indicated, Roast Turkey, Cranberry-Ginger-Citrus Sauce, Gravy, Bread Dressing, Seasoned Peas, Three Bean Salad, Vanilla Mousse Chocolate Chip Garnish, and Milk. During a concurrent observation and interview on 5/25/21, at 11:28 AM, with [NAME] 2, in the kitchen, tray line (process of preparing residents meal trays) 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 provide food that accommodates resident's preferences and allergies for two of 16 sampled residents (Resident 21 and Resident 54) when: 1. Resident 21, with a lactose intolerance allergy, was being served house nourishments, which contain milk, four times a day . 2. Resident 54 was served two of her food dislikes for lunch. These failures had the potential to result in inadequate intake and possible weight loss for Resident 21 and Resident 54. Findings: 1. During an interview on 5/26/21, at 11:11 AM, with Family Member (FM) 1, FM 1 stated, [Resident 21] is Lactose intolerant. It gives her digestive issues. During a review of Resident 21's Order Summary Report (OSR), dated May 2021, the OSR indicated, allergies: Lactose Intolerant. Regular diet, add HN [house nourishment] to all meals. Sugar free house nourishment two times a day between meals. During a review of Resident 21's Care Plan (CP), dated 1/5/20, the CP indicated, Nutrition: [Resident 21] is also Lactose intolerant. Will not serve foods/drinks 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.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 12) responsible party (RP) was properly notified of Medicare benefit changes. This failure had the potential for Residents 12's RP to not make an informed decision regarding Medicare services. Findings: During a concurrent interview and record review on 5/26/21, at 3:49 PM, with Minimum Data Set Nurse (MDSN), MDSN stated, the MDSNs were responsible for completing the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN -form used to inform residents and RP of their potential financial liability and appeal rights and protections should they wish to receive care and services that may not be covered by Medicare). MDSN confirmed, that there was no documentation on the SNFABN for Resident 12 dated 1/4/2020 and 12/4/2020 in the areas titled Care, Reason Medicare may not pay:, or the Estimated Cost. She stated, option 3 was selected (I don't want the care listed above. I understand that I'm not responsible for paying, and I can't appeal to see if Medicare…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 plans for two of 16 sampled residents (Resident 32 and Resident 5 ) when: 1. Resident 32 had a limitation in range of motion (ROM) to his lower extremities. 2. Resident 5 had a physicians' order (PO) for passive range of motion (PROM) to her bilateral lower extremities (BLE). These failures had the potential to result in staff being unaware of residents' needs and Resident 32 and Resident 5 not getting required treatments. Findings: 1. During a concurrent observation and interview on 5/24/21, at 11:45 AM, with Certified Nursing Assistant (CNA ) 4, in the hallway near Resident 32's room, Resident 32 was observed sitting in his wheelchair. CNA 4 stated, Resident 32 has limitation in range of motion to his lower extremities. During a review of Resident 32's Quarterly Minimum Data Set (MDS - a standardized assessment tool), dated 3/21/21, the MDS indicated, Section G Functional Status. Functional Limitation in Range of Motion . Impairment on both sides. B. Lower extremity (hip, knee, ankle, foot).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 16 sampled residents (Resident 32 and Resident 44) were assisted with grooming. These failures had the potential for the residents not to maintain their highest practicable level of functioning and well-being. Findings: 1. During a concurrent observation and interview on 5/25/21, at 3:18 PM, with Certified Nursing Assistant (CNA) 5, in Resident 44's room, Resident 44 was observed to have long fingernails with black colored debris underneath all his fingernails. CNA 5 stated, Resident 44 was unable to perform his personal hygiene and required assistance to clean and trim his fingernails. CNA 5 stated, Resident 44 should have been assisted by staff in cleaning and trimming his fingernails. 2. During a concurrent observation and interview on 5/25/21, at 3:24 PM, with CNA 5, in Resident 32's room, Resident 32 was observed to have long fingernails with black colored debris underneath all his fingernails. CNA 5 stated, the fingernails needed to be trimmed and cleaned. During a review of Resident 32's…

