Civita Care Center At Salmon Brook

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy and staff interview for the only resident reviewed for Dementia Care (Resident #89), the facility failed to revise the resident's comprehensive individualized interdisciplinary dementia care plan timely. The findings include: Resident #89's diagnosis includes dementia with behavioral disturbance. The Minimum Data Set assessment dated [DATE] identified Resident #89 had a diagnosis of non-Alzheimer's dementia and indicated care planning for cognitive loss/dementia would be addressed in the care plan. A care plan dated 8/15/2024 indicated Resident #89 had cognition/acute delirium/hallucinations. Interventions included 1:1 visit in a quiet environment to provide reality orientation offering opportunity to verbalize needs, feelings, to involve family and supportive care Advanced Practice Registered Nurse (APRN). The annual MDS assessment dated [DATE] indicated Resident #89 was noted with a diagnosis of dementia and cognitive loss/dementia to be addressed 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 clinical record review, review of facility policy and staff interviews only the resident (Resident #65), reviewed for Activities of Daily Living (ADL), the facility failed to ensure ADL care was provided every two hours per facility practice. The findings include: Resident #65's diagnosis includes spinal cord injury. A care plan dated 4/28/2025 identified Resident #65 was dependent for ADL and required two people for care The quarterly MDS assessment dated [DATE] identified Resident #65 was cognitively intact and was dependent for toileting and personal hygiene. An interview on 6/17/2025 at 12:00 PM with Resident #65 identified she/he had to wait 5 hours to get changed after a bowel movement on 6/13/2025. The resident indicated that the nurse aide from the evening shift informed him/her the nurse aide needed to wait for help from a staff member in the other wing secondary to she was the only one assigned to the wing. The resident indicated that she/he called his/her family member, who then called 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, facility policy and interview for the only sampled resident (Resident #20) reviewed for Communication/ Sensory, the facility failed to administer eye medications according to physician's orders.The findings include: Resident #20 's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), tremor, unspecified and anxiety disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #20 as cognitively intact, vision was reported as adequate, and noted resident uses corrective lenses. Independent in eating, toilet hygiene and bed mobility. The care plan dated 6/11/25 identified impaired visual function related to cataracts and glaucoma. Interventions included: to review medications for side effects which affect vision. Arrange consultation with eye care practitioner as required. Monitor/document/report when needed (PRN) any signs and symptoms of acute eye problems. A physician's order dated 6/8/25 directed to give 1 drop of Moxifloxacin HCl…

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, review of facility staffing posting, resident interviews, review of the Facility Assessment and staff interviews, the facility failed to provide sufficient staff to care for the needs of a dependent resident (Resident #65) in accordance to facility staffing ratios. The findings include: Resident #65's diagnosis includes spinal cord injury. A care plan dated 4/28/2025 identified Resident #65 was dependent for ADL and required two people for care The quarterly MDS assessment dated [DATE] identified Resident #65 was cognitively intact and was dependent for toileting and personal hygiene. An interview on 6/17/2025 at 12:00 PM with Resident #65 identified she/he had to wait 5 hours to get changed after a bowel movement on 6/13/2025. The resident indicated that the nurse aide from the evening shift informed him/her the nurse aide needed to wait for help from a staff member in the other wing secondary to she was the only one assigned to the wing. The resident indicated that she/he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy and interviews, the facility failed to ensure staff closed and locked the nursing supervisor's office door with medications stored on counters in unsecured containers and unlocked cabinets when leaving the area. The facility failed to ensure Residents #20, # 21, 38, 71 and #80's eye drops located in one medication cart were dated once opened and failed to remove expired Intravenous Therapy equipment and medication. The facility failed to remove discharge resident medications timely. The findings included: 1.An observation on [DATE] at 09:45 AM identified the nursing supervisor's office door open with no staff inside and or within eyesight. Further observations identified a clear plastic case labeled with emergency medications inside and under the clear box was an orange emergency medication box with a handle without a lock allowing ease of removal from the office. After a few minutes at 9:48 AM with no staff returning to the office the Regional Nurse (RN #1) 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 of glucometer monitoring, review of facility policy and interviews, the facility failed to ensure that used lancets were disposed of in a manner to contain and prevent any potential contamination/spread of bloodborne pathogens. The findings include: An observation and interview on 6/17/2025 at 7:38 AM of the facility procedure for glucometer use while obtaining a fingerstick with a retractable one time use sharps lancet for a blood glucose reading on unit B. Further observation identified once the procedure was completed the lancet was placed into a plastic disposable drink cup with no lid and not secured, then placed on top of the treatment cart which did not have any sharps containers available. RN #2 indicated once all finger sticks were completed the cup was brought to the sharp's container located on the medication cart where the used lancets were then poured into the sharp's container. An observation and interview on 6/17/25 7:43 AM on the A-wing with LPN #3 indicated the plastic disposable drink cup with no lid and not secured located on top of the…

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

Based on observations, facility policy and interviews, the facility failed to ensure that laundry equipment within the facility was maintained timely and in proper working order. The findings include: Interview with Resident #15 on 5/28/25 at 12:19 PM identified staff complain there is not enough washcloths for care, it has taken weeks to get personal laundry back and staff have told him/her the facility has only one (1) working washing machine. Interview with Resident #2 on 5/28/25 at 12:24 PM identified his/her personal laundry was sent to laundry eight (8) days ago, he/she had not received it back, and he/she had to wear dirty clothing because he/she had no clean clothing left to wear. Resident #2 identified he/she reported the laundry delay to the Administrator a few days prior and inquired with the laundry staff who reported the facility had only one working washing machine. Interview with Resident #3 on 5/28/25 at 12:38 PM identified the facility does not have enough washcloths or towels for bathing, he/she has had to use sheets as towels, and staff told him/her they do not…

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, facility documentation and interviews, the facility failed to ensure that building equipment was maintained to provide a clean, comfortable, home-like environment for the residents. The findings include: Interview with Resident #15 on 5/28/25 at 12:19 PM identified staff complain there is not enough washcloths for care, it has taken weeks to get personal laundry back and staff have told him/her the facility has only one (1) working washing machine. Interview with Resident #2 on 5/28/25 at 12:24 PM identified his/her personal laundry was sent to laundry eight (8) days ago, he/she had not received it back, and he/she had to wear dirty clothing because he/she had no clean clothing left to wear. Resident #2 identified he/she reported the laundry delay to the Administrator a few days prior and inquired with the laundry staff who reported the facility had only one working washing machine. Interview with Resident #3 on 5/28/25 at 12:38 PM identified the facility does not have enough washcloths or towels for bathing, he/she has had to use sheets as towels, and staff…

