Bridgeview Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the risk and benefits of bed rails ( bed canes - safety device placed on the side of the bed used to help people with mobility issues move) for two of five sampled residents (Resident 10, Resident 14), when Resident 10 and 14 were using bed rails and did not have a bed safety assessment completed. This failure had the potential to put residents at risk for entrapment, accidents, and injuries.Findings: During a review of the facility policy titled Bed Safety and Bed Rails, dated 8/2022 indicated that bed rails come in different types, shapes and sizes and that the use of bed rails or side rails is prohibited unless the criteria for the use of bed rails has been met. The criteria includes attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. The resident assessment determines the risk for entrapment, accidents and hazards, mobility restrictions, and psychosocial outcomes. During a…

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

Based on observation, interview, and record review, the facility failed to ensure that their emergency drug kits (E-kit) had accurate or complete record keeping, when 1 of 4 antibiotic tablets was found to be unaccounted for. This failure had the potential for medications to be potentially lost or diverted without documentation. Findings:A review of facility policy titled Medication ordering and receiving from pharmacy: 1C5: Emergency Pharmacy Service and Emergency Kits, dated 8/2014, indicated, The nurse records the medication use from the emergency kit on the medication order/use form and Calls the pharmacy for replacement of the kit/dose and/or flags the kit with a color-coded lock to indicate need for replacement of kit/dose as soon as possible after the medication has been administered.During an inspection of the facility's medication storage room on 1/6/26 at 10:32 am, the emergency supply kit (a locked, specialized container or electronic cabinet that holds a small supply of critical medications, and allows staff to access and give medications without waiting for delivery)…

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 that Pharmacy staff were conducting accurate Medication Regimen Reviews for 1 of 34 sampled residents, when Resident 8 was found to have unnecessary medication prescribed for an incorrect diagnosis for 3 months. This failure had the potential to harm residents when medications were not monitored by pharmacy. Findings:A review of facility policy titled, Medication Monitoring & Management, dated 8/2014, indicated, When a resident receives a new medication, the medication order is evaluated for the following . A written diagnosis, an indication, and/or documented objective findings support each medication. This policy also showed The interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication-related problems (on an ongoing basis).A review of Resident 8'S medical records titled admission Summary, indicated that Resident 8 was admitted to the facility on [DATE] with diagnoses included Unspecified…

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 that medications were stored at the correct temperatures. This failure had the potential for medications to not be therapeutically effective. Findings:A review of facility policy titled Medication Storage in the facility, dated 8/2014, showed Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.During an observation of Medication Storage room [ROOM NUMBER] on 1/6/26 at 10:32 am, two types of rectal suppository medications were found inside the refrigerator, which had a reading of 34 degrees Fahrenheit. These medications were found to be:1) Acetaminophen (a medication used to treat fevers and mild to moderate pain) Suppository (a dissolving capsule inserted into the rectum, and releases medication), 650 milligrams (MG); packages for two residents found.A review of Manufacturer's Specifications for acetaminophen suppository, indicated Store at 20-25…

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, record review, and policy review, the facility failed to ensure two of seven sampled residents (Resident 13, and Resident 65) medical records contained accurate documentation when their Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) inaccurately indicated that Resident 13 and Resident 65 had advance directives (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated [inability to make decisions]).These failures had the potential to result in delays or inaccuracies in Resident 13, and Resident 65's wishes being carried out if they were incapacitated.Findings: Review of a facility policy titled Advance Directives revised September 2022, indicated that Determining existence of advance…

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 records review, the facility failed to report a major injury for one of three sampled residents (Resident 4), when Restorative Nursing Assistant H (RNA H) left Resident 4 alone outside on a patio for 30 minutes, where Resident 4 fell and sustained a subdural hematoma (bleeding between the brain and its lining) This failure resulted in delaying an investigation into a major injury, and had the potential for other incidents not to be reported. FindingsDuring a review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.19.1, page J-26, dated [DATE]. The CMS document defined Major Injury as Including bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma. During a review of facility policy titled Assessing Falls and Their Causes, revised [DATE], the policy indicated that the facility should attempt to identify the cause of a fall, and Within 24 hours of a fall,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to honor an activity preference that was developed in the activity care plan for one of three residents (Resident 1).This failure had the potential for Resident 1's mental and psychosocial needs not to be met.Findings:A review of a facility policy titled Activity Programs revised June of 2018, indicated activity programs are designed to meet the Interests of and support the physical, mental and psychosocial well-being of each resident. The Activities Program is provided to support the well-being of residents and to encourage both Independence and community interaction. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. The Activities Program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities. Activities are considered any endeavor, other than routine ADLs, in which the resident participates, that is…

