River Bend Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were stored securely for a census of 86, when:1. An open container of glucometer test strips was not labeled with the open date;2. One eye drop medication had no legible open date;3. Keys to the controlled substance cabinets and refrigerator were not secured.These failures had the potential for residents to receive medications or treatments that were unsafe or with reduced potency or accuracy, and increased risk of access to controlled substances by unauthorized individuals.During a concurrent observation and interview on 8/14/25 at 10:55 a.m. with Licensed Nurse (LN 6) in the hallway near room [ROOM NUMBER], the medication cart was inspected and found an open box of glucometer test strips that was not labeled with an open date. The directions on the box indicated use within 6 months after first opening. LN 6 confirmed the box should have been labeled with an open date. LN 6 was not able to state how long after opening…

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

Based on observation, interview, and record review, the facility failed to protect residents from acquiring scabies (contagious skin infestation caused by mites), when the facility had three residents who tested positive for scabies (Resident 1, Resident 2, and Resident 3) and facility wide prophylaxis was not completed per public health recommendations. This failure had the potential for multiple vulnerable residents to acquire scabies and suffer the effects of infestation including infection. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in March 2023 with multiple diagnoses including cerebral infarction (stroke- disrupted blood flow to the brain causing brain tissue death), ventilator dependence (requires a mechanical ventilator to breathe), tracheostomy (opening in neck to provide airway for breathing), and heart failure (heart does not pump blood as well as it should). A review of Resident 1's Change in Condition Evaluation, dated 12/13/24, indicated .Patient was tested for scabies with Positive results .Interventions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 wound care plan was updated and revised timely for one of 3 sampled residents (Resident 1) when Resident 1's moisture related skin condition deteriorated to a pressure ulcer stage 4 (pressure injuries extended to muscle, tendon, or bone) to include interventions ordered by the physician. This failure had the potential to result in an inaccurate evaluation of the progress of wound healing for Resident 1. Findings: During a review of Resident 1's admission records, the records indicated Resident 1 was admitted in October 2022 and readmitted in January 2023 with diagnoses that included respiratory failure (not enough oxygen in the body), muscle wasting, diabetes (too much sugar in the blood), and reduced mobility. Resident 1's Minimum Data Set (MDS, an assessment tool) indicated Resident 1 had moderate cognitive impairment. During a review of Resident 1's IDT [Interdisciplinary Team] Skin Integrity Review, dated 9/10/24, the review indicated, WEEKLY WOUND EVALUATION: 9/10/24 SITE: Sacrococcyx [tailbone]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 according to professional standards of practice for one of three sampled residents (Resident 1), when the facility did not obtain instructions for follow up care for Resident 1 who had electrodes placed for an EEG (electroencephalogram- measures electrical activity in the brain) machine and appointment for removal of electrodes was missed. This failure had the potential to have caused the scalp skin injuries after the electrodes were removed at the facility. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility initially in June 2013 with multiple diagnoses including dysphagia (difficulty swallowing) following cerebral infarction (stroke-lack of blood flow to the brain), quadriplegia (paralysis of all four limbs), and epilepsy (a seizure disorder). A review of Resident 1's Order Summary Report, active orders as of 10/4/24, indicated order 9/23/24, .medical device (EEG) Pressure injury (on scalp to forehead): - Cleanse with wound cleanser or normal…

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

Based on observation, interview, and record review, the facility failed to maintain timely and appropriate pharmaceutical services for one out of three sampled residents (Resident 1) when a prescribed medication was unavailable to be administered as ordered by the physician. This failure caused Resident 1 to experience worsening tremors, increased rigidity, loss of balance, confusion, and agitation due to not achieving the therapeutic dose. Findings: Resident 1 was admitted to the facility in early 2024 with diagnoses that included parkinsonism (brain condition that cause slowed movements, rigidity (stiffness), and tremors), fibromyalgia (a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory, and mood issues), muscle wasting, atrophy, and difficulty walking. During a review of Resident 1's Order Summary Report (OSR), dated 6/4/24, the OSR indicated, Rytary® Oral Capsule Extended Release 23.75-95 MG [mg, unit of measure] (Carbidopa-Levodopa) Give 2 capsules by mouth three times a day related to PARKINSONISM . During a review of Resident 1's…