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 falls, the facility failed to ensure a fall intervention was implemented according to the plan of care and according to physician order, after a resident who was identified as a high fall risk, sustained a fall out of bed. The findings include: Resident #1's diagnoses included altered mental status, muscle weakness, atherosclerotic heart disease (the build-up of plaque in the arteries limiting blood flow to the heart) and congestive heart failure (the hearts inability to pump blood as efficiently as it should). The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 10), required substantial assistance for bed mobility and was dependent on staff for personal hygiene and transfers. The Resident Care Plan (RCP) dated 10/26/22 identified Resident #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 review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for impaired skin integrity, the facility failed to ensure preventative interventions were initiated and implemented according to facility policy for a resident admitted to the facility with an active pressure injury and after the development of a facility acquired pressure injury. The findings include: Resident #1's diagnoses included altered mental status, muscle weakness, atherosclerotic heart disease (the build-up of plaque in the arteries limiting blood flow to the heart) and congestive heart failure (the heart's inability to pump blood as efficiently as it should). A nurse's note dated 9/29/22 at 1:01 PM identified that Resident #1 was admitted to the facility with a stage 2 pressure injury (partial thickness wound) to the coccyx measuring 2 centimeters (cm) by 1 cm. A Braden Scale assessment dated [DATE] identified that Resident #1 was at a high risk for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation and interviews for one (1) of three (3) residents (Resident #4) reviewed for dependent care, the facility failed to ensure complete and accurate Nurse Aide documentation. The findings include: Resident #4's diagnoses included dementia, altered mental status, anxiety disorder and malnutrition. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 8), required setup assistance for eating and was dependent on staff for personal care, bed mobility and transfers. The Resident Care Plan (RCP) dated 4/29/25 identified Resident #4 required assistance with Activities of Daily Living (ADLs). Interventions included staff providing all Resident #4's care if he/she was unable to participate in ADLs. Observation on 5/28/25 at 12:34 PM identified Resident #4 was dressed and sitting in his/her wheelchair at the bedside. Resident #4 appeared clean, well…

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, facility documentation, facility policy, and interviews for one (1) of five (5) sampled residents (Resident #1) who were reviewed for podiatry services, the facility failed to ensure Resident #1 was added to the podiatrist's priority schedule following a diagnosis of an infection of the left great toe. The findings include: Resident #1's diagnoses included diabetes with polyneuropathy (nerve pain). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Basic Interview for Mental Status (BIMS) score of 10 out of 15 indicating some memory recall deficits and was dependent on staff for personal care. The current Resident Care Plan identified Resident #1 had diabetes mellitus. Interventions directed to wash the feet daily with mild soap and water, dry thoroughly, may use a light dusting powder or lotion, and do not apply lotion or powder between the toes, and to monitor skin and report any issues. A physician's order dated 2/1/25 directed diabetic foot…

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, facility documentation, and staff interviews for one of three (Resident #1 and Resident #2) reviewed for accidents, the facility failed to ensure wander guard bracelet physician orders were obtained timely for residents identified as high wander risk and failed to ensure physician orders directed wander guard bracelet daily function checks. The findings include: 1. Record review identified Resident #1 had a diagnosis of Alzheimer's disease and delusional disorders, and Resident #1 had a Power of Attorney (POA) for care decisions and finances. Wander risk evaluation dated 1/10/2025 identified Resident #1 scored a 12 which indicated Resident #1 was a high wander risk. The Resident Care Plan (RCP) dated 1/14/2025 identified an elopement risk/wanderer related to disoriented to place. Interventions directed to distract from wandering by offering diversions, identify patterns of wandering, reorient, and use of a wander guard bracelet. admission Minimum Data Set (MDS) dated [DATE] 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 observations, staff interviews, and review of facility policy, regarding medication administration, the facility failed to ensure the failed to ensure only authorized personnel had access to the keys, including keys to the medication rooms and medications, and failed to ensure separately locked, permanently affixed compartments for the storage of controlled drugs was maintained. The findings include: Interview and continuous observations with RN #2 on 2/19/2025 at 10:26 AM in a hallway located near the kitchen identified she does not keep the nursing supervisor keys on her person because they are too heavy and stated she keeps them in the nursing supervisor office. Observation of the supervisor office (located on a different wing) identified the supervisor door was open and APRN #1, ADNS and Resident #4 were in the office near a desk. Resident #4 was standing and ambulated independently. RN #2 opened an unlocked top drawer next to the door, and removed two (2) rings of keys. RN #2 demonstrated she had keys to all areas of the facility, including medication storage,…

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 clinical record review, facility documentation review, facility policy review, and interviews for facility Administration review, the facility failed to ensure the facility administered 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 administration failed to: Ensure a Governing Body was in place. Ensure the Medical Director was appointed by a Governing Body. Ensure the State Agency was notified timely of a reportable event. Ensure the clinical record was complete and accurate to include documentation or an RN assessment. Ensure prevent a resident with a known wander risk had access to unlocked egress from the facility. Ensure wander guard bracelet orders were accurate and timely. Ensure medications were secured and only authorized staff had access to keys. Ensure annual in-service training was completed timely. Ensure facility policies were reviewed and approved annually. Ensure 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.

Based on facility documentation, facility record review, and interviews for governing body review, the facility failed to ensure that they had a governing body, or designated persons functioning as a governing body that is legally responsible for establishing and implementing policies regarding the management and operation of the facility, and failed to ensure the Administrator was appointed by a governing body. The findings include: Review of facility documentation failed to identify a facility governing body. Review of the Administrator's employee file failed to identify the Administrator was appointed by the facility governing body. The review of facility policy and procedure master manual failed to identify an annual review of the facility policies was conducted. Review of facility Elopement Policy with no date provided on 2/19/2025, and review of facility Elopement Policy dated 6/2023 provided on 2/28/2025 identified the policies did not match. Interview with the DNS, Administrator, and Regional Nurse on 2/25/2025 at 11:36 AM identified the facility had three (3) Elopement…

