The Grove Post-Acute

Based on observation, interview, and record review, the facility failed to notify the RP (Responsible Party) of the transfer and the reason for the transfer for one resident (Resident 132) out of 32 sampled residents. This failure increased the risk for Resident 132's RP not be informed of the resident's discharge rights. Findings: Review of Resident 132's admission record indicated Resident 132 was admitted in December 2024 with several diagnoses including memory deficit following other cerebral vascular disease (memory problems caused by inadequate blood flow in parts of the brain) and dementia (a progressive decline in mental abilities). Review of Resident 132's Minimum Data Set (MDS, a federally mandated assessment tool) dated 12/13/24, indicated Resident 132 had severely impaired cognition. Review of Resident 132's Nurse's Notes dated 12/13/24, indicated, Resident sent to ER [emergency room] due to disturbing behaviors. During a concurrent observation and interview on 3/7/25 at 9:02 a.m. with the Director of Nursing (DON), the DON confirmed that there was no documentation that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 timely submit a Minimum Data Set (MDS, a federally mandated resident assessment tool) for one of 32 sampled residents (Resident 119) when the discharge assessment was not completed and transmitted according to the required regulatory time frame. This failure had the potential to result in incomplete information being submitted to Centers for Medicare and Medicaid Services (CMS). Findings: A review of Resident 119's admission record indicated she was admitted to the facility on 9/2024 and discharged on 10/4/24. In a concurrent interview and record review on 3/6/25 at 11:08 a.m., with the MDS Coordinator 1 (MDSC 1), Resident 119's MDS assessments were reviewed. MDSC 1 confirmed Resident 119's discharge assessment was completed and transmitted more than 14 days from the date of discharge. In an interview on 3/7/25 at 8:35 a.m. with the Director of Nursing (DON), the DON stated she expected the MDSC 1 to follow the required timeframes for MDS submission. A review of the facility's policy titled MDS Completion and Submission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 32 sampled residents (Resident 125) had a PASARR (Pre admission Screening and Resident Review, a federal requirement to ensure individuals with serious mental illness, intellectual disability, or other related conditions are not inappropriately placed in nursing homes for long term care and receive services in the most integrated setting) completed. This failure had the potential for the facility not to provide or seek appropriate mental health services for Resident 125. Findings: A review of Resident 125's admission Record indicated Resident 125 was admitted to the facility in December 2024 with multiple diagnoses including Major Depressive Disorder ( a common and serious condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life). During a review of Resident 125's medical record, under PASARR, the document titled DHCS[Department of Health Care Services], dated 12/13/2024 indicated, . If the individual remains in the NF[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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3b. A review of the admission Record indicated Resident 115 was initially admitted [DATE] and recently admitted [DATE]. with diagnoses including Diabetes mellitus with diabetic neuropathy (nerve damage caused by high blood sugar levels). A review of Resident 115's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 1/17/25 indicated Resident 115 had moderate cognitive impairment with a score of 12 out of 15 in the Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident). A review of Resident 115's physician order dated 1/13/25 indicated, COMPRESSION SOCKS: CNA [Certified Nursing Assistant] to apply COMPRESSION SOCKS to BLE [bilateral lower extremities] during the day and remove at bedtime as tolerated . Further review of Resident 115's clinical records indicated the following: - admission H & P [History & Physical] dated 1/10/25 indicated, .Edema [swelling caused by excess fluid…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 promote safety measures for one of 32 sampled residents (Resident 50) when Resident 50's order for the use of wander guard (a device that allows sensors on doors to alarm to keep track of wandering residents) was not followed as ordered. This failure increased Resident 50's risk for elopement. Findings: A review of an admission record for Resident 50 indicated she was admitted in November 2024 with diagnoses including vascular dementia (a type of dementia caused by problems with blood flow to the brain affecting thinking, memory, and behavior). A review of Resident 50's Order Summary Report (OSR) dated 11/10/24 indicated an order to apply wander guard to the left arm/wrist and check placement every shift due to episodes of going out of the facility unassisted. During observations on 3/4/25 at 11:50 a.m., 3/5/25 at 1:45 p.m., and 3/6/25 at 9 a.m., Resident 50 was observed not wearing a wander guard. During a concurrent observation, interview, and record review on 3/6/25 at 10:28 a.m., with the Assistant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the pharmacy recommendations for one of 32 sampled residents (Resident 54) during a Medication Regimen Review (MRR) was communicated to the physician. This failure had the potential for Resident 54 to experience adverse effects from the medication. Findings: A review of the admission Record indicated Resident 54 was admitted [DATE] with multiple diagnoses including insomnia (trouble falling asleep or staying asleep). A review of Resident 54's Medication Administration Record (MAR, daily documentation record used by a licensed nurse to document medication and treatment given to a resident) included the following orders: -an order dated 4/4/24 for Melatonin (used to treat insomnia) 3 mg (milligram, unit of measurement) give 1 tablet by mouth for insomnia; -an order dated 4/4/24 for Melatonin 3 mg give 1 tablet by mouth as needed for insomnia. May give one additional tablet at bedtime, total of 6 mg per day; and, -an order dated 6/1/24 for…

