Riverdale Post Acute

Based on observations, record review and interviews, the facility failed to ensure residents were treated with respect and dignity by providing care in a dignified, respectful and individualized manner for one (#26) of four residents reviewed out of 36 sample residents and on one of three units. Specifically, the facility failed to: -Ensure residents who were prescribed a puree diet received the menu options as listed on the main menu or according to their preference and prescribed diet order; and, -Provide residents on the Aspen unit with non-disposable beverage cups at meals. Findings include: I. Failed to ensure residents who were prescribed a puree diet, received the menu options as listed on the main menu or according to their preference and prescribed diet order A. Facility policy and procedure The Resident Food Preferences policy, revised July 2017, was provided by the nursing home administrator (NHA) on 3/26/25 at 11:32 a.m. It read in pertinent part, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure four (#59, #39, #97 and #42) of nine residents out of 36 sample residents were kept free from abuse. Specifically, the facility failed to: -Protect Resident #59 and Resident #39 from sexual abuse by Resident #62; -Protect Resident #97 and Resident #34 from physical abuse by each other; and, -Protect Resident #42 from physical abuse by Resident #58. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, was provided by the nursing home administrator (NHA) on 3/23/25 at 12:41 p.m. It read in pertinent part, Residents have the right to be free from abuse. The facility will implement measures to address factors that may lead to abusive situations. The facility will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. The facility will investigate and report 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to develop a comprehensive care plan for three (#1, #75 and #249) of six residents out of 36 sample residents for services to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to: -Ensure a comprehensive care plan was developed to address Resident #1's use of supplemental oxygen and a peripherally inserted central catheter (PICC); and, -Ensure a comprehensive care plan was developed to address Resident #75 and Resident #249's insomnia. Findings include: I. Facility policy and procedure The Comprehensive Person-Centered Care Plans policy, revised March 2022, was provided by the nursing home administrator (NHA) on 3/26/25 at 6:42 p.m. The policy read in pertinent part, The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Assessments of residents are ongoing and care plans are revised as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and interviews, the facility failed to ensure three (#95, #75 and #249) of five residents out of 36 sample residents were as free from unnecessary medications as possible. Specifically, the facility failed to: -Ensure consents were obtained that included the risks versus benefits for psychotropic medications for Resident #95, Resident #75 and Resident #249; and. -Ensure Resident #95 and Resident #75 had behavior monitoring in place for the use of psychotropic medications. Findings include: I. Facility policy and procedure The Psychotropic Medication Use policy, revised July 2022, was provided by the nursing home administrator (NHA) on 3/26/25 at 6:24 p.m. It revealed in pertinent part, Drugs in the following categories are considered psychotropic medications and are subject to specific prescribing, monitoring, and review requirements: anti-psychotics, anti-depressants, anti-anxiety medications and hypnotics. Residents, families and/or the representative are involved in the medication…