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 that direct care staff had competencies necessary to care for one out of three sampled residents (Resident 4) when Restorative Nursing Assistant H (RNA H) left Resident 4 alone on a patio for 30 minutes, where Resident 4 fell and sustained a major head injury. This deficient practice resulted in Resident 4 experiencing a major head injury, admission to an acute care hospital, a decline in condition, and eventually death. This failure also had the potential for incompetent staff to care for other residents. FindingsDuring a review of records titled Restorative Nursing Assistant (RNA) Job Description, indicated that RNA H signed the document on 8/26/25, indicating they understood the duties and responsibilities outlined. The RNA Job Description indicated that RNA H's Duties and Responsibilities included Follow established safety precautions in the performance of all duties.Help residents to perform tasks for him/herself as appropriate as assigned…

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 report an abuse allegation for one of five sampled residents (Resident 4) when Resident 4 informed staff that they had been slapped in the face by another resident on 6/20/25. This failure had the potential to result in psychosocial and emotional harm for Resident 4 and had the potential to place all the residents at risk for undetected/unreported elder neglect or abuse.Findings:During a review of the facility's policy titled, Abuse Investigation and Reporting, revised 7/2017, indicated that:1. All reports and findings of resident abuse shall be reported to local, state and federal agencies, and thoroughly investigated by facility management.2. All alleged violations involving abuse will be reported by the facility Administrator to the state licensing/certification agency responsible for surveying/licensing the facility. During a review of Residents 4's admission record, indicated Resident 4 was admitted on [DATE] with diagnoses that included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) were free from accidents and hazards when: a) post fall evaluations did not determine the reason for the falls. b) residents care plan interventions were not reevaluated for effectiveness. c) new interventions were not developed prevent further falls and injuries. d) direct care staff did not know how to identify high risk fall residents and find their fall plan of care. This resulted in multiple repeated resident falls and had the potential for all residents to be at risk for fall/injuries. Findings: A review of the facility ' s policy titled Clinical Protocol for Falls, revised March 2018, indicated under: Treatment/Management 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its…

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, record review, and observation, the facility failed to meet this requirement when construction materials were improperly stored in the room of three residents (Residents 2, 3 and 4). This had the potential for accidents and hazards and created an environment that residents did not find home like. Findings: In an interview on 1/13/25 at 9:35 AM, Family Member 1 stated that her mother's room was set up for four residents, but the fourth bed area was taken up by piles of flooring material and adhesive or paint with a privacy curtain pulled around it. She stated that the materials were a tripping and hazard and made it difficult to clean the room thoroughly. In an interview on 1/15/25 at 10:00 AM, Facility Administrator A (FA) A stated that she was familiar with the situation with the storage of materials in room [ROOM NUMBER] of the facility. room [ROOM NUMBER] had been vacant, but then we needed the room and had no place to store the flooring. FA A stated that maintenance stacked the flooring…

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 safety and sanitation requirements were met in accordance with professional standards for food service safety when: 1. Food was not properly stored, labeled and dated, with expired food items present in kitchen refrigerator/freezers. 2. Kitchen and food service equipment was not in sanitary condition; 3. The kitchen environment was not in sanitary condition; 4. Resident food was not stored or labeled per policy and procedure (P&P) in the resident refrigerator/freezer, and the refrigerator was visibly dirty inside. These failures created the potential risk for exposure to food- and waterborne illnesses in a medically vulnerable population of 105 residents who receive food stored and prepared in the facility. Findings: 1. A review of P&P titled Refrigerators and Freezers, dated 12/2014, indicated the facility will: A. Ensure safe refrigerator/freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. B. Supervisors will be responsible for ensuring food items 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. A review of the facility's policy titled Resident Rights and Dignity revised February 2021, indicated Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation 11. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. A review of Resident 101's admission Record dated 5/28/24, indicated Resident 101 was admitted to the facility on [DATE] with diagnoses that included stroke (blood flow to the brain is blocked and some brain cells die causing disabilities), muscle weakness, difficulty in walking, and major depressive disorder. A review of Resident 101's Quarterly MDS dated [DATE], indicated Resident 101's BIMS score was 07, indicating Resident 101's cognition was severely impaired. Resident 101's Functional Abilities and Goals assessment indicated Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure allegations of abuse for three out of five sampled residents (Residents 22, 35, and 40) were investigated and residents were protected during this process when: 1. Certified Nurse Assistant (CNA) M did not report suspicions of abuse when CNA M noticed Resident 22 showed fear during care. 2. CNA J did not report an allegation made by Resident 40 that the Housekeeper (HSK) A instructed Resident 40 to clean her own toilet. 3. When facility staff did not report an allegation of staff to resident physical abuse, when CNA E held down Resident 35. This placed all residents at risk for staff to resident abuse and had the potential for physical and psychosocial harm. Findings: A review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, indicated, suspicion and allegations of abuse would be investigated, and residents would be protected from further abuse during the investigation. A review of the facility's policy titled Abuse,…

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 The facility failed to provide medically related Social Services, that met the needs of the residents, for four out of 22 sampled residents (Residents 35, 87, 90, and 98) when: 1. Social Service care plans (a document that described resident goals and the interventions [instruction, actions, education, and care required] that facility staff would utilize to assist in residents reaching their goals) were not updated quarterly (every 3 months) or as needed for Residents 87 and 90. 2. Care conference meeting (meeting held quarterly to discuss care, needs, and goals, that included the resident, social services, nursing, activities director and the dietary department) notes did not reflect a discharge plan or discharge planning needs for Resident 90. 3. Social Services did not assist Resident 90 with financial documents when requested. 4. Outside services and referrals were not made in a timely manner for Resident 98. 5. Dental services were not provided in a timely manner for Resident 35. These failures had the…