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

Based on observation, interview, and record review the facility failed to ensure the medication error rate was less than five percent (5%) for a census of 132 when: 1. Licensed Nurse 1 (LN 1) did not follow the physician's order in administering Resident 13's prescribed medication; 2. Resident 115 was given another resident's supply of insulin glargine (long-acting insulin); and 3. Three of Resident 83's morning medication were combined and administered at the same time through the feeding tube with no regard for medication reactions (therapeutic response). These failures resulted in a medication error rate of 23.08% for the facility. Findings: 1. A review of an admission record for Resident 13 indicated he was admitted to the facility in December 2009 with diagnoses including hyperlipidemia (high cholesterol, too much fat in the blood). In an observation on 3/4/25 at 8:50 a.m., during Medication Administration with LN 1, LN 1 was observed preparing Resident 13's morning medications, LN 1 scooped a teaspoon (tsp., unit of measurement) of psyllium powder (used for constipation) 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 one resident (Resident 115) for a census of 132 was free from significant medication error when Resident 115 was administered another resident's insulin. This failure increased Resident 115's risk for receiving the wrong medication and complications of diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) including diabetic coma. Findings: A review of Resident 115's admission Record indicated he was admitted in January 2025 with diagnoses including Type 1 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of an Order Summary Report (OSR) for Resident 115 dated 2/27/25 indicated an order for insulin glargine, inject 22 units subcutaneously (SQ, under the skin) daily in the morning. On 3/4/25 the following concurrent observations and interviews were conducted with Licensed Nurse 2 (LN 2): - At 9:45 a.m., LN 2 checked Resident 115's blood sugar level, LN 2 stated it was 375; - At 9:50 a.m., LN 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 update the medication label for one (Resident 115) out of a census of 132 when Resident 115's insulin glargine (long-acting insulin) order was changed. This failure increased the potential for unsafe administration of medication to residents. Findings: A review of Resident 115's admission Record indicated he was admitted in January 2025 with diagnoses including Type 1 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of an Order Summary Report (OSR) for Resident 115 dated 2/27/25 indicated an order for insulin glargine, inject 22 units subcutaneously (SQ, under the skin) daily in the morning. In a concurrent observation and interview on 3/4/25 at 9:50 a.m., during Medication Administration with Licensed Nurse 2 (LN 2), LN 2 withdrew 22 units of insulin glargine from the vial, LN 2 stated the order for Resident 115 had been changed to 22 units daily in the morning . LN 2 confirmed the dosage [27 units] written on the label in the insulin vial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services furnished by outside resources had written agreements when two of 32 sampled residents' (Resident 56 and Resident 96) dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed) services were provided without existing agreements with dialysis clinic. This failure had the potential to result in the lack of responsibility and accountability in the dialysis services received by Resident 56 and Resident 96. Findings: 1a. A review of the admission Record indicated Resident 56 was initially admitted [DATE] with diagnoses including end stage renal disease (ESRD, irreversible kidney failure) and dependence on renal dialysis. A review of Resident 56's physician order dated 12/3/24 indicated, DIALYSIS: Hemodialysis [Dialysis company name and address] .Schedule: (Monday, Wednesday, Friday) . 2a. A review of the admission Record indicated Resident 96 was initially admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an effective infection control program, for a census of 132, when: 1. Personal Protective Equipment (PPE-clothing and equipment that is worn or used for for protection against hazardous substances and or environments) was not contained properly in the trash for Resident 15; 2. The Licensed Nurse 2 (LN 2) did not perform safe administration of insulin for Resident 115; and, 3. Resident 46's nebulizer (machine that turns liquid medication into an inhalable mist through a connected mouthpiece that allows the medication to enter the lungs directly) tubing was not changed as scheduled and the incentive spirometer (a handheld plastic device that helps exercise the lungs and breathe deeply) was not stored appropriately. These failures increased the risk of spreading infections and or transmission of diseases to the vulnerable residents residing in the facility. Findings: 1. Review of Resident 15's admission record indicated Resident 15…

