Riverside Health & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for 1 of 5 residents (Resident #195) reviewed for change in condition, the facility failed to ensure the clinical record was complete and accurate to include an RN assessment. The findings include:Resident #195 had diagnoses that included heart failure, atherosclerotic heart disease with angina, and hypercholesterolemia.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #195 had a Brief Interview of Mental Status (BIMS) score of seven (7) indicative of severely impaired cognition, required setup assistance with personal hygiene, and was independent with bed mobility and transfers.The RCP dated 10/24/2025 Resident #195 had congestive heart failure. Interventions directed to give cardiac medications as ordered, monitor vital signs and notify medical doctor of significant abnormalities, and oxygen as ordered.Review of the vital signs report dated 1/5/2026 at 8:20 AM identified 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 clinical record reviews, review of facility policy, and interviews for one (1) of four (4) sampled residents (Resident #1) reviewed for an allegation of resident-to-resident abuse, Resident #1 was not provided the right to be free from physical abuse when Resident #1 was punched in the face by Resident #2 following an earlier verbal altercation between Resident #1 and Resident #2. The findings include:Resident #1's diagnoses included anxiety disorder, persistent mood disorder, and major depressive disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status score of fifteen (15) out of fifteen (15) indicating Resident #1 was alert and oriented, utilized a wheelchair for mobility, and was able to self-propel independently once in the wheelchair. The resident care plan identified Resident #1 had the potential to be verbally aggressive, poor impulse coping, and poor boundary setting. Resident #2's diagnoses included quadriplegia,…

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 review of the clinical record, facility documentation, and facility policy, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to reassess a resident's elopement/wander risk timely when resident had a change in condition and mobility status, resulting in an elopement from the facility. The findings include: Resident #1's diagnoses included dementia, psychotic disturbance, mood disturbance, anxiety, and a history of a fall with a laceration to the head.Review of hospital Discharge summary dated [DATE] identified admission after a witnessed fall at home with head strike and head laceration. History of dementia, family reported often sleeps in a recliner and gets in and out of the recliner throughout the night. Nursing admission assessment dated [DATE] identified Resident #1 was alert and oriented to person, place, time and situation, required maximum assistance of two (2) staff for transfers, and unable to determine gait at the time of assessment, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #3) reviewed for behaviors, the facility failed to ensure the care plan was reviewed and revised with appropriate interventions to manage behaviors for a resident who expressed suicidal ideations with intent. The findings include:Resident #1 had diagnoses that included suicidal ideation, paranoid schizophrenia, bipolar disorder, hallucinations, psychosis, anxiety, and depression.The physician's orders dated 6/7/2025 directed to monitor the number of behavior occurrences of restlessness, withdrawn, sadness, agitation, intervention, and outcome every shift.The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (BIMS score of 15), was occasionally incontinent of bowel, presence of an indwelling foley catheter, dependent with personal hygiene, toileting, required substantial assistance with eating, toileting, required touching…

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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to remove environmental hazards and implement safety interventions for a resident with expressed suicidal ideation and intent. The resident was transferred to the emergency department (ED) 4 times over a 38-day period for expressions of suicidal ideations with intent. The findings include:Resident #1 had diagnoses that included suicidal ideation, paranoid schizophrenia, bipolar disorder, hallucinations, psychosis, anxiety, and depression. Review of the undated Kardex Report identified Resident #1 requires supervision and assistance with self-feeding after set-up with intermittent verbal cues for attention to task with one staff. The physician's orders dated 6/7/2025 directed to monitor the number of behavior occurrences of restlessness, withdrawn, sadness, agitation, intervention, and outcome every shift. The 5-day Minimum…

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 clinical record reviews, review of facility documentation, facility policies, and interviews for one (1) of four (4) sampled residents (Resident #2) who was a readmission to the facility after a hospital stay, the facility failed to ensure the physician's orders from the hospital discharge summary were accurately transcribed into the resident's Medication Administration Record. The findings include: Resident #2's diagnoses included Parkinson's Disease, vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, major depressive disorder and multisystem degeneration of the autonomic nervous system. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15) indicating Resident #2 had some memory recall deficits. The Resident Care Plan dated 1/13/25 identified Resident #2 required the use of psychotropic medication, antipsychotics and selective serotonin…

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 clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for change in condition, the facility failed to notify the provider timely when a resident was identified to have low blood sugar levels. The findings include: Resident #1's diagnoses included diabetes, IGG4 related disease (chronic inflammatory condition affects multiple organs) and end stage renal disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (indicative of no cognitive impairment), was a diabetic and received insulin two (2) days during the prior seven (7) days. The Resident Care Plan (RCP) dated 1/11/2025 identified Resident #1 had diabetes with hypoglycemia. Interventions directed to obtain blood sugars as ordered by the MD, monitor/document/report prn any signs and symptoms of hypoglycemia, monitor/document/report prn compliance…