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, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for quality of care, the facility failed to ensure the record was complete and accurate to include an RN assessment following an elopement. The findings include: Record review identified Resident #1 had a diagnosis of Alzheimer's disease and delusional disorders. admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition, and ambulated independently. The Resident Care Plan (RCP) dated 1/14/2025 identified an elopement risk/wanderer related to disoriented to place. Interventions directed to distract from wandering by offering diversions, identify patterns of wandering, reorient, and use wander guard bracelet. Facility reportable event dated 2/18/2025 at 5:00 AM identified Resident #1 was noted to be missing from his/her room at 4:00 AM. Staff were alerted and the building and grounds were searched.…

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 and interviews for two of five employee files (NA #2 and NA #3) reviewed for in-service training, the facility failed to ensure the Nurse Aides had 12 hours of annual training. The findings include: Review of NA #2 employee file identified NA #2 was hired on 8/10/2023. Additional review identified the only education provided during 2023, 2024 and through 2/27/2025 included Intravenous (IV) therapy education. No additional education, including general orientation education was provided. Review of NA #3 employee file identified NA #3 was hired on 7/20/2023. Additional review identified NA #3's annual education included education on resident rights, abuse/retaliation, and dementia. Review of facility employee files for NA #2 and NA #3 failed to identify 12 hours of annual in-service training was provided. Interview with the DNS on 2/27/2025 at 10:52 AM identified all NAs should have a minimum of 12 hours annual in-service training. The DNS was unable to explain why NA #2 and NA #3 did not have the required 12 hours of annual in-service education…

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, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #7) who were reviewed for an allegation of abuse, the facility failed to ensure a staff member did not video tape the resident and post the video on social [NAME]. The findings include: Resident #7's diagnoses included Alzheimer's, depression, and agitation. The annual Minimum Data Set assessment dated [DATE] identified Resident #7 had poor memory recall deficits, and was dependent on staff with transfers, personal hygiene, and dressing. The Resident Care Plan dated 11/5/24 identified Resident #7 had impaired thought processes related to Alzheimer's. Interventions directed to cue, anticipate needs, alleviate anxiety. The Facility Reported Incident report date1/14/25 at 12:00 PM identified a staff member reported that videos were recorded of a staff member interacting with residents in an unprofessional manner. The investigation identified in 1/14/25 a staff member brought…

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, facility documentation and staff interviews for 1 of 3 sampled residents reviewed for accidents (Resident #2), the facility failed to conduct a thorough investigation for an injury of unknown origin. The findings include: Resident #2 was admitted to the facility in August 2024 with diagnoses that included dementia with behaviors, adjustment disorder with mixed anxiety and depression. A Resident Care Plan dated 11/6/24 identified a problem with behaviors, being physically aggressive, destructive in his/her room, and was noted to take the television off of the wall in his/her room. Interventions included to allow Resident #2 to make decisions regarding treatment regimen, encourage participation during care and activities and praise the resident when behavior was appropriate. Nursing notes dated 12/3/24 through 12/10/24 identified that Resident #2 did not exhibit any negative behaviors or anxiety. The quarterly Minimum Data Assessment (MDS) assessment dated [DATE] identified Resident #2 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility documentation, and staff interviews for 2 of 3 residents (Resident #1 and Resident #3) reviewed for accidents, the facility failed to complete neurological assessments following an unwitnessed fall, and for 1 of 3 residents reviewed for accidents (Resident #2), the facility failed to provide documentation of wrist stabilization per APRN recommendations following a fracture. The findings include: 1. Resident #1 had a diagnosis of dementia, falls, osteoporosis, and adjustment disorder. Quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 indicating severely impaired cognition, no behaviors, required maximal assistance with toileting, and was independent with ambulation. Resident Care Plan (RCP) dated 1/18/2025 identified a risk for falls and required assist with ADLs. Interventions directed to offer assistance with ADL's and was assist of one (1) for transfers. Facility incident report dated 1/18/2025 at 2:35…

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 allegation of neglect, the facility failed to conduct a thorough investigation for a resident with an allegation of neglect. The findings include: Resident #1 was admitted to the facility with diagnoses that included spina bifida, neurogenic bladder and spinal stenosis. A physician's order dated 4/25/24 directed to ensure Resident #1 was turned and repositioned every two hours every shift for wound prevention. Braden scale dated 4/26/24 identified Resident #1 was at risk for developing pressure sores. The MDS dated [DATE] identified Resident #1 had no impairments in cognition, no behaviors, was incontinent of bowel and bladder and required extensive assistance of one staff for toilet use and bed mobility. The care plan dated 7/23/24 identified Resident #1 had an ADL self-care performance deficit related to spina bifida. Interventions included to offer…

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 activities of daily living, the facility failed to ensure a resident who required extensive assistance with activities of daily living was provided incontinent care and turning and repositioning in accordance with the plan of care and physician orders. The findings include: Resident #1 had diagnoses that included spina bifida, neurogenic bladder and spinal stenosis. A physician's order dated 4/25/24 directed to ensure Resident #1 was turned and repositioned every two hours, every shift for wound prevention. Braden scale dated 4/26/24 identified Resident #1 was at risk for developing pressure sores. The MDS dated [DATE] identified Resident #1 had no impairments in cognition, no behaviors, was incontinent of bowel and bladder and required extensive assistance of one staff for toilet use and bed mobility. The care plan dated 7/23/24 identified Resident #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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for neglect, the facility failed to ensure appropriate staffing to meet the needs of the resident. The findings include: Resident #1 had diagnoses that included spina bifida, neurogenic bladder and spinal stenosis. A physician's order dated 4/25/24 directed to ensure Resident #1 was turned and repositioned every two hours, every shift for wound prevention. Braden scale dated 4/26/24 identified Resident #1 was at risk for developing pressure sores. The MDS dated [DATE] identified Resident #1 had no impairments in cognition, no behaviors, was incontinent of bowel and bladder and required extensive assistance of one staff for toilet use and bed mobility. The care plan dated 7/23/24 identified Resident #1 had an Activity of Daily Living (ADL) self-care performance deficit related to spina bifida with interventions that included to offer Resident #1 early care 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 clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for a change in condition, the facility failed to ensure hospital discharge orders were acted on timely. The findings include: Resident #1 diagnoses included cellulitis and abscess of the mouth, Clostridium Difficile, malnutrition, and cerebral infarction (stroke). The Resident Care Plan dated 12/8/2023 identified a nutritional problem with a history of significant weight loss. Interventions directed to for signs and symptoms of dysphagia (difficulty swallowing) and to provide serve diet as ordered. Review of physician's orders dated 1/10/2024 directed regular texture diet, thin liquids. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was alert and oriented. Nursing note dated 2/19/2024 at 10:02 AM identified Resident #1 presented with increased facial swelling, numbness, and left side facial droop, unable to smile or raise…