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

Based on observation, interview, and record review, the facility failed to maintain a homelike environment for one of 32 sampled residents (Resident 99) when a patio door was in disrepair. This failure had the potential to minimize Resident 99's psychosocial well-being and made the resident feel uncomfortable. Findings: A review of Resident 99's admission Record indicated Resident 99 was admitted to the facility in September 2024 with multiple diagnoses including muscle weakness, difficulty walking, and depression (a mental health condition characterized by persistent sadness, loss of interest, and low energy that can significantly interfere with daily life). A review of Resident 99's Minimum Data Set (MDS- a federally mandated assessment tool), Cognitive Patterns, dated 12/30/24, indicated Resident 99 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 12 out of 15 that indicated Resident 99 had moderate cognitive impairment. During a concurrent observation and interview on 3/4/25 at 8:29 a.m. in Resident 99's room, a shattered glass patio door with…

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

Based on interview and record review, the facility failed to report an incident of an injury of unknown origin timely for one of three sampled residents (Resident 1) as required by the regulations. This failure resulted in a delay in the investigation process and decreased the facility's potential to protect patients from physical and psychosocial harm. Findings: During a review of Resident 1's admission records, the records indicated Resident 1 was admitted in October 2023 with diagnoses that included pathological fracture (broken bone caused by disease) of right humerus (upper arm bone), displaced oblique fracture (diagonal break in the bone) of shaft of humerus (long middle portion of the upper arm bone) of right arm, and dementia (group of symptoms affecting memory, thinking and social abilities). Residents 1's Minimum Data Set (MDS, an assessment tool) indicated Resident 1 had severe cognitive impairment. During a review of Resident 1's nurses notes, dated 6/19/24 at 1:05 p.m., the notes indicated, CNA [Certified Nursing Assistant] reported that res [resident] has R [right] arm…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Minimum Data Set (MDS, an assessment tool) for one of three sampled residents (Resident 1) accurately reflected Resident 1 ' s behavioral symptoms when her MDS Section E Behavior was not accurately documented. This failure had the potential to result in Resident 1 not receiving interventions to improve behavioral symptoms and placed Resident 1 at risk for injury. Findings: During a review of Resident 1 ' s admission records, the records indicated Resident 1 was admitted in October 2023 with diagnoses that included pathological fracture (broken bone caused by disease) of right humerus (upper arm bone), displaced oblique fracture (diagonal break in the bone) of shaft of humerus (long middle portion of the upper arm bone) of left arm, and dementia (group of symptoms affecting memory, thinking and social abilities). Residents 1 ' s Minimum Data Set (MDS, an assessment tool) indicated Resident 1 had severe cognitive impairment. During a review of Resident 1 ' s quarterly MDS Section E, dated 4/16/24, the section…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three sampled residents (Resident 1 and Resident 2) were free from physical abuse when Resident 1 and Resident 2 were in a physical altercation that resulted in Resident 1 sustaining a skin tear on her right forearm and discoloration on her right upper arm. This failure had the potential to result in serious physical injuries for Resident 1 and Resident 2. Findings: A review of a facility document titled admission Record, indicated Resident 1 was admitted to the facility in 2023 with diagnoses including depression and anxiety disorders. Review of Resident 1 ' s Minimum Data Set (MDS, an assessment tool), dated 2/6/24, indicated Resident 1 had a Brief Interview of Mental Status (BIMS) score of 11 out of 15, which indicated moderate cognitive impairment. Review of Resident 1 ' s medical record titled, SBAR [Situation, Background, Assessment, Recommendation] and Initial COC [Change of Condition]/Alert charting and Skilled Documentation,…