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

Based on observation, interview, and record review, the facility failed to ensure medications and medication supplies were stored and labeled in accordance with currently accepted professional principles when: 1. Two loose pills were found in the drawer of medication cart 2. 2. Six medications that were being dispensed were opened and not dated. 3. Four Foley drainage bags (A bag that collects urine which comes from the bladder through a catheter tube) in a storage room ready for use were expired. 4. Pro-Stat concentrated liquid protein medical food was being dispensed but had expired. These failures had the potential for medication misuse, medication ineffectiveness, and potential exposure to harmful pathogens (bacteria, viruses, fungi) from expired supplies for residents. Findings: 1. During a concurrent observation and interview with the Assistant Director of Nursing (ADON) on 10/2/24 at 10:12 am, an inspection of medication cart 2 was performed. Two loose pills were observed in the middle drawer the medication cart. The ADON confirmed that there should not be loose pills in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prepare and serve food that maintained an appetizing flavor, texture, appearance, and at a palatable (pleasant taste) temperature when 5 of 22 sampled residents (Residents 11, 35, 77, 84, 215) when: 1.Resident 77 stated the food was overcooked and could not even cut it. 2. Resident 84 stated the pork was undercooked, and he had to throw it away. 3. Resident 11's ice cream was served melted. 4. Resident 35's food was served cold, ice cream was served melted, and biscuits were served burnt. 5. Resident 215's pizza was served burnt. These failures resulted in meals to be served overcooked, undercooked, cold, unpleasant, and not meet the resident food preference, which had the potential for residents to decrease meal intakes and have weight loss issues. Findings 1. During a review of Resident 84's clinical record, indicated that Resident 77 was admitted to the facility on [DATE] with diagnoses which included stroke, diabetes (high blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of 22 (Resident 35 and 40) residents were free from abuse and the potential for ongoing abuse when: 1. Certified Nursing Assistant (CNA) E grabbed and held Resident 35's arm when attempting to do personal cares and CNA E continued to be assigned to Resident 35's room after the incident. 2. Housekeeper (HSK) A made Resident 40 clean her own toilet that had feces on it. HSK A continued to be assigned to clean Resident 40's room. This failure caused emotional distress and mental anguish for Resident 35 and Resident 40. Findings: A review of the State Operations Manual (SOM) revised 2/3/23, indicated abuse is defined as the willful (to act deliberately) infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. A review of the facility's policy titled Resident Rights Revised December 2021, indicated Federal and state laws guarantee certain basic rights to all…

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 report suspicions and allegations of abuse for three out of five sampled residents (Residents 22, 35, and 40) when: 1. Certified Nurse Assistant (CNA) M did not report suspicions of abuse when CNA M noticed Resident 22 showed fear during care. 2. CNA J did not report an allegation made by Resident 40 that the Housekeeper (HSK) A instructed Resident 40 to clean her own toilet. 3. Facility staff did not report an allegation of staff to resident physical abuse, when CNA E held down Resident 35. The failure to report abuse suspicions and allegations had the potential for residents' to be at risk for staff to resident abuse and had the potential to cause psychosocial harm and negatively impact the resident's overall wellbeing. Findings: A review of the facility's policy and procedures (P&P) titled, Abuse Prevention Program, revised 12/1/16, indicated, the facility would .report any allegations of abuse within timeframes as required by federal requirements. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure accurate and complete documentation for one of three closed records reviewed when Resident 112 was transferred to an acute care hospital and the facility did not document the date and time of their transfer, where they transferred to, how they were transported, or the disposition of their personal effects and medications. This failure had the potential to negatively impact Resident 112's continuity of care and had the potential risk of them receiving inadequate care or services. Findings: During a review of the facility's policy, titled, Transfer or Discharge Documentation, no revised date provided, indicated: - When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. - When a resident is transferred or discharged from the facility, the following information will be documented 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 23 (Resident 101) residents had non-skid footwear on to prevent falls as per his care plan. The facility's lack of safety intervention for Resident 101 had the potential for injury related to unwitnessed falls. Findings: A review of Resident 101's admission Record dated 5/28/24, indicated Resident 101 was admitted to the facility on [DATE] with diagnoses that included stroke (blood flow to the brain is blocked and some brain cells die causing disabilities), muscle weakness, difficulty in walking, and major depressive disorder. A review of Resident 101's Quarterly Minimum Data Set (MDS, a standardized assessment of an adult's functional, medical, psychosocial, and cognitive status) dated 9/4/24, indicated Resident 101's Brief Interview for Mental Status (BIMS, evaluates a person's cognition, [ability to think, learn, remember, use judgement, and make decisions] with scores from 00 to15) score was 07, indicating Resident 101'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide appropriate care for two out of three sampled residents (Residents 87 and 214) with a gastrostomy tube (g-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) when: 1. Licensed Nurses (LN) did not follow Resident 87's Physician orders regarding g-tube feeding (Physician prescribed liquid nutrition [formula/feedings] amounts, hydration (free water provided for hydration), water flushes (water flushes aide in keeping the g-tube unclogged and maintained), and inaccurately documented intake amounts. 2. For Resident 87, LNs provided g-tube care without a Physician's order and did not document the care that was provided. 3. Resident 214 received an excessive amount of fluids. These failures placed g-tube residents at risk for fluid overload (too much fluid that placed residents at risk for choking), g-tube malfunction, and had the potential for a decline…