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

Based on observation, interview, and record review, the facility failed to ensure residents' right to personal privacy and confidentiality of his or her personal medical information when meal tray tickets were thrown into the general kitchen trash. This failure had the potential of compromising resident privacy for 54 residents receiving facility prepared meals. Findings: During a concurrent observation and interview on 8/20/24 at 9:36 a.m. near the dish washing sink, with Dietary Aide 1 (DA 1), DA 1 was preparing the breakfast meal trays to be washed and, while doing so, threw the resident meal tray tickets into the kitchen's general trash. When asked what is done with the resident meal tray tickets, he pointed to the trash and stated, I throw them in here. A review of the facility's meal tray tickets for 8/20/24 were noted to include the following information: resident name, room number, diet order, food allergies, food preferences, and special dietary needs. During an interview on 8/20/24 at 9:39 a.m. with the District Kitchen Supervisor (DKS), the DKS confirmed that meal tray…

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

Based on observation, interview, and record review, the facility failed to ensure kitchen staff had the knowledge and competencies to carry out dietary functions when: 1. A cook was unable to correctly read the temperature in one of the reach in freezers; 2. A Dietary Aide did not know how to check the temperature of a dishwashing machine; 3. A cook did not use a recipe when preparing pureed foods; and, 4. A cook used the wrong scoop size to measure out food quantities. These failures had the potential of leading to food borne illness or weight loss for 54 Residents receiving facility prepared food. Findings: 1. During an interview on 8/19/24 at 10:23 a.m. near the kitchen's rear exit, with [NAME] 1 (CK 1), CK 1 was asked to check the temperature of the reach in freezer near the kitchen's rear exit. CK 1 was unable to differentiate between Fahrenheit (F, a unit of measurement for temperature) and Celsius (C, a unit of measurement for temperature) on the temperature probe used in the reach in freezer. CK 1 was also unable to state what temperature the reach in freezer should be. When…

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Based on observation, interview, and record review, the facility failed to follow the recipe for pureed food for three out 20 residents (Resident 37, Resident 63 and Resident 85) receiving a pureed diet when a kitchen staff member used the wrong scoop size to measure out food quantities. This failure had the potential to place residents receiving a pureed diet at risk for malnutrition and weight loss. Findings: During a review of the facility's [Facility Name Diet Guide Sheet] (DGS), undated, the DGS indicated that residents on the dysphagia (difficulty swallowing) mechanical (food texture modified in a way to help residents swallow easier) and dysphagia puree diets should receive a #8 scoop (1/2 cup) serving of pureed potatoes and a #8 scoop serving of pureed cream style corn. During a concurrent observation and interview on 8/20/24 at 12:02 p.m. in the food preparation area of the kitchen, with [NAME] 2 (CK 2) and District Kitchen Supervisor (DKS), CK 2 used a 3/8 scoop to measure the pureed potatoes and a ¼ scoop to measure out the pureed corn which caused residents on a pureed…

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

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a manner to conserve nutritive value and palatability for 20 residents receiving a pureed diet when the pureed bread was prepared without using a recipe. This failure had the potential of leading to poor intake and malnutrition for the 20 residents receiving pureed meals. Findings: During a concurrent observation and interview on 8/20/24 at 10:03 a.m. in the food preparation area, with the [NAME] (CK 2), CK 2 was observed pureeing slices of bread in a blender. CK 2 added an unmeasured amount of milk, bread, and water to the blender container then blended the ingredients. CK 2 then poured the pureed bread into a metal food container and started adding an unmeasured amount of food thickener. CK 2 indicated that, when making purees, he makes them without a recipe and goes by feel. During a concurrent observation and interview on 8/20/24 at 12:35 p.m. near the kitchen entrance, with the Dietary Supervisor (DS), the DS brought two lunch test trays that contained one regular consistency…