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

Based on observations, record review and interviews, the facility failed to ensure residents received food and fluids prepared in a form designed to meet his or her needs. Specifically, the facility failed to ensure residents who were prescribed mechanically altered diets had food prepared according to their diet orders of puree and mechanical soft as indicated on their meal tray cards. Findings include: I. Facility policy and procedure The Therapeutic Diets policy, undated, was provided by the nursing home administrator (NHA) on 3/26/25 at 11:32 a.m. It read in pertinent part, Diet orders should match the terminology used by the food and nutrition services department. A therapeutic diet is considered a diet ordered by a physician, practitioner, or dietitian as part of treatment for disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: altered consistency diet. If a mechanically altered diet is ordered, the provider will specify the texture modification. The dietitian, nursing staff and attending physician will…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and interviews, the facility failed to ensure the facility's binding arbitration agreement was thoroughly and accurately explained to the residents and or resident representatives before signing the agreement for three (#54, #85 and #96) of four residents out of 36 sample residents. Specifically, the facility failed to: -Thoroughly explain the binding arbitration agreement in a form and in a manner to ensure Resident #54, Resident #85 and Resident #96 and/or their representatives understood the agreement before signing the arbitration agreement; and, -Ensure the facility staff provided evidence Resident #54, Resident #85 and Resident #96 and/or their representatives acknowledged understanding of the components of the agreement. Findings include: I. Facility policy and procedure The Binding Arbitration Agreement policy, November 2023, was provided by the nursing home administrator (NHA) on 3/26/25 at 6:24 p.m. The policy read in pertinent part, Residents (or representatives) are informed of the nature and implications of any proposed binding arbitration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease on three of three units. Specifically, the facility failed to: -Ensure housekeeping staff followed appropriate hand hygiene processes when cleaning resident rooms; -Ensure high touch surfaces in residents' rooms were cleaned; -Ensure housekeeping staff followed proper cleaning techniques when cleaning residents' bathrooms; and, -Ensure enhanced barrier precautions (EBP) were followed for Resident #1, who had a peripherally inserted central catheter (PICC). Findings include: I. Housekeeping failures A. Professional references According to the Centers for Disease Control and Prevention (CDC), CDC Clinical Safety, Hand Hygiene for Healthcare Worker (2/17/24), retrieved on 4/1/25 from https://www.cdc.gov/clean-hands/hcp/clinical-safety, Know when to clean your hands: immediately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure resident rooms, bathrooms, dining room furniture and hallways received necessary maintenance repairs. Findings include: I. Facility policy and procedure The Safe and Homelike Environment policy, undated, was provided by the nursing home administrator (NHA) on 3/25/25 at 1:53 p.m. The policy read in pertinent part, The facility will provide a safe, clean, and comfortable homelike environment. This ensures that the resident can receive care and services safely and that the physical layout maximizes resident independence and does not pose a safety risk. Environment refers to any location in the facility that is frequented by residents. A homelike environment is one that de-emphasizes the institutional character of the setting. Housekeeping and maintenance services will be provided as necessary to maintain 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 observations, record review and interviews, the facility failed to keep resident medical records in a secure and confidential manner. Specifically, the facility failed to ensure resident meal tickets were stored privately and not accessible to guests to review in order to protect the confidentiality of resident information. Findings include: I. Observations During a continuous observation on 3/25/25, beginning at 11:10 a.m. and ending at 12:37 p.m., the following was observed during the meal preparation and service in the main kitchen and dining room: At 11:10 a.m. resident meal trays were being assembled in the main kitchen by cook (CK) #1. Resident meal tickets were observed in two separate places in the service window between the kitchen and main dining room. The meal tickets were on the left side of the serving counter and on the right side on top of the steam table. The meal tickets contained resident names and physician prescribed diet orders. At 11:37 a.m. a resident representative approached the service window in the dining room and picked up the resident meal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for one (#62) of nine residents reviewed for abuse out of 36 sample residents. Specifically, the facility failed to report an incident of potential sexual abuse involving Resident #62 to the State Survey Agency (SSA). Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, was provided by the nursing home administrator (NHA) on 3/23/25 at 12:41 p.m. It read in pertinent part, Residents have the right to be free from abuse. The facility will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. The facility will investigate and report any allegations within timeframes required by federal requirements. II. Resident #62 A. Resident status Resident #62, age [AGE], was 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 record review and interviews, the facility failed to document resuscitation choices accurately in the medical record for one (#50) of three residents reviewed for advanced directives out of 36 sample residents. Specifically, the facility failed to document Resident #50's refusal to complete a medical orders for scope of treatment (MOST) form (a legal document that allows individuals to outline their wishes for medical interventions and end-of-life care, ensuring their preferences are followed in the event of a serious illness or decline in health) upon admission to the facility or that the resident's resuscitation choices were discussed with the resident or the resident's representative. Findings include: I. Resident #50 A. Resident status Resident #50, age greater than 65, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD - a lung disease with airway obstruction), chronic respiratory failure, type 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure one (#1) of one resident received treatment and care in accordance with professional standards of practice out of 36 sample residents. Specifically, the facility failed to obtain a physician's order and provide routine maintenance and care for a peripherally inserted central catheter (PICC) for Resident #1. Findings include: I. Professional reference According to The National Institutes of Health (NIH) PICC Line Placement (1/10/24), retrieved on 4/2/25 from https://www.ncbi.nlm.nih.gov/books/NBK573064/, Dressings should be changed at least once weekly or per policy and manufacturer's guidelines. After each use, the PICC line should be flushed with normal saline and heparin solution. Nurses are responsible for day-to-day care, education, and monitoring of patients with PICC lines, reporting any concerns promptly. Careful monitoring and maintenance of these lines are paramount in preventing procedural complications. II. Resident #1 A. 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 observations, record review and interviews, the facility failed to ensure one (#50) of three residents out of 36 sample residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being. Specifically, the facility failed to weigh Resident #50, who was identified to have potential nutrition problems, upon admission to monitor the resident's nutritional status. Findings include: I. Facility policy and procedure The Weight Assessment and Interventions policy, revised March 2022, was provided by the nursing home administrator (NHA) on 3/26/25 at 9:09 a.m. It read in pertinent part, Residents weights are monitored for undesirable or united weight loss or gain. Residents are weighed upon admission and at intervals established by the interdisciplinary team (IDT). Weights are recorded in each unit's weight record chart and in the individual's medical record. Any weight change of 5% or more since the last weight assessment is retaken the next…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, record review and interviews, the facility failed to ensure residents with a feeding tube received appropriate treatment and services for one (#96) of three residents reviewed out of 36 sample residents. Specifically, the facility failed to ensure Resident #96 was assessed to ensure her safety while self-administering her tube feedings. Findings include: I. Facility policy and procedure The Enteral Nutrition (feeding tube) policy, revised November 2018, was provided by the nursing home administrator (NHA), on 3/26/25 at 11:43 a.m. It read in pertinent part, Adequate nutritional support through enteral nutrition is provided to residents as ordered. Staff caring residents with feeding tubes are trained on how to recognize and report complications associated with the insertion and/or use of a feeding tube, such as aspiration, skin breakdown around the insertion site, and clogging of the tube. Residents receiving enteral nutrition are periodically reassessed for the continued appropriateness…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observations, record review and interviews, the facility failed to ensure the medication administration error rate was not greater than five percent (%). Specifically, the facility's medication administration error rate was 6.06%, or two errors out of 33 opportunities for error. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed., E.[NAME], St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and interviews, the facility failed to meet all the requirements for the provision of hospice care for one (#26) of five residents out of 36 sample residents. Specifically, the facility failed to ensure the hospice agency notes regarding Resident #26's care were easily accessible to the facility staff in an attempt to effectively coordinate care with the hospice agency. Findings include: I. Facility-Hospice contract The contract between the facility and the hospice services company, dated 7/10/23, was provided by the nursing home administrator (NHA) on 3/25/25 at 3:08 p.m. It read in pertinent part, The hospice and nursing facility shall each prepare and maintain complete and detailed clinical records concerning each residential hospice patient receiving services under this agreement. Each clinical record shall completely, promptly, and accurately document all services provided to, and events concerning, each hospice patient. The hospice and the nursing facility shall each retain 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.