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 of the environment, review of facility documentation and staff interview, the facility failed to ensure that resident areas , dinning room and equipment were maintained in a clean and comfortable homelike manner. The findings included: 1. Observation of Resident [NAME] room identified during the survey bath tile with chip paint. Please reference the following environment observations below: Observation during a tour to the facility on 5/30/23 of the environment identified on A C and D wings sink in need of repair, radiators in need of repair, toilets in need of repair, broken tiles on Resident [NAME] room, holes in walls, peeling paint, and wallpaper peeling. Interview with the DNS on 6/6/23 at 2:45 PM identified the facility maintenance staff conducted room audit for fixing and repairing walls, radiators toilet and other items that require repair on 6/5/23 and will begin completing repairs identified on the audit. 2. Observation on 6/1/2023 at 8:00 AM found the C/D Resident lounge 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 a review of the facility admission/ transfer discharge and staff interview, the facility failed to provided evidence of monthly notification to the state Regional Ombudsman Office of residents' transfers and discharge status in the facility. The finding include: A review of the facility admissions/ transfer and discharge on [DATE] from 3/2023 through 5/2023 failed to reflect that the facility had notified the state Regional Ombudsman Office of residents' transfers and discharge status in the facility monthly. Interview with the DNS on 6/8/23 at 1:57 PM identified she was unable to provide the missing documentation of monthly notification to the Regional Ombudsman Office of residents' transfers and discharge status from 3/2023 through 5/2023.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation and interviews for 1 of 2 sampled residents (Resident #11) reviewed for Pre-admission Screening and Resident Review (PASSR), the facility failed to submit a PASSR level of care when a change in the resident's mental status The findings included: Resident # 11's diagnosis at the time of admission include dementia, hypertension, cancer heart failure and depression. A long-term approval of Nursing facility level of care for Resident # 11 dated 6/5/2020 indicated if serious mental illness is suspected or occurs and there is a change in treatment the facility needs to complete and submit and level of care. The readmission 5 day MDS assessment dated [DATE] identified the resident was moderately cognitively impaired and required limited assistance with ADLs. Resident #11's diagnosis list indicated a diagnosis of bipolar disorder (new diagnosis of serious mental illness) was added on 7/28/2022. Resident # 11's diagnoses included dementia, and bipolar…

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 policy and interviews for 1 resident (Resident # 28) reviewed for Position, Mobility, the facility failed to ensure the physician's orders were followed for a resting hand splint and for 1 of 5 residents observed dining ( Resident # 24), the facility failed to follow facility practice for staff supervision during meal time to meet profession practice. The findings included: 1.Resident #28's diagnoses included cerebrovascular disease, hemiplegia and hemiparesis, and neuralgia and neuritis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #28 as moderately cognitively intact and required one person assistance with toilet use, personal hygiene, bed mobility and transfers. The current Resident Care Plan a self-care deficit with activities of daily living, impaired cognitive function, and an alteration in musculoskeletal status related to right hand contracture. Interventions identified assistance needed in performing activities of daily living 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 clinical record review, facility documentation review, facility policy review, and interviews for 1 sampled resident (Resident #7) reviewed for discharge, the facility failed to timely assist the resident with request to transfer to another facility and for 1 of 2 sampled residents (Resident #51 and Resident # 369) reviewed for Hospice and /or death, the facility failed to ensure medically-related social services were provided. The findings included: The findings included: 1. Resident #7's diagnoses included intracranial injury, transient cerebral ischemic attack, heart failure, depression, anxiety, and adjustment disorder with behavior disturbance. The Resident Care Plan dated [DATE] identified Resident #7 had behavior problems, refused care and was combative/accusatory towards staff at times. Interventions directed to anticipate, meet the residents needs and assist the resident to develop more appropriate methods of coping and interacting. The admission Minimum Data Set (MDS) assessment dated [DATE]…

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 records and interviews, for 2 of 5 sampled residents (Resident # 11), the facility failed to ensure pharmacy recommendations that were approved by the physician were implemented and for Resident # 64, the pharmacy failed to notify the physician the resident's laboratory work was not completed . The findings included: 1. Resident #11's diagnoses included diabetes mellitus, hypertension, heart failure, hyperlipidemia, and dementia. The annual Minimum Data Set (MDS) dated [DATE] identified Resident #11 had mild cognitive impairment. The consultant pharmacist recommendations to Prescriber form dated 12/12/2022 indicated as a result of the pharmacist review recommendations were made to consider monitoring a fasting lipid panel on the next laboratory day and then once yearly thereafter if they are within normal limits. The form further indicated the physician agreed with the recommendations, and signed the form 12/12/2022, indicating to obtain a Complete Blood Count (CBC), lipid panel,…