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 physician progress notes (doctor's note about resident progress, care, and medical issues) were complete, signed and dated at each visit for for two of four sampled residents (Resident 34, and 98). This failure had the potential to negatively affect communication between disciplines and to result in inappropriate care and service for the residents. Findings: During a review of the facility's job description, titled, Medical Director (MD), revised 10/20, indicated that the MD's duties and responsibilities which included: - Interview residents to obtain history, perform physical examination, order labs, and other tests, prescribe medications and treatments as part of the plan of care. - Provide routine medical care for residents as necessary. - Ensure residents attain or maintain their highest practical physical, mental and psychosocial well-being. During a review of Resident 34's clinical record, indicated that Resident 34 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 ensure nursing staff demonstrated appropriate skill sets that were required to care for * out of 22 sampled residents when: 1. Licensed Nurses (LN) did not reassess, notify the Physician, or follow up on Resident 98's potentially infected right eye. 2. LNs and Certified Nurse Assistants (CNA) did not report suspicions or allegations of abuse for Residents 22, 35, and 40. (Refer to F609) 3. LN did not adequately monitor gastrostomy tube (g-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) feedings (liquid hydrations provided through the g-tube) and provided care without a Physician's order. (Refer to F693) 4. LNs did not thoroughly check meal trays to ensure residents received the appropriate food. (Refer to F800) These failures had the potential for hospitalization, and could negatively impact resident's physical, mental, and psychosocial…

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, one of 22 sampled residents (Resident 61) failed to be free of unnecessary psychotropic medications when Resident 61 had a routine Ativan (anti-anxiety medication) order of 0.5 milligrams (mg - a unit of measure) and a pro re nata (PRN - as needed) order for Ativan 0.5 mg. The PRN Ativan order was available for five months without an order end date despite Consulting Pharmacist (CPH) recommendations to discontinue the PRN order or limit the order to 14 days per Centers for Medicare and Medicaid Services (CMS - a federal entity that works to improve the quality of healthcare) regulations. Psychotropic medications affect brain activities associated with mental processes and behaviors and include anti-psychotic, anti-depressant, anti-anxiety and hypnotic (sedating) medications. This deficient practice had the potential for Resident 61 to experience adverse (negative, potentially harmful) side effects from excessive or unnecessary psychotropic medications including…

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 facility's policy and procedure (P&P) on dental services was followed for one of 22 sampled residents (Resident 35). This failure had the potential to result in Resident 1's weight loss due to difficulty eating. Findings: A review of the facility policy titled Dental Examination/Assessment revised December 2013, indicated Upon conducting a dental examination, a resident needing dental services will be promptly referred to a dentist. A review of Resident 35's admission Record dated 8/27/24, indicated he was re-admitted on [DATE] with the diagnoses that included lung disease, depression, left sided paralysis (unable to move his left arm and leg), adult failure to thrive (the feeling of wanting to give up on life), colostomy (a surgical procedure that redirects the colon to an opening in the abdominal wall in which the bowel will exit into a bag), and an indwelling urethral catheter (a tube that goes into the bladder and drains the urine into 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to honor food preferences for five out of 22 sampled residents (Residents 46, 90, 100, 104, and 106) when: 1. Resident 46 received eggs for breakfast. 2. Resident 90 received rice with meals. 3. Resident 100 received tomatoes with a salad. 4. Resident 106 received eggs for breakfast and a tuna fish sandwich for lunch. 5. Resident 104 received carrots, peas, and corn with meals. This failure had the potential to negatively impact psychosocial health and cause weight loss. Findings: 1. A review of the facility's policy and procedure (P&P) titled, Dining and Food Preferences, revised 9/1/17, indicated, resident food preferences would be reviewed, documented, and an alternate meal substitution would be provided. A review of the Resident Council meeting notes, dated 7/23/24, indicated, food complaints from the previous meeting held in June, had not been resolved. The meeting notes did not indicate, what the food complaints were. During a review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure enough nursing staff had the appropriate competencies and skills to implement a respiratory plan of care for one of four sampled resident (Resident 1). This failure resulted in a decline in Resident 1 ' s respiratory and metabolic status (a condition where the decline of the lung function negatively affects the functioning of the rest of the body) resulting in emergent transfer to a hospital for treatment. Refer to F695. Findings: A review of facility policy titled CPAP/BiPAP Support and Cleaning dated March 2015, indicated only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP/BiPAP mask. A resident ' s medical record should be reviewed to determine his/her baseline oxygen saturation, respiratory, circulatory status. The physician ' s order should be reviewed to determine the oxygen concentration and flow and pressure settings for the machine. A review of Resident 1 ' s hospital Discharge…