Based on observations, record review and interviews, the facility failed to ensure one of three units were free from accident hazards. Specifically, the facility failed to ensure the alarm on the door to the outside secured patio was functioning properly. Findings include: I. Facility policy and procedure On 1/13/25 at 12:49 p.m. the director of nursing (DON) said the facility followed the state guidelines for the secured unit. The DON provided a copy of the state guidelines, which read read in pertinent part, Any facility that has one or more resident care units that are secured to prohibit free egress of residents shall comply with the standards in this section in addition to all other applicable requirements of this chapter. Staff in the secure environment shall be experienced and trained in the particular needs and care of its residents. The facility shall identify its method for securing the area and establish and implement procedures for monitoring the effectiveness of the security system. II. Observations On 1/13/25 at 12:15 p.m. the back door on the all-male secured unit 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 observations, record review and interviews, the facility failed to provide an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to take the appropriate measures to control a fly infestation in the kitchen and dining room. Findings include: I. Professional reference According to the Center for Disease Control (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities, pp. 95 (updated 1/8/24), retrieved on 7/25/24 from https://www.cdc.gov/infection-control/hcp/environmental-control/environmental-services.html#cdc_generic_section_6-6-pest-control, Cockroaches, spiders, and mice are among the typical pest populations found in health-care facilities. Insects and rodents can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by passing pathogens from one source to another. Insects and rodents should be kept out of all areas of a health-care facility. From a public health and hygiene perspective, pests should be eradicated from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to maintain an effective program of pest management to ensure the facility was free of pests. Specifically, the facility failed to ensure the main kitchen, dining rooms, resident rooms and hallways were free from flies on three out of three units. Findings include: I. Professional references According to the Colorado Retail Food Establishment Rules and Regulations (last amended 1/1/19) retrieved on 8/1/23 from https://cdphe.colorado.gov/environment/food-regulations, The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by routinely inspecting incoming shipments of food and supplies, routinely inspecting the premises for evidence of pests, using methods, if pests are found, such as trapping devices or other means of pest control, and eliminating harborage conditions. If the windows or doors of a food…