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 of the noon tray line, review of facility documentation and staff interview, the facility failed to provide food at an appetizing temperature . The findings included: Observation with Dietary Director and Regional Food and Nutrition Service Director of the lunch tray line on 6/5/23 started at 12:20 PM identified the last cart left the kitchen at 12:55 PM and arrived at B Wing at 12:58 PM, serving began at 12:59 PM, and the last resident tray was served to Resident #88 at 1:05 PM. Tray line last tray's temperatures on 6/5/23 at 1:07 PM identified the following: that the main entry meal item (sausage) had a temperature (in degrees Fahrenheit) of 121.6/121. surveyor/Dietary Director temperatures _, potatoes at 121.5/117, corn at 130.8/130, and ice cream brought up to unit without being on ice had a somewhat liquid consistency in appearance at 19.4/19 . Review of Facility documentation of Holding Temperatures indicated sausage at 187 degrees, potatoes at 193 degrees, corn at 185 degrees and ice cream at freezer temperatures of 36-41 degrees.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of kitchen, facility documentation, and interviews, the facility failed to properly label foods, discard expired food, maintain, and rotate emergency food supply stock, and serve food at professional standards. The findings include: During the initial kitchen tour with the facility's Dietary Director on 6/5/2023 at 8:40 AM identified the following: a. The dry kitchen stock shelving contained 2 outdated thickened Apple Juice boxes. Additionally, contained several bags of oats with no expiration date, [NAME] grape jelly with no expiration or purchase date. b. The refrigerator contained bags of Milano's grated parmesan cheese (production date of 4/21/23), no expiration date, and cheddar cheese grated (production date of 4/26/23), no opened or expiration date. c. The shelving outside the refrigerator near the cooking prep area contained beef base with no label, and E &S brand chicken soup mix was in a bucket with no open or expiration dates. d. The canned goods area contained several cans 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 observations, clinical record reviews and staff interviews for 3 of 4 sampled residents (Resident #29, Resident #32, Resident #77, and Resident #86) reviewed for dining, the facility failed to provide a dignified dining experience by ensuring all residents were served at the same time. The finding included: 1. Resident #29's diagnoses included cerebral infarction, anemia, and seizure disorder. The quarterly Minimum Data Sheet (MDS) assessment dated [DATE] identified Resident #29 was severely cognitively impaired and required extensive assistance of one person for bed mobility, transfers, dressing, toilet use and personal hygiene, and independent with set up for meals. 2. Resident #32's diagnoses included hemiplegia, diabetes mellitus, anxiety, and depression. The quarterly MDS assessment dated [DATE] identified Resident #32 was alert and cognitively intact and required extensive assistance of two persons for transfers, and toilet use, extensive assistance of one person for bed mobility, dressing, 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 clinical record review, facility documentation review, facility policy review, and interviews for 1 sampled resident (Resident #7) reviewed for person-centered care planning, the facility failed to ensure interdisciplinary care plan meetings were held with the resident and/or Conservator of Person (COP) to ensure participation in the plan of care . The findings include: Resident #7's diagnoses included intracranial injury, transient cerebral ischemic attack, heart failure, depression, anxiety, and adjustment disorder with behavior disturbance. The Resident Care Plan dated 2/7/23 identified Resident #7 had behavior problems, refused care and was combative/accusatory towards staff at times. Interventions directed to anticipate, meet the residents needs and assist the resident to develop more appropriate methods of coping and interacting. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 7 had intact cognition, required extensive assistance with bed mobility, locomotion,…

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 a review of Resident Personal Funds Account statements and staff interviews for 2 sampled residents (Resident # 28 and Resident # 37), the facility failed to ensure the resident and /or responsible party received quarterly Personal Fund Account summaries. The findings included: 1. Resident # 28's diagnoses included heart failure, hypertension, and diabetes mellitus. The quarterly MDS assessment dated [DATE] indicated Resident #28 had slight cognitive impairment. 2. Resident #37's diagnoses included heart failure, cerebral vascular accident, hypertension, and dementia. The quarterly MDS assessment dated [DATE] indicated Resident #37 was cognitively impaired. During an interview on 5/31/23 at 2:54 PM with Resident #37's COP identified s/he had received Personal Funds Account quarterly statements a few times. Resident # 37's COP also indicated it had been over 4 months since s/he had received a quarterly statement therefore s/he had to call the facility to inquire about the statement. The facility was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation review, facility policy review, and interviews for 3 of 5 sampled resident (Residents #1, #7 and # 61) reviewed for advance directives, the facility failed to review the resident's advanced directives to reflect the code status wishes of the resident and/or responsible party/conservator of person (COP) following admission and re-admission from the hospital. The findings included: 1.Resident #1's diagnoses included schizoaffective disorder, paranoid schizophrenia, and personality disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 as cognitively intact and required supervision with bed mobility, transfers, eating and personal hygiene. The current Resident Care Plan identified use of psychotropic, antipsychotic and antidepressant medications, a mood problem related to major depressive disorder, generalized anxiety disorder and suicidal ideation. Interventions directed to administer medications as ordered, monitor 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 clinical record reviews, observations, facility documentation, facility policy and interviews for 2 of 6 sampled residents (Resident # 222) reviewed for abuse the facility failed to ensure the residents was free from verbal abuse and for ( Resident # 70), the facility failed to ensure the resident was free from physical abuse. The findings included: 1. Resident #222 was admitted to the facility on [DATE]. The resident's diagnoses included acute embolism and thrombosis, schizophrenia, vascular dementia with behavior disturbances, mood disturbances and anxiety. The nursing admission assessment dated [DATE] identified the resident smoke one pack of cigarettes daily. The nursing progress note dated 6/2/23 recorded at 3:59 PM identified Resident # 222 was involved in a verbal altercation with a staff member that included yelling and profanity. The resident and staff member were immediately separated, and the police and provider were updated. The conservatory, social worker and psychiatric were updated on 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 clinical records, facility documentation, facility policy and interviews for 1 of 6 residents reviewed for abuse (Resident # 57), the facility failed to implement facility policy for investigating an allegation of physical abuse within 5 working days. The findings include: 1 a. Resident #57's diagnoses included Alzheimer's disease, Peripheral Vascular Disease (PVD), Post- Traumatic Stress Disorder (PTSD), schizophrenia, and anorexia. The quarterly MDS assessment dated [DATE] identified Resident #57 was alert and cognitively intact, required limited assistance of one person for dressing, toilet use and personal hygiene, independent with bed mobility, transfers, ambulation and locomotion, and supervision with set up for eating. The RCP dated 5/28/23 for resident alleges that s/he was hit in the face by Resident # 66 with no injury. However, further review of the 5/28/23 noted a revision for 6/1/23 but failed to identify new intervention for 5/28/23 and 6/1/23. b. Resident # 66's 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 review of clinical records, facility documentation, facility policy and interviews for 2 of 6 residents reviewed for abuse (Resident #6 and # 57), the facility failed to implement facility policy for investigating and reporting an allegation of abuse to the state agency within 2 hours. The findings included: 1. Resident #6's diagnoses included major depressive disorder, anxiety disorder, and type 2 diabetes mellitus. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #6 as cognitively intact and required limited assistance with bed mobility, dressing, toilet use, and personal hygiene. The current Resident Care Plan 6/2023 identified assistance needed in performing activities of daily living with a notation of an allegation that a nurse used derogatory language and responded to Resident #6 inappropriately. Interventions directed to provide encouragement to participate in physical therapy, occupational therapy and speech therapy as indicated, to anticipate and meet 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 review of clinical records, facility documentation, facility policy and interviews for 2 of 6 residents reviewed for abuse (Resident #6 # and # 99), the facility failed to implement facility policy for protecting the resident during an investigation of allegation of abuse. The finding included: 1. Resident #6's diagnoses included major depressive disorder, anxiety disorder, and type 2 diabetes mellitus. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #6 as cognitively intact and required limited assistance with bed mobility, dressing, toilet use, and personal hygiene. The current Resident Care Plan 6/2023 identified assistance needed in performing activities of daily living with a notation of an allegation that a nurse used derogatory language and responded to Resident #6 inappropriately. Interventions directed to provide encouragement to participate in physical therapy, occupational therapy and speech therapy as indicated, to anticipate and meet the resident's needs, and 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 review and interview for 1 of 3 sampled residents for (Resident # 118) reviewed for discharge, the facility failed to ensure the resident had a discharge care plan at the time of admission. The findings included: Resident #118; s diagnoses included adjustment disorder with anxiety, muscle weakness, Urinary Tract Infection (UTI), lower back pain, osteoarthritis of the knee, schizoaffective disorder, and hypertension. Resident # 118 was admitted to the facility on [DATE]. Further review of the resident's clinical record failed to reflect an initial care for discharge planning at the time of admission. The nurse's note dated 3/20/23 at 12:47 PM identified Resident # 118 and the family requested the resident be discharged Against Medical Advice (AMA). Resident # 118 and family were educated regarding risk involved in leaving AMA. A review of Resident # 118 clinical record on 6/8/23 failed to identify a discharge care plan with short and long term goals and interventions. Record review 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 clinical record review, observations, facility policy and interviews for 1 of 1 sampled resident (Resident# 59) reviewed for specialized treatment, the facility failed to ensure the resident's care plan was revised to include a port in the right chest. The findings include: Resident # 59's diagnoses included in part, end stage renal disease, diabetes mellitus, atrial fibrillation, and syncope. The quarterly Minimum Data Set assessment dated [DATE] identified Resident # 59 was cognitively intact and received a specialized treatment. The Resident Care Plan dated 04/25/2023 identified Resident #59 received hemodialysis three times a week. Interventions included in part to check the left arm fistula for bruit and thrill every shift check and to change the dressing daily at the access site, and not to draw blood or take a blood pressure in the arm with the graft. On 5/30/2023 at 1:15 PM an interview and observation of Resident # 59 and the resident's room identified no clamp or dressing near 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 clinical record review and staff interview for 1 of 3 residents (Resident # 118) reviewed for discharge, the facility failed to ensure the resident received a discharge summary prior to the resident's wishes to be discharge Against Medical Advice. The finding include: Resident #118; s diagnoses included adjustment disorder with anxiety, muscle weakness, Urinary Tract Infection (UTI), lower back pain, osteoarthrosis of the knee, schizoaffective disorder, and hypertension. Resident # 118 was admitted to the facility on [DATE]. Further review of the resident's clinical record failed to reflect an initial care for discharge planning at the time of admission. A review of Resident # 118 clinical record failed to identify a discharge care plan. The admission MDS assessment dated [DATE] identified the resident was cognitively intact and required extensive assistance of one to two people with ADLs. The nurse's note dated 3/20/23 at 12:47 PM identified Resident # 118 and the family requested the resident be…