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 clinical record reviews, review of facility documentation, facility policies and interviews for one (1) of four (4) sampled residents (Resident #4) who were dependent on staff for activities of daily living and reviewed for an allegation of being neglected, the facility failed to ensure Resident #4 was provided with toileting hygiene and transferred off the toilet in an appropriate timeframe. The findings include: Resident #4's diagnoses included Parkinson's Disease, osteoarthritis, chronic kidney disease, and macular degeneration. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 was alert and oriented to person, place, and time, was dependent on one (1) staff member for personal and toileting hygiene, required two (2) staff for transfers on and off the toilet and utilized a wheelchair for mobility. The Resident Care Plan dated 11/5/24 identified Resident #4 had a self-care deficit due to Parkinson's Disease. Interventions directed to provide limited assistance of one (1)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for change in condition, the facility failed to ensure staff acted on low blood sugar test results timely, and failed to ensure an endocrinology appointment was made timely for a resident with a known history of low blood sugars. The findings include: Resident #1's diagnoses included diabetes, IGG4 related disease (chronic inflammatory condition affects multiple organs) and end stage renal disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (indicative of no cognitive impairment), was a diabetic and received insulin two (2) days during the prior seven (7) days. The Resident Care Plan (RCP) dated 1/11/2025 identified Resident #1 had diabetes with hypoglycemia. Interventions directed to obtain blood sugars as ordered by the MD,…

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 clinical record reviews, review of facility documentation, facility policy and interviews for one (1) of four (4) sampled residents (Resident #4) who required a mechanical lift for transfers, the facility failed to ensure the appropriate number of staff conducted the transfer in accordance with the physician's order. The findings include: Resident #4's diagnoses included Parkinson's Disease, osteoarthritis, , chronic kidney disease, and macular degeneration. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 was alert and oriented to person, place, and time, was dependent on one (1) staff member for personal and toileting hygiene, required two (2) staff for transfers on and off the toilet and utilized a wheelchair for mobility. The Resident Care Plan dated 11/5/24 identified Resident #4 had a self-care deficit due to Parkinson's Disease. Interventions directed to provide limited assistance of one (1) staff member with most activities of daily living and transfer assistance of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for change in condition, the facility failed to ensure to ensure the Glucagon order was written accurately the clinical record was complete and accurate to include accurate orders for Glucose/Glucagon, and failed to ensure documentation of nursing actions for a resident with low bloods sugars. The findings include: Resident #1's diagnoses included diabetes, IGG4 related disease (chronic inflammatory condition affects multiple organs) and end stage renal disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (indicative of no cognitive impairment), was a diabetic and received insulin two (2) days during the prior seven (7) days. The Resident Care Plan (RCP) dated 1/11/2025 identified Resident #1 had diabetes with hypoglycemia. Interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, review of facility policy and interviews for one sampled resident (Resident #90) reviewed for foot care, the facility failed to ensure the resident was seen by a podiatrist. The findings include: Resident #90 was admitted to the facility in April of 2023 with diagnoses that included type 2 diabetes mellitus, hyperlipidemia, and hypertension. The quarterly MDS assessment dated [DATE] identified Resident #90 was cognitively intact, was dependent for lower body dressing, for putting on and removing shoes, toileting, and bathing. It further identified the resident was wheelchair dependent and required staff for locomotion. The care plan dated 11/30/23 identified Resident #90 had a self-care deficit with interventions that directed for the assistance of two staff members for showering or bathing. The care plan further identified the potential for skin breakdown due to diabetes with interventions that directed skin checks with care and weekly skin evaluations. Review of…

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

Based on observations, review of facility policy, and interviews, the facility failed to ensure food items were properly stored and labeled and failed to ensure that two dietary aides (#1 and #2) had their hair restrained properly. The findings include: Observation of the kitchen with the Food Service Supervisor on 1/2/24 at 10:00 AM identified the walk-in freezer contained opened bags of frozen turkey burger patties and chicken breast without a noted expiration date. Continued observations with the Food Service Supervisor on 1/2/24 of the dry storage area identified one opened bag of breadcrumbs that did not have a noted expiration date, one opened bag of spaghetti pasta without an expiration date and three opened bags of muffin mixes without expiration date or a best use by date. Observation on 1/2/24 at 10:00 AM identified Dietary Aide #1, and Dietary Aide #2 with hair hanging several inches past the nape of the neck beyond the edge of the hair net. Interview with Food Service Supervisor on 1/2/24 at 10:20 AM identified that the food located in the freezer and dry storage must…