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

F812 Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for a total of 54 residents who received facility prepared foods when: 1. Proper food labeling was not followed for items in the freezers, refrigerator, dry storage, and spice shelf; 2. Expired food items were found in the refrigerator, dry storage, and spice shelf; 3. Personal milk cartons were not stored at appropriate temperatures; 4. Kitchen reach in freezers contained multiple boxes of food items that were exposed and open to the freezer environment; a plastic container of brown sugar was not sealed properly; 5. Frozen foods were not stored at appropriate temperatures; 6. A steam table pan was found stored wet; 7. No air gaps were found in the produce sink; 8. The kitchen can opener had a chipped blade; and 9. A kitchen staff member was not wearing a beard restraint. These failures had the potential to lead to food borne illness for the 54 residents receiving facility prepared meals. 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 observation, interview, and record review, the facility failed to ensure proper infection practices were followed when: 1. Respiratory Therapist (RT) did not perform hand hygiene during a breathing treatment for Resident 66; 2. The isolation trash can was not covered for Resident 66; 3. Oxygen tubing used by Resident 139 was not labeled and additional oxygen tubing and nebulizer facemasks were labeled with an expired date; 4. An air fan was found with black residue and lint in Resident 41's room; and 5. Three plastic trash containers were open and had no lid cover during lunch meal in the facility dining room. These failures had the potential to increase the transmission and spread of infection. Findings: 1.Resident 66 was admitted to the facility in mid-2024 with diagnoses which included chronic obstructive pulmonary disease (lung disease), atrial fibrillation (an irregular heart rate), and heart failure. During a concurrent observation and interview on [DATE] at 8:35 a.m. at Resident 66's bedside the…