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, and interviews for 1 of 1 sampled resident, (Resident #64) reviewed for ADLs (Activities of Daily Living), the facility failed to assist the resident with applying footwear. The findings include: Resident #64's diagnoses included dementia, spondylosis of lumbar (lower back) region, depression, anxiety disorder, transient cerebral ischemic attack (mini stroke), type 2 diabetes mellitus, and aphasia (inability to understand or express speech). A quarterly MDS assessment dated [DATE] identified Resident #64 as alert and severely cognitively impaired, the resident required extensive assistance of one for toilet use, dressing, and personal hygiene, limited assistance of one for bed mobility and transfers, and supervision with set-up for eating. A Resident Care Plan dated 12/16/22 for impaired cognitive function and thought function secondary to a communication problem related to aphasia. Interventions included asking yes/no questions to determine needs by using…

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, observations, review of facility and staff interview for 1 of 3 residents at risk for pressure ulcer development for( Resident # 89), the facility failed to ensure that the resident's air mattress was set according to the plan of care and for 1 of 3 residents at risk for skin break down (Resident # 356), the facility failed to provide evidence that staff consistently turn and repositioned and off loaded the residents heel to prevent further skin breakdown. The finding included: 1. Resident #89's diagnoses included dementia, cerebral infarction, anemia, iron deficiency, atrial fibrillation, and heart failure. A Resident Care Plan dated 12/16/22 identified Resident # 89 at increased for skin breakdown secondary to fragile skin, compromised nutritional status, decreased ability to perform activities of daily living (ADL's) and decreased mobility. Interventions included: the use of a pressure reducing mattress, turning, and repositioning frequently to reduce risk of breakdown 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 clinical record review and staff interviews for 1 sampled residents, (Resident #64), reviewed for accident, the facility failed to the resident received the necessary supervision to prevent an accident and for for 1 of 3 residents (Resident # 77) who require assistance with mechanical lift for transfers, the facility failed to ensure the resident's skin was safe during a transfer to prevent an injury. The findings include: 1. Resident #64's diagnoses included dementia, spondylosis of lumbar (lower back) region, depression, anxiety disorder, transient cerebral ischemic attack (mini stroke), type 2 diabetes mellitus, and aphasia (inability to understand or express speech). A Resident Care Plan dated 12/16/22 identified the resident had impaired cognitive function and thought function, and a communication problem related to aphasia, and noted the resident wanders due to impaired safety awareness. Interventions included ensuring wander guard was in place, distract resident from wandering by offering…

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, observation, facility policy and interviews for 1 resident (Resident # 6) reviewed for Respiratory Care, the facility failed to ensure the physician's orders were followed regarding oxygen therapy. The findings include: 1. Resident #6's diagnoses included chronic obstructive pulmonary disease, acute respiratory failure with hypoxia and pulmonary hypertension. A physician's order dated 3/7/23 directed Resident # 6's oxygen to be worn continuously at two liters via nasal cannula and to keep oxygen saturation above 90% with titration, if needed, at hour of sleep. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #6 as cognitively intact and required limited assistance with toilet use, personal hygiene, bed mobility and dressing. The current Resident Care Plan identified assistance needed in performing activities of daily living secondary to diagnosis of COPD, and oxygen therapy related to respiratory illness. Interventions directed to provide encouragement…

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, facility policy and interviews for 1 of 1 sampled resident (Resident# 59) reviewed for specialized treatment, the facility failed to ensure the resident's plan of care included emergency measures. The findings included: 1a. Resident # 59's diagnoses included in part, end stage renal disease, diabetes mellitus, atrial fibrillation, and syncope. The quarterly Minimum Data Set assessment dated [DATE] identified Resident # 59 was cognitively intact and received a specialized treatment. The Resident Care Plan dated 04/25/2023 identified Resident #59 received hemodialysis three times a week. Interventions included in part to check the left arm fistula for bruit and thrill every shift check and to change the dressing daily at the access site, and not to draw blood or take a blood pressure in the arm with the graft. On 5/30/2023 at 1:15 PM an interview and observation of Resident # 59 and the resident's room identified no clamp or dressing near the resident's bed side.…