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 review of the clinical record, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #166) reviewed for mood/behavior, the facility failed to follow physician orders for Depakote levels every 6 months, The findings include: Resident #166's diagnoses included Alzheimer's dementia, delusional disorder, impulse disorder, and major depressive disorder. The quarterly MDS assessment dated [DATE], identified Resident #166 was severely cognitively impaired, required supervision or touch assistance for grooming, toileting, ambulation, and moderate assist of one for dressing. The care plan dated 12/17/23 identified a concern with amorous behaviors with interventions that included: 15-minute checks, staff explaining appropriate vs inappropriate boundaries, and refer to psychiatry and or social work as needed for support. A physician's order dated 11/2/23 directed to have a Depakote (antiepileptic medication and used to treat mania/behaviors) level drawn every…

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 clinical record review, observations, review of facility policy and interviews for one of three sampled residents (Resident #54) reviewed for respiratory care, the facility failed to ensure a physician's order was in place directing the use of oxygen therapy for a resident utilizing oxygen. The findings include: Resident #54's diagnoses included chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure, sleep apnea, and chronic bronchitis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #54 was cognitively intact, required moderate assistance with toileting, transfers, and personal hygiene. It further identified Resident #54 had shortness of breath or trouble breathing when lying flat and required oxygen therapy. Observation on 1/3/24 at 10:15 AM identified Resident #54 seated in a wheelchair wearing a nasal cannula connected to the oxygen concentrator set at 2.5 liters/minute (LPM). Observation on 1/3/24 at 2:22 PM with RN #6 identified…

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, review of facility documentation, review of facility policy, and interviews for two medication administration carts, the facility failed to ensure accurate accounting of the disposition of a schedule II medication and failed to ensure accurate accounting of a narcotic medication. The findings include: 1. A review of the facility's narcotic count records for the 3C unit for the months of November 1, 2023, through January 10, 2024, identified that the controlled drug count was counted for each shift, which was indicated by the signature of the oncoming and off-going nurse. The narcotic count record sheet identified that discrepancies must be reported to the Nursing Supervisor immediately. Observation of the C Wing controlled medications located in the C/D medication storage room fridge on 1/4/24 at 10:30 AM with LPN #11 identified 3 bottles of Lorazepam Intensol Oral Concentrate (liquid anxiolytic) 2 milligram/milliliter (mg/ml) for one resident: a) A bottle of Lorazepam Intensol Oral Concentrate 2mg/ml with the Prescription # (Rx#) 12905610 contained 27.75…

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, review of facility policy and interviews, the facility failed to ensure expired medications were not in use and removed from circulation and failed to ensure medications were not stored with food items. The findings include: 1. Observation of the C Wing medication cart on 1/4/24 at 10:30 AM with the Charge Nurse (LPN #11) identified the following expired medications in the top drawer of the medication cart: a. Simethicone 80 milligrams (mg) (Gas Relief) had an expiration date of 9/2023, which was 4 months past the expiration date. b. Vitamin B6 50 mg had an expiration date of 10/2023, which was 3 months past the expiration date. c. One Daily Multi-Vitamin had an expiration date of 10/2023, which was 3 months past the expiration date. d. One Daily Multivitamin with Mineral had an expiration date of 11/2023, which was 2 months past the expiration date. e. Magnesium Oxide 400 mg had an expiration date of 11/2023, which was 2 months past the expiration date. f. Vitamin B12 500 micrograms (mcg) had an expiration date of 12/2023, which was 1 month past 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 review of the clinical record, review of facility documentation, and interviews for one sampled resident (Resident #135) reviewed for hospice, the facility failed to ensure that the clinical record included all appropriate hospice documentation. The findings include: Resident #135's diagnosis included malignant neoplasm of the mouth, chronic obstructive pulmonary disease (COPD), and Pain. The quarterly Minimum Data Set assessment dated [DATE] identified Resident # 135 had intact cognition, required extensive assistance of one person for personal hygiene, dressing, toileting, and was receiving hospice services. The Resident Care Plan dated 11/22/23 identified the Resident as receiving Hospice services and directed coordination of care between Hospice and the facility staff. Interventions included: to document in the Hospice and facility EMR per protocol, to ensure the Hospice binder is in place and includes the Hospice care plan and is kept up to date. A Physicians order dated 7/27/23, directed 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 clinical record reviews, review of facility documentation and interviews for one of two sampled residents (Resident #1) who were reviewed for an incident involving a verbal altercation with a staff member, the facility failed to refrain from utilizing inappropriate language to ensure the resident was treated with respect and dignity. The findings include: Resident #1's diagnoses included anxiety disorder, persistent mood disorder. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 made consistent and reasonable decisions regarding tasks of daily life, required two (2) person extensive assistance with turning and repositioning when in bed, dressing, and one (1) person extensive assistance with personal hygiene. The Resident Care Plan dated 8/29/23 identified the resident had a behavior problem, being intrusive, self-limiting, poor boundary setting making inappropriate and/or sexual jokes/remarks. Interventions directed to adm8inister medications as ordered, encourage the 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 clinical record reviews, review of facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) who was a new admission with a diagnosis of difficulty with swallowing and a recent history of aspiration, the facility nurse failed to transcribe the hospital physician's orders for one (1) to one (1) assistance to maintain aspiration precautions and the speech therapist failed to input into the physician's order the recommendations for full supervision with meals. The findings include: Resident #1's diagnoses included dysphagia, cognitive communication deficit, mild cognitive impairment, acute respiratory failure with hypoxia, cardiac arrest due to underlying cardiac condition. The hospital Discharge summary dated [DATE] identified during the hospitalization Resident #1 was evaluated by a Speech Language Pathologist on 2/20/23 and was cleared for a regular diet. On 2/21/23, Resident #1 subsequently lost pulses, a code blue was called, and Cardiopulmonary…