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

Based on interview and record review, the facility failed to report immediately to officials an alleged violation involving physical abuse between two residents (Resident 1 and Resident 2) of three sampled residents, when the Department received the report of alleged violation greater than two hours after the incident's occurrence. This failure decreased the facility's potential to protect vulnerable residents and provide a safe environment. Findings: Review of Resident 1's note titled, IDT [Interdisplinary Team] - Grievance Investigation, intervention/s and Resolution, dated 5/2/24, indicated Resident 1 reported on 5/1/24 around 8 p.m. that her roommate struck the front of her right arm causing a skin tear and discoloration, as well as discoloration on her right upper arm. Review of Resident 2's note titled, IDT - Grievance Investigation, intervention/s and Resolution, dated 5/2/24, indicated, [Resident 1] .was swinging her arms .and hitting [Resident 2] .and [Resident 2] pushed [Resident 1] . The IDT note further stipulated that both residents were interviewed, and both parties…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, comfortable, and homelike environment was provided when: 1. One of 32 sampled residents (Resident 106) low air loss mattress (LAL, a pressure relieving and redistribution device to help prevent skin breakdown) was not in good working condition; and 2. Five of 12 sampled rooms had holes and peeling paint on the walls. This failure increased the risk for Resident 106 to develop skin breakdown and the disrepair in the rooms may negatively impact the well being of residents. Findings: 1. A review of the clinical record indicated Resident 106 was admitted early September of 2023 with diagnoses including difficulty in walking and low back pain. Resident 106's physician order dated 12/14/23 indicated, TREATMENT: LAL (Low air loss) Mattress for wound management/preventative measures. Check placement, SETTING and functionality QS [every shift]. A review of Resident 106's care plan indicated resident was at risk for skin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administer appropriate treatment and services to maintain continence for one of 32 sampled residents (Resident 47), who was assessed as a candidate for bladder retraining and the bladder retraining was not provided. This failure resulted in Resident 47 not receiving the services and assistance to maintain her continence and resulted in decline of resident's continence. Findings: A review of the admission Record indicated the facility admitted Resident 47 in 2023 with multiple diagnoses which included muscle weakness and difficulty in walking. A review of the quarterly Minimum Data Set (MDS, an assessment tool) completed 1/31/24, indicated that Resident 47 scored 11 out of 15 on a BIMS assessment (Brief Interview of Mental Status, a test of cognition) indicating the resident's cognition was moderately impaired. The MDS indicated Resident 47 exhibited no indications of psychosis, such as hallucinations (sensory experience of something not present), delusions (an impression or belief not based in reality), 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 its pharmaceutical policies and procedures for a census of 120, when: 1. Two used and unsealed E-Kit boxes (Emergency-Kit, storage box containing emergency supplies of medication) were not removed and replaced with the potential for not having all the emergency medications available to the residents and increased risk of drug diversion; and 2. Resident 433's intravenous (IV, medication given through the vein) antibiotics (medication that treat bacterial infections) was not administered per physician's order with the potential for his infection not to be resolved. Findings: 1. During an inspection of medication room for units 4 and 5 on 4/9/24 at 2:10 p.m., E-kit #3 was found to be previously opened with missing 1 out of three medications. There was no record when the missing medication was taken out of the E-kit. E-Kit #16 was accessed on 2/16/24 with missing 1 out of four medications, but still not replaced by the pharmacy. During an interview on 4/9/24 at 2:10 p.m. with Infection Preventionist…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 32 sampled residents (Resident 107), was free from unnecessary drugs when Resident 107 did not have adequate indication for the use of Seroquel (a psychotropic medication indicated for psychosis; affects the mind, emotions, and behavior). This failure resulted in Resident 107 receiving unnecessary medication for an excessive duration and placed the resident at risk for adverse (unwanted) effects and further decline in health. Findings: A review of the admission record indicated the facility admitted Resident 107 in the fall of 2023 with diagnoses which included dementia (a decline in memory and social skills that interfere with daily functioning) without behavioral, psychotic, and mood disturbances. A review of the Minimum Data Set (MDS, an assessment tool), dated 1/17/24, indicated Resident 107 was cognitively impaired. The MDS indicated the resident did not exhibit any verbal or physical symptoms toward others and had no behaviors of causing self injury. The MDS indicated the resident had no…