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 that one of four residents (Resident 1) was educated, informed and allowed to make her own medical decisions before administering a psychotropic (alters mood and behavior). This failure resulted in Resident 1 to receive an unnecessary medication and had the potential for adverse effects such as sedation, dry mouth, weakness, headaches, dizziness, nausea and being unable to sleep. Refer to F758. Findings: A review of a facility policy titled Informed Consent Policy, undated, under documentation form, indicated This verification that informed consent was given shall be made available to the facility from either the person who obtained the consent (physician or nurse practitioner - only if they were the one who prescribed the medication) or who gave the consent (patient/resident, or responsible party, if patient/resident is not capable) in either verbal, FAX, e-mail, or document (copy or original). The facility staff who are authorized to take such…

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 create an accurate comprehensive admission assessment for one four sampled residents (Resident 1) when a physician ordered treatment for a Bilevel Positive Airway Pressure (BiPAP-a device to help breathing) was not identified. This resulted in a decline in Resident 1 ' s respiratory and metabolic status (a condition where the decline of the lung function negatively affects the functioning of the rest of the body) requiring a transfer to a hospital for emergent treatment. Findings: A review of a facility policy titled Resident Assessments F636; F637; F638 undated, indicated a comprehensive assessment of each resident is completed at intervals. Comprehensive admission Minimum Data Set (MDS, resident assessment) include Care Area Assessment (CAA) process for resident care planning. Information for the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to create a baseline care plan that included a respiratory treatment for one four sampled residents (Resident 1) when she did not receive her physician ordered Bilevel Positive Airway Pressure (BiPAP-a device that helps breathing). This resulted in a decline in Resident 1 ' s respiratory and metabolic status (a condition where the decline of the lung function negatively affects the functioning of the rest of the body) requiring a transfer to a hospital for emergent treatment. Findings: A review of a policy and procedure titled Care Plans - Baseline - F655, revised March 2022, indicated that the baseline care plan includes instructions needed to provide effective, person-centered care of the resident .must include the minimum healthcare information necessary to properly care for the resident including .physician orders. The baseline care plan is used until the staff can conduct the comprehensive assessment and develop a comprehensive care plan to meet the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one of four residents (Resident 1) was free of an unnecessary psychotropic medication (drug prescribed to affect the mind, emotions, or behavior) when she was prescribed Lexapro (medication used to treat depression and anxiety) was administered without clinical indication. This failure resulted in Resident 1 to receive an unnecessary medication and put her at risk for adverse side effects such as sedation, dry mouth, weakness, headaches, dizziness, nausea and being unable to sleep. Refer to F552. Findings: A review of facility policy titled Psychotropic Medication Use, dated July 2022, indicated the use of any psychotropic medication is based on comprehensive review of the resident. Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record. A review of facility…

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 Medical Director (MD) supervised the development and implementation of a plan of care for one of four sampled residents (Resident 1) when: 1. Upon admission orders for BiPAP (device to help breathing) were not implemented. Refer to F 695 2.a. Informed consent was not obtained before administering a psychotropic (alters mood behavior) medication. Refer to F 552 b. An unnecessary psychotropic was prescribed without clinical justification. Refer to F 758 This failure resulted in respiratory failure that required emergent hospitalization and an unnecessary psychotropic medication to be administered without clinical justification. Findings: A review of a facility policy titled Medical Director revised July 2016, indicated physician services are under the general supervision of the Medical Director (MD). The MD was responsible for ensuring adequate and appropriate physician services. MD was to oversee and help develop and implement care related…

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 safety and sanitation guidelines were followed when: 1. The ice machine was not in sanitary condition, 2. Time Temperature Control for Safety Foods (TCS) (food that requires time and temperature to limit the growth of illness causing bacteria) were not handled safely, 3. Food was not stored safely, 4. Food preparation equipment was not cleaned or air dried, 5. Nonfood contact surfaces were not clean, and 6. One food preparation sink and one steamer did not have an air gap. These failures had the potential to cause food borne illnesses in a medically vulnerable population of 99 who received food prepared in the kitchen. Findings: 1. According to the USDA Food Code 2022 Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, food-contact surfaces and utensils shall be clean to sight and touch. During a review of the facility's policy and procedure titled, Ice, dated 9/2017, indicated, ice will be prepared and distributed in a safe and sanitary manner.…