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

Based on observation, interview and record review, the facility failed to maintain one out of three reach-in freezers in safe operating condition when the freezer was found running at unsafe temperatures. This failure had the potential to lead to growth of bacteria and food borne illness for all 54 residents eating facility prepared meals. Findings: During a concurrent observation and interview on 8/19/24 at 8:18 a.m., in the facility kitchen, with the Dietary Supervisor (DS), the reach in freezer closest to the DS's office (freezer 1) had a temperature reading of 16 degrees Fahrenheit (F, a unit of measurement for temperature). The DM confirmed the temperature reading and stated, It should be colder. The DS stated, I think the freezer [freezer 1] was last serviced in July of this year [2024] but there is no scheduled maintenance .it might be broken. During a concurrent observation and interview on 8/19/24 at 10:26 a.m., in the facility kitchen, with the DS, freezer 1 had a temperature reading of 20 F. All ice cream, gelato, and orange sherbet containers being stored in the freezer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe, functional, sanitary, clean and comfortable environment was provided for a census of 89, when: 1. Several missing slats on the window blinds, three fluorescent bulbs not functioning, and three open trash containers without lids were found in the dining room; and 2. Resident 19 had a strong odor and foul-smelling room environment. These failures had the potential to result in the residents not attaining their highest practicable physical, mental and psychosocial well-being. Findings: 1. During a concurrent observation and interview on 8/19/24 at 11:42 a.m. in the facility dining room, Resident 12 stated, The place could be much better. During a concurrent observation and interview on 8/19/24 at 12:15 p.m. in the dining room, the window blinds next to the table of Resident 12 had four missing slats. Restorative Nursing Aide 3 (RNA 3) verified the missing slats, and stated, It has been a while those blinds had been missing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 required in-service training, competency skills and techniques were provided for two out of two sampled Contracted Certified Nursing Assistants (CCNA) CCNA 15 and CCNA 16, when the facility was unable to provide documentation to demonstrate the CCNAs received no less than 12 hours of annual in-services. This failure had the potential to significantly compromise the quality of services provided to the residents. Findings: During a concurrent interview and record review on 8/20/24 at 9:40 a.m. with the Director of Staff Development (DSD), the DSD confirmed she could not find the missing documentation to support dementia management training for CCNA 15. During a concurrent interview and record review on 8/20/24 at 10:25 a.m. with the Director of Nursing (DON), the DON stated, The facility used contracted staff through a staffing agency, and the contracted nursing staffing agency is expected to provide CCNAs with mandatory training documentation. During an interview on 8/22/24 at 2:25 p.m. with the Administrator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dignity and privacy were promoted for two of 30 sampled residents (Resident 52 and Resident 19), when: 1. Staff did not knock nor identify himself and entered Resident 52's room; and, 2. Resident 19 was left with a pungent, strong body odor and foul-smelling immediate environment. These failures resulted in negatively impacting Resident 52 and Resident 19's emotional, mental, and psychosocial well-being. Findings: 1. Resident 52 was admitted in early of 2024 with diagnoses which included post-traumatic stress disorder (PTSD), depression, and chronic pain. During a review of Resident 52's Minimum Data Set (MDS, an assessment tool), dated 7/25/24, the MDS indicated Resident 52 had no memory impairment and had episodes of feeling down, depressed and hopeless. During a review of Resident 52's Nursing Care Plan (NCP), dated 8/1/24, the NCP indicated, At risk for altered well-being & reduced sense of well-being related to: DX [diagnosis]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 comprehensive care plans were developed and implemented for two out of 30 sampled residents (Resident 52 and Resident 85), when: 1. Resident 52's emotional issues and environmental concerns were not developed; and, 2. Resident 85 had no care plan developed and implemented for activities. These failures had the potential to result in residents not attaining their highest practicable physical, mental and psychosocial well-being. Findings: 1. Resident 52 was admitted in early 2024 with diagnoses which included post-traumatic stress disorder (PTSD), depression, and chronic pain. During a review of Resident 52's Minimum Data Set (MDS, an assessment tool), dated 7/25/24, the MDS indicated Resident 52 had no memory impairment and had episodes of feeling down, depressed, and hopeless. During a concurrent observation and interview on 8/19/24 at 11:10 a.m. in Resident 52's room, Resident 52 sat on the edge of the bed, awake, alert and verbally responsive. Resident 52 stated, I have been here six months .People here don't…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise the comprehensive care plan for two of 30 sampled residents (Resident 18 and Resident 139), when: 1. Resident 18's nutrition care plan was not updated for an adaptive device; and, 2. Resident 139's pain care plan was not updated for a new pain medication. These failures had the potential to result in Resident 18 and Resident 139's not attaining their highest practicable well-being. Findings: 1. Resident 18 was admitted to the facility in late 2015 with diagnoses which included stroke, diabetes (uncontrolled blood sugar levels), left sided hemiplegia (paralysis on one side of the body), dysphagia (swallowing difficulty), and muscle weakness. During a review of Resident 18's Nursing Care Plan (NCP), dated 5/20/20, the NCP indicated, Adaptive equipment: Sipper cups and Divided plate for all meals .No changes have been made since the last review. During a review of Resident 18's NCP, dated 8/19/20, the NCP indicated, SELF CARE DEFICIT:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 necessary services to maintain good grooming and personal hygiene were provided for two out of 30 sampled residents (Resident 19 and Resident 29), when: 1. Resident 19 was unkempt and the immediate environment had a strong foul-smelling odor; and, 2. Resident 29's fingernails were long and with jagged ends. These failures had the potential to result in the residents not attaining their highest practicable well-being. Findings: 1. Resident 19 was admitted in early 2020 with diagnoses which included post-traumatic stress disorder (PTSD), blindness, and anxiety. During a review of Resident 19's Minimum Data Set (MDS, an assessment tool), dated 7/19/24, the MDS indicated Resident 19 had moderate memory impairment and did not reject ADL (activities of daily living) assistance. During a review of Resident 19's Nursing Care Plan (NCP), dated 5/9/23, the NCP indicated, ADL SELF CARE DEFICIT: [Resident 19] is at risk for self-care deficit…