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

Based on observation, interview, and record review the facility failed to properly store medications for a census of 120, when: 1. Two expired medications were found in the medication refrigerator, which could lead to the resident receiving expired or ineffective medication; 2. Three loose pills were found in a medication cart, which could result in diversion of the loose medication; and 3. Two prescription blister packs were found displaced and stuck in the back of the medication cart, which could result in drug diversion. Findings: 1. During an observation of medication storage room for units 2 and 3 on 4/9/24 at 11:15 a.m., two expired ertapenem intravenous medication bags (an antibiotic medication used to treat infections) were found in the medication refrigerator with an expiration date of 4/7/24 on the label. During an interview with Licensed Nurse (LN) 1 on 4/9/24 at 11:17 a.m., LN 1 acknowledged the medication bags were expired. LN 1 stated expired medications should have been removed. During an interview with the Director of Nursing (DON) on 4/11/24 at 1:05 p.m., the DON…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 foods that conserved nutritive value, flavor, and palatability when vegetables and pureed meals were prepared without following the recipe with measured ingredients. This failure had the potential of leading to poor intake, malnutrition, and weight loss for the 117 residents eating facility prepared meals. Findings: During an observation on 4/10/24 at 10:54 a.m., in the kitchen, [NAME] 1 (CK 1) was observed preparing stir fry vegetables for lunch. After placing the vegetables into the steam pan, CK 1 was observed adding unmeasured garlic powder and salt to the vegetables by pouring into her gloved hand and proceeding to add to the mixture. During an interview on 4/10/24 at 4:20 p.m. with the Registered Dietitian (RD), the RD stated, The recipe should be followed. It should be measured, it could be salty or not salty enough. During a review of the facility provided recipe titled, RECIPE: STIR FRY VEGETABLES (Healthcare Menus Direct, LLC. 2024), the recipe indicated, Ingredients .Salt, Serves 120, 1Tbsp…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 store, prepare, and distribute food in accordance with professional standards for food service safety for a total of 117 residents who received facility prepared foods when: 1. Food labeling not followed; 2. Expired foods not discarded; 3. Egg and tuna salad not kept in safe food temperature range; 4. Freezer door frame had ice build-up suggesting temperature fluctuations; 5. Ice build-up on food items stored in reach-in freezer; 6. Can opener had missing metal from the cutting tip; 7. Dust, dirt, and food debris in kitchen areas including dry food storage, refrigerator and under the stove; 8. Box of lentils was left open to air; 9. Improper use of thermometer during food temperature check; and 10. Wet pans on storage, and wet, stained blender container. These failures had the potential to lead to food borne illness. Findings: 1. During an observation on 4/9/24, within the initial kitchen tour beginning at 8:34 a.m., the following items were observed not having proper labeling: - Eight bowls of undated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide rehabilitation services for one of 32 sampled residents (Resident 4), when Resident 4 did not receive physical therapy (PT) evaluation and treatment as ordered by the resident's physician. This failure prevented Resident 4 from attaining and maintaining the highest practicable functional level and had the potential to result in further decline of Resident 4's mobility. Findings: A review of the admission Records indicated that the facility admitted Resident 4 in 2022 with multiple diagnoses which included high blood pressure and heart disease. Resident 4 was admitted while receiving hospice services which was revoked on 12/28/23. A review of Resident 4's history and physical indicated the resident had a history of multiple falls and the last fall resulted in a right femur (thigh bone) fracture. Resident 4's clinical records indicated the resident was readmitted from the hospital on [DATE] with non-weight bearing status (not allowed to put any…