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 effective Quality Assessment and performance Improvement (QAPI) plan was in place for identifying and responding to resident care concerns with a good faith effort, by implementing, monitoring, and evaluating action plans for weight loss, pressure ulcers, staffing and competency, and abuse. This failure had the potential to affect how the facility ensures care and services are delivered meet accepted standards of quality, identify problems and opportunities for improvement, and ensure progress toward correction or improvement was achieved and sustained. Findings: A review of a policy titled, Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership, with a revised date of March 2020, indicated, The administrator . is ultimately responsible for the QAPI program, and for interpreting its results and findings to the governing body. The document indicated that the responsibilities of the QAPI committee included: identify, evaluate, monitor, and improve facility systems and processes…

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 that one of six sampled residents, (Resident 303) received communication in a language that she could understand and verbalize needs in order to make informed care choices and decisions, when the resident only spoke Spanish and no interpreter services were used in the facility. This failure had the potential for the resident's needs and preferences not being met and the potential for complications of health status related to recent heart valve replacement and diabetes. Findings: During a review of a policy not dated, titled Translation and/or Interpretation of Facility Services, indicated the facility's language access program will ensure residents with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. Competent oral translation of vital information that is not available in written translation shall be provided in a timely manner at no cost to the resident through…

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 resident complaints were acted upon timely and implement plans of action to correct the identified issues. This failure resulted in ongoing unresolved complaints. Findings: A review of a facility policy titled Resident Council revised February 2021, indicated the purpose of the resident council was to provide a forum for residents/families to have input in the operation of the facility. They can discuss their concerns and suggestions for improvement. A resident council response form will be used to track their resolution. The facility department will be responsible for addressing the item of concern. The quality assurance and performance improvement (QAPI) will review information and feedback from the council and may be referred to the committee when there was a pattern in the issue the council identified. A review of the resident council meetings minutes indicated: On 10/27/22, dietary services spoke to the resident about consistency on time…

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 and interview, the facility failed to ensure the right to personal privacy for all residents who showered when there was no system for communicating when a shower was or was not in use without opening the door. This failure had the potential to cause distress for the residents and threaten their health and well-being. Findings: During a concurrent observation and interview, on 6/20/23, at 9:50 AM, Certified Nursing Assistant (CNA) M opened the door to the shower room across from room [ROOM NUMBER]. CNA M used the keypad combination lock. An unknown resident was in a shower chair, bathing in the shower stall. When asked if there was any way to know if the shower was in use before opening the door, besides listening for the sound of running water, CNA M said no. There was no sign outside the door to indicate a resident was bathing. Soon a second staff member attempted to open the shower room door using the keypad before being told someone was already in the shower. During an interview, on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a clean, safe, comfortable and homelike environment for ten of ten sampled residents (Residents 10, 17, 21, 24, 29, 33, 51, 58, 300, and 302) when: 1. The walls were in disrepair in room [ROOM NUMBER]. 2. A screen was protruding from the window in room six. 3. Vertical blinds were broken in room [ROOM NUMBER]. 4. Screens were in disrepair with holes in rooms 24, 30, 32, 34, and 35. 5. A picture was not hung on the wall and a piece of furniture not assembled for Resident 24. This failure had the potential to allow pests to enter through the open windows and to create a visually unpleasant environment, both of which could have negatively impacted the residents' health and well-being. Findings: 1. A review of Resident 51's clinical record showed they were admitted to the facility on [DATE]. Resident 51's diagnoses included psychosis (a loss of touch with reality), anxiety, and depression. During an observation, on 6/20/23, at 2:39 PM, Resident 51…

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 direct care and administrative staff reported allegations of staff to resident abuse to the mandated agencies for three of three sampled residents (Resident 63, 74 and 86). This had the potential to put all residents at risk for abuse from staff at the facility. Findings: A review of a facility policy titled Abuse Prevention Program revised December 2016, indicated residents have the right to be free from abuse, neglect, misappropriation of property, verbal, mental, sexual, and physical abuse. Identify and assess incidents of abuse. Investigate and report any allegations for abuse within the timeframes as required by federal requirements. Protect residents during the abuse investigations. A review of the resident concern and grievance log, indicated from 2/2-6/10/23, seven out of 11 resident complaints listed the concern was related to nursing and Certified Nursing Assistant (CNA) care. A review of the resident grievance/complaint form dated 2/2/23, the Social Service Director (SSD) documented Resident…

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

Based on interview and record review the facility failed to ensure allegations of staff to resident abuse were investigated and residents were protected during this process for three of three residents (Residents 63, 74 and 86). This put all residents at risk for staff to resident abuse. Findings: A review of a facility policy titled Abuse Prevention Program revised December 2016, indicated residents have the right to be free from abuse, neglect, misappropriation of property, verbal, mental, sexual, and physical abuse. Protect residents during the allegation of abuse investigations. A review of the resident grievance/complaint form dated 2/2/23, the Social Service Director (SSD) documented Resident 63's complaint that CNA E (agency registry staff) took his call light device and television (TV) remote away from him, so he could not use it. Resident 63 explained at 2 AM on 2/1/23, he yelled and hollered for help so he could use the restroom, CNA E told him to go (urinate) in his continence briefs. Resident 63 further explained at some point he got the TV remote back and not the call…