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 facility documentation review, facility policy review, and interviews for facility Administration review, the facility failed to administer its resources effectively and to ensure effective administrative oversight of staff and resident care timely to maintain the highest practicable physical, mental, and psychosocial well-being of residents. The findings include: The facility failed to implement full, one (1) to one (1), supervision during meals and when eating food. The facility nurse failed to transcribe a physician's order upon admission for one (1) to one (1) assistance to maintain aspiration precautions. The speech therapist failed to transcribe as a physician's order the recommendations for full supervision with meals. Please cross reference F689 and F658. Based on the deficiencies during the survey, immediate jeopardy and substandard care was identified in the areas of Comprehensive Resident Centered Care Plans and Quality of Care. Interview with the Director of Nurses on 7/26/23 at 12:55 PM failed to identify administrative oversight of the facility processes to…

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

Based on observation, review of facility documentation, facility policy and interview the facility failed to ensure medications were within their expiration, and that refrigerated narcotic medications were maintained in separately locked, permanently affixed compartments. The findings include: 1. Observation on 8/25/21 at 12:00 PM in the 4 AB medication room identified the following. Eighteen single dose Acetaminophen suppositories with an expiration date of 4/20. One single dose Influenza vaccine with an expiration date of 6/30/19. One single dose Influenza vaccine with an expiration date of 6/30/20. Two single dose Influenza vaccines with an expiration date of 5/10/21. Subsequent to surveyor inquiry, LPN #2 disposed of expired medications. 2. Observation on 8/25/21 at 2:05 PM in the 3 AB medication room identified the following. One Heparin lock flush with an expiration date of 4/21. Interview with RN #2 on 8/25/21 at 2:10 PM identified the Heparin lock flush was expired. Subsequent to surveyor injury, RN #2 disposed of the expired medication. Interview with the DNS on 8/27/21 at…

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, facility documentation, facility policy, and interviews the facility failed to ensure food in the kitchen was dated, labeled, and discarded after the expiration date, and failed to ensure dietary staff followed infection control policy during food preparation. The findings include: Observation on 8/23/21 at 10:15 AM with the Assistant Director of Dietary in the kitchen identified the center large refrigerator contained 3 trays with a total of 35 individual salads which were not dated/labeled. The Assistant Director of Dietary indicated the label dating machine did not have any ink in it and the afternoon staff are new and do not know how to change the ink cartridge in the machine. The dry storage room and milk refrigerator had a cart on wheels with 4 shelves with trays with different colored liquids on each tray without dates or labels. There were 48 four-ounce cups with plastic disposable lids on them. The Assistant Director of Dietary indicated the cups should have been dated and labeled. In the refrigerator behind the prep table there were 2 large…