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

Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were followed when, 1. A blood pressure monitor (device used to measure blood pressure) was not disinfected according to manufacturer's instructions after being used during medication pass observation, and 2. A laundry room exhaust fan located above the clean linen area was coated with thick, sticky substance. These failures had the potential to transmit pathogens or bodily fluids for 120 residents residing in the facility. Findings: 1. During a medication pass observation with Licensed Nurse (LN) 1 on 4/9/24 at 8:30 a.m., LN 1 used a blood pressure monitor to measure a resident's blood pressure inside the resident's room. The blood pressure monitor was then taken out of resident's room and parked outside in the hallway without being cleaned and disinfected. LN 1 moved on to the next patient on the list for morning medication pass. During an interview with LN 1 on 4/9/24 at approximately 11:15 a.m., LN 1 acknowledged that the blood pressure monitor and cuffs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 discharge MDS (Minimum Data Set, an assessment tool) assessment was completed and transmitted to the Centers for Medicare and Medicaid Services (CMS) System within the required time frame for one resident (Resident 112), for a census of 120. This failure resulted in the most recent MDS resident assessment not being reported to CMS as required. Findings: A review of Resident 112's clinical record indicated, he was admitted to the facility late 2023 with multiple diagnoses that included essential hypertension (high blood pressure). A review of Resident 112's NOTICE OF TRANSFER/ DISCHARGE indicated, Resident 112 was discharged from the facility on 12/6/23. During a concurrent interview and record review on 4/12/24 at 8:51 a.m., the Minimum Data Set Coordinator (MDSC) verified Resident 112 had no MDS discharge assessment. She stated the discharge assessment was missed and she was not able to complete the assessment on time. She further stated the discharge assessment was supposed to be completed within 14 days of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool used to guide care) for one of 32 sampled residents (Resident 52) accurately reflected Resident 52's Physician's Order for Life Sustaining Treatment (POLST) when her MDS Section S RESIDENT ASSESSMENT AND CARE SCREENING was not accurately documented. This failure had the potential to result in Resident 52 receiving interventions that were contrary to his own choices. Findings: A review of Resident 52's clinical record indicated, he was admitted to the facility early 2024 with multiple diagnoses that included acute paralytic syndrome (weakness that progresses) following cerebral infarction (blood vessel in the brain is blocked or narrowed, causing lack of blood flow to a part of the brain). A review of Resident 52's POLST dated, [DATE] and [DATE] indicated the following: Section A Cardiopulmonary Resuscitation Section (CPR, emergency procedure that combines chest compressions and artificial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 refer one (Resident 22) of 32 sampled residents for Pre-admission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) when the resident received a new mental illness diagnosis. This failure had the potential for Resident 22 to not receive necessary services to meet his mental and psychosocial needs. Findings: A review of Resident 22's clinical record indicated he was admitted to the facility late 2011. His clinical record also indicated he had a diagnosis of Schizoaffective disorder, unspecified (mental illness that affects thought, mood and behavior) with onset date of 11/24/21 and Major Depressive disorder (mood disorder that causes persistent feeling of sadness), single episode with onset date of 8/28/17. During a concurrent interview and record review on 4/10/24 at 10:06 a.m., the Medical Records Director (MRD) verified Resident 22's PASRR Level I assessment was done on 10/24/11 and the form indicated, No…

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

Based on observation, interview, and record review, the facility failed to ensure a comprehensive care plan for refusing nail care was developed for one of 32 sampled residents (Resident 20). This failure had the potential for Resident 20 to spread infection and inflict injury to self due to long fingernails. Findings: A review of the clinical record indicated Resident 20 was admitted with diagnoses that included hemiplegia and hemiparesis (paralysis or muscle weakness on one side of the body) following unspecified cerebrovascular disease (a condition wherein blood flow to the brain was interrupted) affecting right dominant side. Resident 20's Minimum Data Set (MDS, an assessment tool) dated 3/8/24, indicated Resident 20 was cognitively intact with a Brief Interview for Mental Status (BIMS, a tool used to screen cognitive ability) score of 14. A concurrent observation and interview was conducted on 4/9/24 starting at 2 p.m. Resident 20 was observed with fingernails on the left hand approximately 3 inches in length starting to curl and the fingernails on the right hand with blackish…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 32 sampled residents (Resident 20) who was dependent on staff to perform activities of daily living (ADLs, daily activity such as self care including personal hygiene) received the necessary nail care. This failure had the potential for Resident 20 to spread infection and self inflicted injury due to long fingernails. Findings: A review of the clinical record indicated Resident 20 was admitted with diagnoses including hemiplegia and hemiparesis (paralysis or muscle weakness on one side of the body) following unspecified cerebrovascular disease (a condition wherein blood flow to the brain was interrupted) affecting right dominant side. Resident 20's Minimum Data Set (MDS, an assessment tool) dated 3/8/24 indicated Resident 20 was cognitively intact with a Brief Interview for Mental Status (BIMS, a tool used to a screen cognitive ability) score of 14 and he was dependent on staff for personal hygiene. A concurrent observation and interview was conducted on 4/9/24 starting at 2 p.m. Resident 20 was…