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

Based on observation, interview, and record review, the facility failed to meet two of 30 sampled residents' (Resident 37 and Resident 85) activity needs when the residents did not receive in-room visits by staff. This failure increased the potential for residents to experience isolation and depression. Findings: Resident 37 admitted to the facility in late 2019 with diagnoses which included cerebral infarction (stroke, medical condition that occurs when blood flow to the brain is disrupted), aphasia (language disorder that makes it difficult for people to communicate), and quadriplegia (a form of paralysis that affects arms and legs). During a review of Resident 37's care plan (CP), initiated 5/10/22, the CP indicated, .Will continue in room visits 3 x week . During a review of Resident 37's, Activities- Quarterly [assessment] ., dated 5/17/24, the assessment indicated, Resident receives 1:1 in room visits with the activity staff .staff will continue to do in room visit. During a review of Resident 37's, CUSTOM IDT [Interdisciplinary Team] CARE CONFERENCE FORM .ACTIVITIES, 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 attempt appropriate alternatives, obtain physician's orders, and obtain an informed consent prior to using bed rails (adjustable metal or rigid plastic bars that attach to the side of the bed) for 1 of 30 residents (Resident 63). This failure had the potential to result in entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail), injury and/or negative physical outcomes to skin integrity or muscle function. Findings: Resident 63 was admitted on [DATE] with medical diagnoses including sequelae of cerebral infarction (occurs when blood flow to the brain is blocked or a blood vessel in the brain bursts), muscle wasting and atrophy (muscles weakening and shrinking), and dysphagia (difficulty swallowing). During a review of Resident 63's Minimum Data Set (MDS, an assessment tool), dated 8/5/24, the MDS indicated Resident 63 had memory impairment. During an observation on 8/19/24 at 12:24 p.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 ensure an accurate inventory of narcotics (a medication that is used to relieve pain) for two of 30 sampled residents (Resident 66 and Resident 76) when six tablets of narcotics were not entered into the residents Medication Administration Record (MAR, document that serves as a legal record of the drugs administered to a resident). This failure had the increased potential for diversion and not being able to accurately monitor the amount or frequency of medications given to residents. Findings: Resident 66 was admitted to the facility in mid-2024 with diagnoses which included cancer of the head and neck. During a review of Resident 66's physician orders (PO) dated 8/1/24-8/31/24, the PO indicated, Norco Oral Tablet 10-325 MG [mg, a unit of measurement] [Hydrocodone-Acetaminophen] Give 1 tablet .every 6 hours as needed for .pain. During a review of Resident 66's CONTROLLED DRUG RECORD [CDR], Individual Patient's Narcotic Record [a form that keeps count of the number of narcotics dispensed to a resident], entries dated from…