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 review of facility documentation, and interviews, the facility failed to ensure sufficient direct care staffing in accordance with quarterly Payroll Based Journal (PBJ) staffing data report. The findings include: The PBJ Staffing Data Report for Quarter 4, 2022 (July 1- September 30) identified submitted weekend staffing data is excessively low. The PBJ Staffing Data Report for Quarter 1, 2022 (October 1-December 31) identified submitted weekend staffing data is excessively low. Interview with the Administrator on 6/8/23 at 1:18 PM identified he was new in the position and was presently responsible for ensuring that direct care staffing levels were adequate. The Administrator further identified that the facility was using staffing strategies to ensure residents care was provided timely. The facility scheduled adequate numbers of nursing staff but there were many staff call outs and although attempted, they were unable to replace all the call outs. The Administrator indicated the facility was working with corporate regarding nurse aide wages and bonuses, on call staff 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 review of facility documentation, review of facility policy and staff interviews, the facility failed to ensure nurse staffing information was available and was reflective of actual staff worked. The findings include: Review of Daily Nurse Staffing information on 6/7/23 at 1:10 PM dated 5/19, 5/20 and 5/21/23 that was previously posted by the entrance to the facility identified: a. Daily Nurse Staffing Form dated 5/19/23 was not available for review. Interview with Scheduler #1 on 6/8/23 at 2:30 PM identified she was able to locate multiple Daily Nurse Staffing Forms at the front desk and in her office and indicated staffing data from 5/19/23 was missing. b. Daily Nurse Staffing Form dated 5/20/23 identified that 14 nurse aides were working during 7;00AM to 3:00PM shift. Review of the nursing daily staffing sheet identified that 12 nurse aides were actually working during that shift. Further review of the Daily Nurse Staffing Form identified that 12 nurse aides were working during the 3:00PM to 11:00 PM shift. Review of the nursing daily staffing sheet identified that 11…

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 and staff interviews for 1 resident (Resident # 98) reviewed for abuse, the facility failed to address the resident's Post Traumatic Stress Disorder (PTSD) regarding fear of residents entering the room. The findings include: Resident # 98's diagnosis includes PTSD. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 98 as cognitively intact. Interview with Resident #98 on 5/30/23 at 10:54 AM identified s/he experienced Post Traumatic Stress Disorder (PTSD) after experiencing a traumatic event in her/his past and the residents wandering into her/his room scare her/him and s/he is afraid that they will come in at night. Resident #98 indicated he/she had asked facility staff to do something about her/his concern to reduce her/his fear, but they just put a black and white paper stop sign up outside Resident #98' door, but residents still wandered into the room. On 6/07/23 at 3:20 PM an interview and record review with the DNS indicated per the care plan…

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, observations, and staff interview for 1 of 18 residents observed during dining, the facility failed to ensure the residents diet consistency was followed according to the plan of care. The findings include: Resident #21's diagnoses included Myasthenia Gravis, Crohn's disease, and dementia. The resident's care plan dated 4/4/23 indicated Resident #21 had nutritional problems related to food preferences, fair oral intake history of wt. loss and the need for a mechanically altered diet texture. Intervention included: to provide diet as ordered, assist with feeding, and to provide double portions as resident #21 often reached for additional food items due to increased hunger. The care plan indicated Resident#21 had an alteration in gastrointestinal status related to the diagnosis of Crohn's disease. Interventions included in part to avoid foods or beverages that tend to irritate the esophageal lining like, acidic or spicy foods, chocolate, or caffeine. The quarterly Minimum Data Set…

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 and staff interviews for 1 of 3 residents for (Resident # 118) reviewed for discharge, the facility failed to ensure the social worker document a note regarding the resident's discharge status and failed to ensure the facility employed a social worker to assist with resident with resident psychosocial needs. The finding include: Resident #118; s diagnoses included adjustment disorder with anxiety, muscle weakness, Urinary Tract Infection (UTI), lower back pain, osteoarthrosis of the knee, schizoaffective disorder, and hypertension. Resident # 118 was admitted to the facility on [DATE]. Further review of the resident's clinical record failed to reflect an initial care for discharge planning at the time of admission. A review of Resident # 118 clinical record failed to identify a discharge care plan. The admission MDS assessment dated [DATE] identified the resident was cognitively intact and required extensive assistance of one to two people with ADLs. The nurse's note dated…

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

Based on a review of the facilityQuality Assurance and Performance Improvement (QAPI) program, review of facility documentation, review of policy and interviews, the facility failed to implement and maintain effective comprehensive, data driven QAPI program . The findings included: Interview on 5/30 2023 with the Medical Director at 2:00 PM indicated he attends the QAPI meetings that are held at the facility, and he is in contact with the DNS and the Administrator at least weekly regarding the facility issues. Interview with the DNS, the administrator and RN#1 on 6/8/2023 at 7:12 PM identified the Administrator and the DNS were new to their positions and the prior Administrator must have taken the QAPI paperwork when he/she left. The facility was able to produce a sign in sheets labeled medical staff meeting with the attendee's signatures including the medical director and all department heads who attended the quarterly meeting Although, the facility was unable to produce what issues or identified concerns had been previously worked on including the monitoring and evaluation 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 observation, review of the facility infection control program,, facility policy and interviews, the facility failed to maintain measures to prevent growth of Legionella and other opportunistic waterborne pathogens in building systems according to facility practice and failed to perform hand hygiene after picking up a glove from the floor after disinfecting a glucometer. The findings included: 1. Review of facility documents for measures to prevent growth of Legionella and other opportunistic waterborne pathogens in building systems involved monthly/bimonthly system flushes in various areas of the facility per facility practice were not performed November 2022 through March 2023. Interview with Maintenance Director on 6/8/23 at 8:23 AM failed to indicate why the monthly/bimonthly water system flushes were not performed November 2022 through March 2023 per facility practice, however he did indicate there were staffing issues during that timeframe. Interview with the Facility Administrator on 6/8/23 at 8:29 AM failed to identify a policy related to performing monthly/bimonthly…