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 that six of six sampled residents (Residents 23, 29, 32, 33, 64, and 302), received assistance with activities of daily living to attain or maintain their independence when: 1. Routine grooming activities were not completed for Resident 32 and Resident 64. 2. Routine and scheduled showers were not completed for Residents 23, 29, 33 and 302. These failures had the potential to result in the residents feeling depressed with poor self-esteem, and had the potential to contribute to skin breakdown, infection, and negatively impact their ability to attain or maintain their highest practicable level of well-being. Findings: 1. A facility policy, titled, Fingernails/Toenails, Care Of, revised 2/1/18, was reviewed. It's stated purpose was to clean the nail bed, to keep nails trimmed, and to prevent infections. Nail care included daily cleaning and regular trimming. Documentation was to have included date, time, name and title of individual…

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 sufficient staff to meet the individual care needs for 14 out of 20 sampled residents (Residents 63, 26, 10, 15, 250, 33, 29, 23, 302, 32, 64, 68, 57 and room [ROOM NUMBER]) when: 1. Insufficient nursing staff to answer call lights to provide care to dependent residents. This resulted in residents to feel angry and neglected. 2. Showers and nail care were not provided. This had the potential for changes in resident skin conditions not to be identified and to feel undignified. 3. Certified Nursing Assistants (CNAs) performing Activities of Daily Living (ADL,resident care) during meal tray delivery. This resulted in residents to feel frustrated, hungry and food was cold. Findings: 1. A review of the Daily Staffing Sheets for the night shift (NOC, 10:30 PM to 7 AM) indicated: On 2/1/23, three out of five scheduled CNAs signed the sheet. On 2/2/23, three out of four scheduled CNAs signed the sheet. On an undated sheet, three CNAs were…

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

Based on observation, interview, and record review, the facility failed to ensure that Certified Nursing Aides (CNAs) are able to demonstrate competency in skills to follow the residents plan of care to meet their needs. This failure resulted in dependent residents not to receive nursing interventions to ensure their plan of care was implemented. Findings: A review of a Certified Nursing Assistant (CNA) job description undated, indicated they provide routine daily nursing care and services in accordance with the plan of care of each resident based on established nursing care procedures and the direction of a supervisor. Ensures residents needs are maintained with the highest degree of dignity. Promptly answers resident call lights and provides appropriate responses and requests. Performs comprehensive resident care duties including but not limited to bathing, vital signs, changing linens, properly positioning residents and giving AM and PM care. Reports the following in accordance with established facility procedures and regulatory standards resident grievances, complaints and…

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

Based on interview and record review the facility failed to ensure performance reviews for four out of six Certified Nursing Assistants (CNA A, B ,C and D) were completed every 12 months. This had the potential for direct care staff not to provide quality of care and meet the needs of the residents. Findings: During a concurrent interview and employee file review on 6/23/23 11 AM, the Director of Staff Development (DSD) confirmed there were no annuals performance reviews completed for: 1. CNA A, Date Of Hire (DOH) 3/18/22. 2. CNA B, DOH 12/1/21. 3. CNA C, DOH 9/29/2009. 4. CNA D, DOH 7/5/17, the last completed annual evaluation was on 7/12/2020. During an interview on 6/22/23 2:45 PM, the Administrator (ADMIN) confirmed no annual reviews had been done for CNAs for some time. ADMIN confirmed they currently do not have a policy but verified with management that the expectation was to complete them annually.

Based on observation, interview, and facility policy and procedure review, the facility failed to ensure the menu was followed when: 1. The procedure to puree foods was not followed for eight of eight residents, 2. Correct portion sizes were not followed and 3. Gravy was not added per the menu. This failure had the potential to not meet the resident's nutritional needs. Findings: 1. During a review of the facility's record, Corporate recipe-number 7277; Entrée-Beef, undated, indicated for pureed beef measure the desired number of servings into the food processor. Blend until smooth. Add liquid if product needs thinning. Add commercial thickener (powder substance that thickens the pureed food) if product needs thickening. Liquid and thickener measurements are approximate and slightly more or less may be required to achieve desired pureed consistency. During an observation and interview on 6/21/2023 at 11:12 AM, in the kitchen, with [NAME] 1, [NAME] 1 stated he was preparing pureed meatloaf for eight residents. [NAME] 1 cut the meatloaf into portions and weighed out eight 4-ounce…

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 1 of 6 Residents (Resident 150) the right to be treated with dignity and respect when his clothes were visibly soiled. This failure led to the lack of self-esteem, frustration, and loss of dignity for Resident 150. Findings: During an observation and interview on 6/20/23 at 11:29 AM, Resident 150 was visibly agitated and expressing vocalizations of frustration, indicating it was due to a lack of clean clothing. Resident wearing visibly soiled white shirt, visibly soiled black sweatpants, and socks with shoes on. Resident able to verbalize he was waiting a long time for staff to help him, and then continued to vocalize agitation. During an observation and interview on 6/21/23 8:47 at AM, Resident 150 did state he wanted to buy more clothes to wear. Gestured to visibly soiled black shirt and visibly soiled black sweatpants and said yeah when asked if he wanted clean clothes to wear. Resident 150 stated he would go to Walmart to buy more clothes for himself, but the facility can't take him. During an…