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

Based on observation, interview and record review, the facility failed to ensure food preferences were accommodated for one of 54 residents receiving facility prepared food (Resident 9) when Resident 9's request not to be served cream of wheat for breakfast was disregarded. This failure had the potential to negatively impact Resident 9's nutritional status. Findings: Resident 9 was admitted to the facility in the middle of 2024 with diagnoses which included acute and chronic respiratory failure with hypoxia (a lack of oxygen in the blood), pneumonia (infection of the lungs), and muscle wasting and atrophy (wasting away of a body part). During a review of Resident 9's Minimum Data Set (MDS, an assessment tool), dated 7/26/24, the MDS indicated Resident 9 had a Brief Interview for Mental Score (BIMS) of 13 indicating Resident 9 had no cognitive impairment. During a review of Resident 9's meal tray ticket for breakfast on 8/20/24, the tray ticket indicated, No cream of wheat Oatmeal please 3 butter packets. During a concurrent observation and interview on 8/20/24 at 8:15 a.m. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of 30 sampled residents (Resident 18 and Resident 73) were provided with necessary adaptive equipment for meals as ordered by the physician. This failure had the potential to negatively impact the resident's well-being and contribute to decreased meal intake. Findings: 1. Resident 18 was admitted to the facility in late 2015 with diagnoses which included stroke, diabetes (uncontrolled blood sugar levels), left sided hemiplegia (paralysis on one side of the body), dysphagia (swallowing difficulty), and muscle weakness. During a review of Resident 18's Nursing Care Plan (NCP), dated 8/19/20, the NCP indicated, SELF CARE DEFICIT: due to: Need assistance IN ADL [activity of daily living]: Resident's ability to perform ADL at highest practicable level will be promoted with interventions. During a review of Resident 18's Clinical Physician Orders (CPO), dated 1/12/24, the CPO indicated, Consistent Carbohydrate (CCD) diet, Dysphagia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 call light (a device to alert nursing staff when a resident is in need) was within reach of one resident (Resident 1) out of a sample of four residents. This failure prevented Resident from communicating his care needs and had the potential to increase his anxiety (a feeling of fear, dread, and uneasiness). Findings: A review of Resident 1's admission record indicated, Resident 1 was originally admitted in February 2023 with multiple diagnoses which included, quadriplegia (the inability to use both arms, both legs, and the torso), tracheostomy (a surgical hole in windpipe for breathing), dependent on a ventilator (a machine that helps those who cannot breathe on their own), a voice disorder (inability to use voice to communicate), and an anxiety disorder. An interview on 9/21/23 at 10:23 a.m., CNA 1 stated its important to ensure call lights are in reach of the residents. CNA 1 added if a call light is not in reach the resident could get agitated and feel abandoned. During a concurrent observation…

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

Based on observation, interview, and record review, the facility failed to ensure proper garbage disposal, for a census of 85. This deficient practice had the potential of disease spreading among residents and visitors by vermin and pest infestation. Findings: In an observation on 7/27/21 at 9:35 a.m., two outdoor trash dumpsters in the parking lot were overflowing to the point where lids could not be closed. Approximately 15 white plastic garbage bags were also on the ground around the bins. In a concurrent interview with the Dietary Supervisor (DS), she stated that the bins were regularly collected on Monday, Wednesday and Friday; the contractor did not collect the bins the previous day, Monday. During an interview on 7/28/21 at 12:59 p.m. with the Infection Preventionist, she stated they have had an increase in trash due to more residents on isolation precautions. She further explained she was concerned about infections (from biologic and food waste) coming back into the facility since nurses and staff walking through the parking lot can carry infectious material on their shoes.…

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

Based on observation, interview, and record review the facility failed to maintain food safety when: 1. Freezer 3 had ice build-up on the walls supporting the door; 2. An employee's facial hair was not fully restrained while working in the kitchen; 3. Plastic pans were stacked wet (wet nesting) in the ready to use area; and 4. A leaking pipe was in the walk-in refrigerator which stored food. These failures had the potential to cause food borne illness for 44 residents eating facility prepared meals. Findings: 1. During the initial kitchen tour on 7/27/21 at 8:20 a.m., freezer 3 (a reach-in, chest style freezer) was opened, revealing ice buildup on all four side walls that supported the door. This ice buildup was continuous and up to 1 inch (a unit of measure) in length. This freezer contained diced turkey, sliced turkey, chicken strips, chicken nuggets, and burgers. In an interview with the Maintenance Supervisor (MS) on 7/27/21 at 4:36 p.m., he stated he maintenance of the freezers are conducted monthly but was unable to provide documented evidence of when it was last done. He…

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

Based on interview and record review the facility failed to provide safe food storage of food brought for residents from outside sources nor did they have a mechanism to heat food for later use. This failure had the potential to prevent residents from receiving preferred foods for later enjoyment for the 44 residents eating facility prepared meals. Findings: During the initial tour on 7/27/21 at 10:23 a.m., the Dietary Supervisor (DS) stated residents may have food brought in from restaurants for immediate consumption but went on to explain the facility does not reheat or store resident food for later use. In an interview on 7/27/21 at 4:48 p.m., the Wound Care Nurse stated the facility does not have refrigerators on the nursing unit or in the resident's room to store resident food. She went on to explain, Residents may have food brought in, and if it is within their diet, the resident must eat the food right away as the facility does not store or heat up resident foods. A review of a facility policy titled Food for Residents From Outside Sources, dated 2018, indicated 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.