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

Based on observation, interview, and record review, the facility failed to ensure two of 16 sampled residents (Resident 5 and Resident 21) received restorative care. This failure had the potential to result in decreased safety and independence for Resident 5 and Resident 21. Findings: During a review of Resident 5's physicians orders (PO), dated 5/13/21, the PO indicated Resident 5 was to receive passive range of motion (PROM) to her lower extremities every Tuesday, Thursday, and Saturday. During a concurrent interview and record review on 5/27/21, at 9:14 AM, with the Director of Nursing (DON), DON reviewed the Restorative Record dated 5/21 for Resident 5. DON confirmed multiple dates with no documentation (5/1/21, 5/4/21, 5/11/21, 5/18/21, and 5/20/21). DON stated, If it is not documented it is not done. During an observation on 5/24/21, at 12:15 PM, in Resident 21's room, Resident 21 was lying in bed with a food tray in front of her. During an observation on 5/26/21, at 12 PM, in Resident 21's room, Resident 21 was lying in bed with a food tray in front of her. During a review of…

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

Based on observation, interview, and record review, the facility failed to: 1. Ensure the prefilled syringes (single-dose packet syringes) of Morphine Sulfate (medication used to treat moderate to severe pain) were labeled with expiration dates for two of 16 sampled residents (Resident 1 and Resident 31). This failure had the potential to result in residents receiving expired medications. 2. Remove a medication for one time use only from the medication cart for one of 16 sampled residents (Resident 47). This failure had the potential for medication errors. 3. Remove discontinued medication from the medicine cart for one of 16 Residents (Resident 37). This failure had the potential to contribute to adverse consequences to the residents. Findings: 1. During a concurrent observation and interview on 5/25/2, at 9:35 AM, with Licensed Vocational Nurse (LVN) 2, in the Central Supply Room, prefilled Morphine Sulfate syringes for the following residents were found stored, locked and kept inside the medication cart with no expiration dates: a. Resident 31 - 20 prefilled syringes of 0.25 ml…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 15 Ready Care shakes were stored at the proper temperature prior to being served to residents. This failure had the potential to cause foodborne illnesses for facility's residents. Findings: During a concurrent observation and interview on 5/25/21, at 8:40 AM, with Dietary Aide (DA) 2, in the kitchen, 15 Ready Care Shakes were observed sitting on a cart in a plastic bin. DA 2 stated, the shakes were for the snack cart and staff would be picking up the cart between 9:45 AM -10 AM. DA 2 did not know at what temperature the shakes were supposed to be served. During a concurrent observation and interview on 5/25/21, at 9:15 AM, with DA 2 and the Certified Dietary Manager (CDM), in the kitchen, DA 2 was adding ice to the plastic bin with the 15 Ready Care Shakes. One shake was removed and DA 2 checked the temperature of the liquid inside the carton. The temperature read 60 degrees Fahrenheit (F) (unit of measurement). CDM verified this finding and stated, the shakes are not supposed to sit out of the…

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

Based on observation, interview, and record review, the facility failed to ensure breakfast was served at a preferred time for one of 16 sampled residents (Resident 21). This failure had the potential to result in weight loss and inadequate meal intake. Findings: During an interview on 5/26/21, at 11:11 AM, with Family Member (FM) 1, FM 1 stated, Resident 21 likes to eat breakfast late morning because she does not get up early. During a review of Resident 21's Order Summary Report (OSR), dated May 2021, the OSR indicated, Dietary-Diet: Breakfast @ 0900. During a review of Resident 21's Care Plan (CP), dated 1/5/20, the CP indicated, Nutrition: Move Breakfast to 0900. During a concurrent observation and interview on 5/25/21, at 9:14 AM, with Certified Nursing Assistant (CNA) 3, Resident 21 did not receive a breakfast tray at 9 AM. CNA 3 stated, Resident 21 is served breakfast the same time as all the other residents. During an interview on 5/26/21, at 11:45 AM, with Certified Dietary Manager (CDM), CDM stated, Resident 21 is served breakfast the same time as all the other residents.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an accurate and complete medical record for one of 16 sampled residents (Resident 48) for his G-Tube (gastrostomy tube - a tube inserted surgically through the abdomen into the stomach for nutrition and medications) bolus feeding (a type of feeding method using a syringe to deliver formula through the G-Tube). This failure had the potential for Resident 48 not to receive the appropriate bolus feeding via G-Tube as ordered by the physician. Findings: During a concurrent interview and record review on 5/26/21, at 3:55 PM, with Director of Nursing (DON), Resident 48's Medication Administration Record (MAR), dated May 2021 was reviewed. The MAR indicated, Tube Feed Bolus Feeding of Glucerna (a nutritional supplement for people with diabetes) 1.2 [calories] one can/carton {237 ml - milliliter [a unit of measurement) TID [three times a day] if po [by mouth intake] is <75% [less than 75 percent]. The check marks indicated, Chart Codes / Follow Up Codes. [check mark] = Administered. The MAR had check marks on 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.