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

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the physician was informed of a change of condition for one of 21 sampled residents (Resident 48). This failure had the potential for Resident 48 to have a delay in care and treatment. Findings: A review of the facility P&P titled Acute Condition Changes - Clinical Protocol revised 3/2018 showed in part, 1. The physician will help identify individuals with a significant risk for having acute changes of condition during their stay .2. In addition, the nurse shall assess and document/report the following baseline information: a. Vital signs; .7. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician . Review of the facility document titled Weights and Vitals Summary from 1/6/23 to 2/7/23 showed the following weights and comparison for Resident 48: *On 1/6/23 = 166 lbs., *On 2/5/23 = 153.2 lbs., -12.8 lbs., a 7.7% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -15.6…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive and person-centered Care Plan for one of three sampled residents (Resident 8) when there was nothing included for depression. This failure had the potential for Resident 8's needs to go unmet which could have negatively impacted their health and well-being. Findings: A review of Resident 8's clinical record showed they were admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (a chronic disease of the central nervous system that caused muscle weakness), anxiety (nervousness), psychosis (loss of touch with reality), and schizoaffective disorder bipolar type (a mental health disorder that was marked by a combination of hallucinations or false beliefs and extreme highs and lows of mood). Medications ordered for Resident 8 included olanzapine for psychosis as evidenced by yelling that interfered with care, and clonazepam for anxiety as evidenced by verbalization of worries over health concerns. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary care and services and devices to maintain or improve hearing difficulty, for one of one resident reviewed for communication-sensory (Resident 3). This failure had the potential for Resident 3 to not effectively communicate and express her needs, which potentially negatively affected her well-being and quality of life. Findings: A review of a policy titled, Hearing Impaired Resident, Care of, with a revised date of February 2018, indicated, Staff will assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other residents and visitors. A review of the facility's records indicated Resident 3 was admitted to the facility on [DATE] after a hospital stay, with an initial admission date of 11/26/2019. Resident 3 had diagnoses that included: generalized muscle weakness, vascular dementia, cognitive communication deficit (difficulty with thinking and how someone uses language),…

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 residents out of six sampled residents (Resident 302 and 303) were treated for pain in a timely manner by not identifying and reporting a new onset of pain. This failure resulted in altered mood, and the potential to cause a decline in health status and overall quality of life. Findings: 1- A review of a policy revised March 2018, titled Pain-Clinical Protocol, indicated the nursing staff will assess each individual for pain upon admission to the facility and when there is onset of new pain. The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated. The staff and physician will evaluate how pain is affecting mood, activities of daily living, sleep, quality of life, as well as how pain can be contributing to complications such as gait disturbances, social isolation, and falls. During a record review, Resident 302 was admitted to the facility on [DATE] for diagnoses…

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 accommodate seven out of out of 20 residents (Residents 10, 20, 24, 35, 36, 64, and 82) with preferred food preferences when dietary staff did not update or serve the dietary preferences the residents requested or tried to obtain an alternate. This failure created the potential for a lack of the variety in foods and flavors needed to encourage meal intakes, enhance resident's quality of life, and had the potential to contribute to weight loss. Findings: During a review of a policy revised October 2017, titled Food and Nutrition Services, indicated each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking in consideration the preferences of each resident. Food and Nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and is served at a safe 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 facility policy and procedure review, the facility failed to ensure the policy titled, Foods Brought by Family/Visitors' dated 3/2022, was implemented. These failures posed the risk of resident food brought to the facility from the outside not being handled in a safe manner which posed the risk of food borne illnesses. Findings: During a review of the facility's policy and procedure titled, Foods Brought by Family/Visitors' dated 3/2022, indicated in part .: 3. Family/visitors are asked to prepare and transport food using safe food handling practices including: a. Safe cooling and reheating processes beholding temperature apprehending cross contamination with raw or undercooked foods d. Hand hygiene 4. Safe food handling practices are explained to family/visitors in a language and format they understand. 5. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from facility-prepared food. a. Nonperishable foods are stored in re-sealable containers 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 observation, interview and record review, the facility failed to ensure one of three trash bin lids were tight fitting when one of three lids had a hole. This had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility. Findings: According to the USDA Food Code 2022 Section 5-501. 113 Covering Receptacles, Receptacles and waste handling units for refuse, recyclables, and return tables shall be kept covered: (B) with tight fitting lids or door if kept outside the food establishment. Review of the facility's policy and procedure titled, Dispose of Garbage and Refuse, dated 8/2017, indicated, all garbage and refuse will be collected and disposed of in a safe manner. Appropriate lids are provided for all containers. On 6/20/2023 at 3:05 PM an observation of the trash bins located in the rear parking lot and concurrent interview was conducted with the Director of Maintenance (DM). The lid on the recycle bin used for cardboard boxes had an open area on one of the two lids. DM confirmed there…

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