During a dining observation on 7/27/21 between noon and 1:00 p.m., residents were not offered hand washing or sanitizer prior to eating their meal. In reviewing resident trays, sanitizing wipes were not on the meal tray for personal hygiene. During a concurrent observation and interview on 7/27/21 at 12:53 p.m., the final tray was passed and again no hand hygiene was observed. CNA 4 started to feed the resident. When asked, she stated she had not washed the resident's hands or offered sanitizing gel prior to the meal. She then looked over the tray for a sanitizing wipe and concurred that there was not one. In an interview with the Infection Preventionist on 7/28/21 at 12:59 p.m., she stated residents should have their hands washed and dried prior to meals, as well as positioned in an appropriate position for eating. If a resident can get up, they should be encouraged to wash their hands with soap and water, for others we can use hand sanitizer. She further explained that keeping hands clean is one of the steps taken to avoid getting sick and spreading germs to others. A review of a…

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

Based on interview and record review, the facility failed to ensure care plans were implemented for: the use of a low air loss (LAL, pressure reducing) mattress, repositioning every two hours, and elbow and knee splints for one resident (Resident 30) for a census of 85. These failures had the potential to cause a decline in Resident 30's range of motion and reopening and development of pressure ulcers. Findings: A review of an admission record indicated Resident 30 was admitted to the facility in November 2016 with diagnoses including quadriplegia (partial or complete paralysis of both the arms and the legs) and persistent vegetative state. Review of a MDS (Minimum Data Set, an assessment tool), dated 5/12/21, indicated Resident 30 was totally dependent on and required two or more staff for physical assistance. It also indicated Resident 30 did not have any skin ulcers and was receiving a pressure reducing device for a chair and bed; was in a turning/repositioning program; and required the application of nonsurgical dressings. A review of Resident 30's progress note, dated 6/13/21,…