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

Based on observations, interviews and record review, the facility failed to ensure resident's had the right to a dignified existence. Specifically, the facility failed to provide a dignified living experience adequate by answering resident call lights timely in two of three units that resulted in call light response times up to two hours and 55 minutes. Findings include: I. Facility policy The Answering the Call Light policy, revised October 2010, was provided by the nursing home administrator (NHA) on 7/27/23 at 1:07 p.m. It read in pertinent part, When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. Report all defective call lights to the nurse supervisor promptly. Answer the resident's call light as soon as possible. Be courteous in answering the resident's call. Steps in the procedure: turn off the signal light; identify yourself and call the resident by his or her name; list to the resident's request; do what the resident asks of you if permitted; if uncertain ask the nurse supervisor for assistance. II. 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 interviews and record review, the facility failed to ensure freedom from resident-to-resident abuse for three (#71, #43 and #10) of six residents reviewed out of 35 sample residents. Specifically the facility failed to ensure Residents #71, #43 and #10 were free from abuse by Resident #39. All four residents lived in the secure unit. Cross-reference F744, dementia care services. Findings include: I. Facility policy The Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy, last revised in April 2021, was provided by the nursing home administrator (NHA) on 7/24/23. It read in pertinent part: Protect residents from abuse by anyone including, but not limited to: other residents. Develop and implement policies and protocols to prevent and identify: abuse or mistreatment of residents. Identify and investigate all possible incidents of abuse. II. Abuse incidents involving Resident #39 against other residents Facility investigation reports and medical record documentation revealed 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 record review and interview, the facility failed to conduct yearly certified nurse aide (CNA) performance reviews and provide training based on the annual reviews for five (#2, #4, #5, #6 and #7) of five CNA training files reviewed. Specifically, the facility failed to provide performance evaluation reviews annually and provide 12 hours of regular in-service education on the outcome of these reviews for CNAs hired prior to July 2022. Findings include: I. Record review Upon review of five CNA training files, it was identified none of the five CNAs had evidence a performance review was completed and annual competencies or associated training totaling 12 hours per year was completed. CNAs reviewed included CNA #2, CNA #4, CNA #5, CNA #6 and CNA #7. The inservice records were reviewed starting July 2022 and documented the title of the inservice and date of completion, but failed to show total hours completed. II. Staff interview The nursing home administrator (NHA) was interviewed on 7/27/23 at 12:30 p.m. She said the competencies were included in the online inservice as post…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and interviews the facility failed to ensure three (#39, #10 and #71) of six residents reviewed for dementia care of 32 sample residents received the appropriate dementia care treatment and services to maintain their highest practical physical, mental, and psychosocial well-being. Specifically the facility failed to: -Assess, identify and implement measures to engage Residents #39, #10 and #71 activities to help prevent resident-to-resident altercations; -Update care plans following resident to resident abuse incidents for Resident #39, #10 and #71; and, -Ensure interventions were implemented to prevent Resident #39 from abusing other residents further. Findings include: I. Resident #39 A. Resident status Resident #39, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO) diagnoses included senile degeneration of the brain (decreased ability to think, concentrate, or remember), mood disorder due to known physiological condition (traumatic brain…