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

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and assistive devices were provided for 2 of 32 sampled residents (Resident 87 and Resident 90) when: 1. Resident 87 had a fall with a facility staff present; and 2. Resident 90 had an unwitnessed fall. These failures had the potential for Resident 87 and Resident 90 to have increased incidences of fall and injury. Findings: 1. A review of the clinical record indicated Resident 87 was admitted with diagnoses that included encounter for surgical aftercare following surgery on the nervous system (includes the brain and spinal cord) and history of falling. The Minimum Data Set (MDS, an assessment tool), dated 2/5/24, indicated Resident 87 had short term and long term memory problems and required the assistance of 2 or more staff to walk at least 10 feet in a room. Further review of the clinical record indicated Resident 87 had a Fall Assessment, dated 1/29/24, that indicated Resident 87 was a high risk for falls with a score of 55. A care plan, dated 1/29/24, indicated Resident 87 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide one of 32 sampled residents (Resident 97), who was identified at risk for dehydration with sufficient fluids to maintain proper hydration, when Resident 97 did not meet her estimated fluid needs as assessed by the Registered Dietitian. This failure placed Resident 97 at further risk for dehydration. Findings: A review of the admission Record indicated the facility admitted Resident 97 last year with multiple diagnoses, which included dementia (impaired ability to remember, think and make decisions) and chronic mental disorders. A review of Resident 97's Minimum Data Set (MDS, an assessment tool), dated 2/21/24, indicated the resident had severe cognitive impairment. A review of the physician's order, dated 3/1/23, indicated Resident 97's diet consisted of mechanical soft (texture -modified diet, designed for residents who have difficulty chewing and swallowing) and thickened fluids. A review of the care plan titled, Alteration in…

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

Based on observation, interview, and record review, the facility failed to administer oxygen therapy in accordance with the physician's order and the resident's care plan for one of 32 sampled residents (Resident 80), when Resident 80 did not receive the prescribed amount of oxygen. This failure resulted in Resident 80 receiving more oxygen than ordered by the physician and had the potential for the resident to experience serious health complications related to too much supplemental oxygen. Findings: A review of the admission Record indicated the facility admitted Resident 80 in 2021 with multiple diagnoses, including Chronic Obstructive Pulmonary Disease, (COPD, a chronic lung disease causing airflow blockage and breathing problems) and respiratory failure. A review of the physician's order, dated 12/14/23 indicated, Oxygen at 2 L/min [liters - a unit of measurement/minute] continuous via Nasal Cannula [NC, a thin plastic tube with two prongs to deliver supplemental oxygen directly into nostrils]. Maintain O2 [oxygen blood saturation level] above 92% (for COPD 89% and above). 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 provide adequate supervision to ensure the safety for one of four residents identified at risk for wandering (Resident 1) when he left the facility unsupervised, wandered to a busy street, was found by fire department, and the resident was brought back to the facility. This failure had the risk potential to jeopardize Resident 1's health and safety. Findings: According to Resident 1's 'admission Record,' he was admitted by the facility recently with multiple diagnoses which included Neurocognitive disorders with Lewy bodies( Lewy body dementia is a disease which can lead to problems with thinking, movement, behavior, and mood) , Schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly) and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). Resident 1 scored 13 out of 15 in a Brief Interview for Mental Status (BIMS, a tool that tests memory and recall) contained in his MDS (Minimum Data Set, an assessment tool)…

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