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

Based on interview and record review, the facility failed to ensure Restorative Nursing Services [person-centered nursing care designed to improve or maintain the functional ability of residents] were provided as scheduled for one resident (Resident 30), for a census of 85. This failure had the potential for a further reduction in range of motion for Resident 30. Findings: A review of an admission record indicated Resident 30 was admitted to the facility in November 2016 with diagnoses including quadriplegia (partial or complete paralysis of both the arms and the legs) and persistent vegetative state. Review of a MDS (Minimum Data Set, an assessment tool), dated 5/12/21, indicated Resident 30 was impaired in functional range of motion in both arms and legs. A review of Resident 30's care plan, revised 5/4/21, indicated, Resident is at risk for decline in ROM [Range of Motion] and/or functional mobility . Interventions/Tasks [for staff to implement] .RNA [Restorative Nurse Assistant] to apply bilateral knee extension splints for up to 4 hours or as tolerated [daily] 5 [times] a week…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident (Resident 48) maintained the resident's desired weight, for a census of 85. This deficient practice placed the resident at risk for negative physical and psychosocial effects of undesired weight loss. Findings: A review of an admission record indicated Resident 48 was admitted in August of 2019 with diagnoses of dysphagia (difficulty swallowing) and required tube feedings (formula feedings via a tube directly to the stomach) to maintain nutritional status. In an interview on 7/28/21 at 8:24 a.m., Resident 48 reported weight loss over the past two months which left Resident 48 weak. Resident 48 denied desiring the weight loss and preferred to weigh around 200 pounds (lbs). Resident 48 believed the weight loss was related to staff having forgot to start his tube feeds. A record review indicated Resident 48 weighed 197 lbs upon admission and currently weighed 182 lbs on 7/5/21. In an interview with the Registered Dietitian (RD) on 7/29/21 at 2:30 p.m., the RD stated she was not aware of Resident 48'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, record and policy review, the facility failed to ensure a safe enteral feeding (tube feeding, delivery of nutrients through a feeding tube directly into the stomach) was performed for two residents (Resident 45 and Resident 74), for a census of 85, when: 1. Resident 45's head of bed was not elevated at least 30 degrees during the tube feeding; and 2. Resident 74's feeding tube formula was not correctly labeled nor the tubing dated. These failures increased the potential to result in aspiration (when liquid enters the airway or lungs) and incorrect labeling. Findings: 1. A review of an admission record indicated Resident 45 was admitted in February 2021 with diagnoses including dysphagia (difficulty swallowing). A review of Resident 45's order summary report, dated 7/30/21, indicated, an active physician's order for the head of the bed to be elevated 30 degrees at all times starting on 2/21/21. A review of a Physician/NP (Nurse Practitioner)/ PA (Physician Assistant) progress note, dated 7/26/21 at 11:37 a.m., indicated, .[Resident 45] has a PEG [type…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nursing care designed to improve or maintain the functional ability of residents was provided as scheduled for one resident (Resident 30), for a census of 85. This failure had the potential for Resident 30 to develop contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: A review of an admission record indicated Resident 30 was admitted to the facility in November 2016 with diagnoses including quadriplegia (partial or complete paralysis of both the arms and the legs) and persistent vegetative state. Review of a MDS (Minimum Data Set, an assessment tool), dated 5/12/21, indicated Resident 30 was impaired in functional range of motion in both arms and legs. A review of Resident 30's care plan, revised 5/4/21, indicated, Resident is at risk for decline in ROM [Range of Motion] and/or functional mobility . Interventions/Tasks [for staff to implement] .RNA [Restorative Nurse Assistant] to apply bilateral knee extension splints for up to 4…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record and policy review, the facility failed to ensure the Emergency kit (E-kit, a limited amount of medications for use in an emergency) was replaced after medication removal within the required timeframe, for a census of 85. This failure decreased the facility's ability to have medications available during an emergency. Findings: An inspection of the medication room in Station 1 was conducted on 7/28/21 starting at 2:42 p.m. with the Assistant Director of Nursing (ADON). The Intravenous (IV, medications to be given through a vein) E-kit had a red seal and the ADON confirmed the E-kit was previously opened. In a concurrent interview and record review on 7/29/21 at 11:40 a.m., the ADON confirmed a medication was taken out from the IV E-kit on 7/24/21 and the E-kit was not replaced within 72 hours. The ADON stated her expectation was for nurses to follow-up with the pharmacy when replacement was not received as scheduled. In a telephone interview on 7/30/21 at 1:38 p.m., the Pharmacy Consultant (PC) stated once the E-kit was opened, the licensed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 wound solution (used for cleansing, irrigating, moistening and gentle removal of unhealthy tissue) was properly labeled, for a census of 85. This failure had the potential to cause cross contamination and increase the risk of infection. Findings: An inspection of the medication cart #3 was conducted on 7/29/21 starting at 2:44 p.m. with Licensed Nurse 1 (LN 1). The LN 1 confirmed the observation of an opened and unlabeled wound solution in the bottom drawer with approximately 100 milliliters (ml, unit of measure) of fluid remaining in a 475 ml bottle. The LN 1 was unaware which resident the solution was used for. In a telephone interview on 7/30/21 at 1:38 p.m., the Pharmacy Consultant (PC) stated if the wound solution was supplied by the pharmacy, it should have a label with the residents' name on the bottle. In an interview on 7/30/21 at 5:05 p.m., the Director of Nursing (DON) stated the facility did not know for which resident the unlabeled and undated wound solution was used for. A review 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.