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

Based on observation and interviews, the facility failed to ensure that each resident received food that was palatable, attractive, and an appetizing temperature. Specifically, the facility failed to: -Ensure food was palatable and attractive when delivered to residents; -Ensure food was served at a safe and appetizing temperature; and, -Provide condiments with meals. Findings include: I. Resident interviews Resident #56 was interviewed on 7/24/23 at 10:13 a.m. The resident said she had received burnt eggs. The resident said lunch was usually yucky and the food was runny and cold. Resident #25 was interviewed on 7/24/23 at 10:18 a.m. Resident #25 said the food was horrible and she tried not to eat what they had available at the facility. She said her daughter brought in food because the facility's food was very bad. Resident #45 was interviewed on 7/24/23 at 10:31 a.m. The resident said the food was bad and the bananas were overripe. Resident #24 was interviewed on 7/24/23 at 10:42 a.m. The resident said the food was bad and she would not eat it. She said if she ate the food she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident interview, record review and staff interviews the facility failed to ensure one (#81) of five residents reviewed out of 35 sample residents receive proper foot care and treatment according to standards of practice. Specifically, the facility failed to ensure Resident #81 was seen by the podiatrist timely for toenail care. Findings include: I. Facility policy The Referral Agreements policy, revised October 2008, was provided by the nursing home administrator (NHA) on 7/27/23 at 1:07 p.m. It read in pertinent part, To facilitate referrals, the facility has entered into referral agreements with agencies that will provide services to residents. The scope of agencies and the agreements are consistent with the needs of the facility's resident population. Inquiries concerning the availability and use of referral agencies should be directed to social services or to the Administrator. II. Resident status Resident #81, age under age [AGE], was admitted on [DATE]. According to the July 2023 computerized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and record review the facility failed to provide timely dental services to meet resident needs for one (#10) of three residents reviewed for dental services out of 35 sample residents. Specifically, the facility failed to assist Resident #10 schedule a consultation for an oral surgeon to have his remaining teeth removed and to get fitted for dentures after the facility received the referral. Findings include I. Facility policy The Availability for Dental Services policy, revised August 2007, was provided by the nursing home administrator (NHA) on 7/27/23 at 12:00 p.m. and read in pertinent part: Oral healthcare and dental services will be provided for each resident; -Social services will be responsible for making necessary dental appointments; -All requests for routine and emergency dental services should be directed to social services to assure that appointments can be made in a timely manner. II. Resident status Resident #10, age [AGE], was admitted on [DATE]. According to the July 2023…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observation the facility failed to ensure resident food preferences for one (#24) out of five sample residents were honored out of 35 sample residents. Specifically, the facility failed to provide Resident #24 with the preferred vegetarian diet. Findings include: I. Facility policy and procedure The Resident Food Preferences policy and procedure, revised 2017, was delivered by the nursing home administrator (NHA) on 7/26/23 at 12:40 p.m. It read in pertinent part: Upon the resident's admission the dietitian or nursing staff will identify a resident's food preferences. Nursing staff will document the resident's food and eating preferences in the care plan. The Food Services Department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. The facility's Quality Assessment and Performance Improvement (QAPI) committee will periodically review issues related to food preferences and meals to try to identify more widespread…

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