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, review of the clinical record, and facility documentation for 1 resident (Resident #137) reviewed for limited range of motion, the facility failed to ensure the call bell was within the resident's reach. The findings include: Resident #137 was admitted to the facility on [DATE] with diagnoses that included a history of stroke with left sided weakness. The quarterly MDS dated [DATE] identified Resident #137 had intact cognition and required limited assistance with transfers. The corresponding care plan identified to encourage Resident #137 to use the call bell for assistance. Intermittent observations on 8/23 and 8/24/21 during the 7:00 AM - 3:00 PM shift identified Resident #137 was out of bed in the wheelchair in his/her room. Although Resident #137 was on the left side of his/her bed, the call bell was tied to the side rail on the right side and covered by the sheets/blankets out of the resident's reach. The facility failed to ensure the resident's call light was within the resident'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 observation, interview, and review of facility policy, for 1 resident (Resident #62) reviewed as part of the stage one sample, the facility failed to ensure resident equipment was maintained in a clean and sanitary manner. The findings include: Resident #62 had diagnoses that included history of a stroke with aphasia. The quarterly MDS dated [DATE] identified Resident #62 had short and long-term memory impairment and required the use of a feeding tube to receive adequate nutrition. The corresponding care plan identified Resident #62 had the potential for a nutrition problem with interventions that included to provide tube feeding for adequate nutrition. Review of the August 2021 physician's orders directed to administer Jevity 1.5 via gastric tube at 60 ml/hr., on at 7:00 PM off at 7:00 AM. Observation on 8/23/21 at 10:30 AM identified a feeding tube pump and pole next to Resident # 62's bed. The pole was caked with an unidentified dried material with a long yellow stained piece of tape, and the pump…

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, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #69) reviewed for grievances, the facility failed to ensure the grievance process was followed. The findings include: Resident #69 was admitted to the facility on [DATE] with diagnoses that included partial intestinal obstruction and diabetes. The admission person items form failed to reflect that Resident #69 had a cell phone. The admission MDS dated [DATE] identified Resident #69 had moderately impaired cognition. The care plan dated 5/3/21 identified interventions to increase communication between Resident #69 and caregivers/family about living environment, and explain all treatments, medications, rules, and options. Interview with Resident #69 on 8/23/21 at 12:02 PM identified someone stole her/his phone about 3 months ago and he/she reported it to the charge nurse and social worker. Resident #69 indicated he/she left the phone in the room on the charger, and when he/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 observation, review of the clinical record, facility documentation facility policy and interview for 2 residents (Resident #35 and 85) reviewed for smoking, the facility failed to follow their policy regarding using the non-combustible ashtray with self-closing covers. The findings include: 1. Resident #35 was admitted to the facility on [DATE] and had diagnoses that included a history of a stroke and seizure disorder. Review of a nursing safety smoking screen, completed by a registered nurse, dated 4/22/20, identified Resident #35 had cognitive loss, no visual loss, smokes 2 - 5 cigarettes per day, cannot light own cigarette, can hold cigarette. Resident #35 is safe to smoke with supervision. The screen included a smoking care plan that indicated staff are to complete ongoing evaluation of the resident's ability to smoke safely. The clinical record failed to reflect that another safety smoking screen had been completed subsequent to 4/22/20. The quarterly MDS dated [DATE] identified Resident #35 had…

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, review of the clinical record, facility documentation and interview for 1 resident (Resident #146) reviewed for respiratory care, the facility failed to ensure oxygen tubing was changed according to the facility policy. The findings include: Resident #146 was admitted to the facility on [DATE] with diagnoses that included COPD. Physician's order dated August 2021 directed to administer oxygen at 2 liters per minute continuous via nasal cannula overnight. Additionally, the order directed to change the oxygen tubing weekly on Tuesday. Observation on 8/23 and 8/24/21 identified Resident #146's oxygen tubing was dated as having been changed on 8/10/21, 14 days ago. Interview with the ICN on 8/25/21 at 12:00 PM identified that oxygen tubing should be changed weekly per the doctor's order. The facility failed to ensure the oxygen tubing was changed according to the physician order.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy and interview, the facility failed to ensure that staff performed hand hygiene during meal delivery. The findings include: Observation on 8/23/21 at 12:10 PM on the 4 B unit identified the following. Three nurse aides were passing meal trays to the residents in their rooms. One nurse aide was noted to go into room [ROOM NUMBER], move the tray table, move the resident's wheelchair and set up the resident's tray. The nurse aide proceeded to leave the room without the benefit of hand hygiene and obtain another meal tray and set up the next residents meal. Interview with the ICN on 8/25/21 at 12:00 PM identified that hand hygiene should be performed after each resident/resident environment contact. Review of the policy on hand hygiene identified hand hygiene continues to be the primary precaution for preventing the transmission of infection. Soap, water, alcohol-based rub and a sink are readily available in appropriate locations including resident care areas and 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.