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, facility policy and interviews for 2 of 2 sampled residents (Resident #108 and Resident #43) reviewed for Infection Control, the facility failed to offer flu and pneumococcal vaccinations. The findings included: 1. Resident #108's diagnoses included acute respiratory failure, depression, and anxiety disorder. The Resident Care Plan dated 12/4/22 identified needing assistance with activities of daily living and a self-care performance deficit. Interventions directed to assist resident with activities of daily living and provide all care if unable to participate in activities of daily living The annual Minimum Data Set assessment dated [DATE] identified Resident #108 as cognitively intact and required extensive assistance with toilet use and personal hygiene. 2. Resident #43's diagnoses included end stage renal disease, major depressive disorder, and type 2 diabetes mellitus. The annual Minimum Data Set assessment dated [DATE] identified Resident #43 as cognitively intact 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 clinical record review, facility documentation review, interview for 1 sampled resident (Resident #320) reviewed for COVID-19 infection, the facility failed to timely inform the resident, and family representative by 5:00 PM the next calendar day following the occurrence of five confirmed COVID-19 infections. The findings include: Resident #320's diagnoses included diabetes, glaucoma, heart failure and chronic kidney disease. The admission Minimum Data Set assessment dated [DATE] identified that Resident #320 had moderately impaired cognition, required extensive assistance with transfer and locomotion on unit . Interview with Person #1 on 6/5/23 at 10 AM identified she/he had not been notified of residents who resided at the facility and tested positive for COVID-19 by 5/20/22. Interview with RN #5 Infection Preventionist (IP) on 6/6/23 at 10:48 AM identified during testing, symptomatic residents tested positive for COVID-19, as indicated by a rapid antigen test. Binax rapid antigen test was 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 clinical record reviews, facility policy and interviews for 1 sampled resident (Resident #108) reviewed for Infection Control, the facility failed to offer the Covid-19 vaccine to the resident. The findings include: Resident #108's diagnoses included acute respiratory failure with hypoxia, depression, and anxiety disorder. The Resident Care Plan dated 12/4/22 identified needing assistance with activities of daily living and a self-care performance deficit. Interventions directed to assist resident with activities of daily living and provide all care if unable to participate in his/her activities of daily living. The annual Minimum Data Set assessment dated [DATE] identified Resident #108 as cognitively intact and required extensive assistance with toilet use and personal hygiene. Interview and review of clinical records with RN #5 on 6/8/23 at 10:44 AM failed to identify Resident #108 was offered the Covid 19 vaccine upon admission to the facility. RN #5 indicated residents should be offered the Covid…

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, observation and staff interview for 1 of 3 residents at risk for pressure ulcer development for( Resident # 68), the facility failed to ensure that the resident's air mattress was check to ensure adequate and proper functioning of the mattress . The finding include: Resident #68's diagnoses included Alzheimer's disease, atrial fibrillation, heart failure, and acute kidney failure. A Resident Care Plan dated 2/3/23 identified Resident #68 at increased risk of skin breakdown and pressure ulcer development, secondary to incontinence, decreased bed mobility. Interventions included daily skin inspections, assisted routine scheduled toileting, turning and repositioning. A physician order dated 2/3/23 directed Braden (skin assessment of residents at risk for forming pressure sores) every shift. A podiatry physician progress note dated 2/23/23 indicated Resident #68 had dry, cracked, scaly, atrophic (frail skin), thin skinned feet and recommended moisturizing lotion to both feet 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 review, facility policy review and interviews for one of two residents (Resident #89) reviewed for pressure ulcers, the facility failed to ensure the resident's representative was notified timely when a new pressure ulcer was identified. The findings include: Resident #89's diagnoses included type 2 diabetes mellitus, congestive heart failure and dementia. The Braden Scale for Predicting Pressure Sore Risk dated 11/10/20 identified a score of 16, which indicated Resident #89 was at risk for developing pressure sores (a score of 15-18 indicates At Risk, and 13-14 indicates Moderate Risk). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #89 had moderately impaired cognition, required extensive assistance of one person with bed mobility, was at risk for developing pressure ulcers, and had no unhealed pressure ulcers at the time of the assessment. The assessment further identified pressure reducing devices were in place for Resident #89's bed and chair. 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 clinical record review, facility documentation review, facility policy review, and interviews for one of three residents reviewed for abuse (Resident #92), the facility failed to complete a thorough investigation for a resident injury of unknown origin. The findings include: Resident # 92's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting unspecified side, cerebral infarction, and intercostal pain. The annual MDS assessment dated [DATE] identified Resident #92 had severe cognitive impairment, and required extensive assistance with two people for all transfers. The Resident Care Plan (RCP) dated 8/31/20 identified an ADL self-care deficit. Interventions directed that Resident #92 was totally dependent on staff for dressing, personal hygiene and transfers. In addition, staff to don a right upper extremity sling when out of bed and off when in bed for a history of right sided weakness. Review of The Facility's Reportable Event for R#92 dated 9/4/20 identified that 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 clinical record review, facility policy review and interviews for one of two residents (Resident #89) reviewed for pressure ulcers, the facility failed to ensure weekly skin audits were completed in accordance with physician's orders, and the facility failed to ensure a thorough nursing assessment was completed when a new pressure ulcer was identified. The findings include: Resident #89's diagnoses included type 2 diabetes mellitus, congestive heart failure and dementia. The Braden Scale for Predicting Pressure Sore Risk dated 11/10/20 identified a score of 16, which indicated Resident #89 was at risk for developing pressure sores (a score of 15-18 indicates At Risk, and 13-14 indicates Moderate Risk). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #89 had moderately impaired cognition, required extensive assistance of one person with bed mobility, was at risk for developing pressure ulcers, and had no unhealed pressure ulcers at the time of the assessment. 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 clinical record review, facility documentation review, facility policy review and interviews for two of five residents reviewed for Unnecessary Medications, (Resident #76 and Resident #95), the facility failed to ensure consistent target behavior monitoring for a resident with dementia who received antipsychotic medication, and the facility failed to ensure monitor targeted behaviors in accordance with physician's orders for a resident on an antipsychotic medication. The findings include: a. Resident #76's diagnoses included traumatic brain injury, diabetes, and vascular dementia. The admission MDS dated [DATE] identified Resident #76 had severe cognitive impairment, exhibited physical behaviors towards others for four to six days out during the seven-day look-back period, and had received antipsychotic medication. The care plan dated 2/19/21 identified Resident #76 had a behavior problem related to history of agitation, self-inflicted scratches, yelling out, combative towards staff at times, 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 observations, clinical record review, and facility policy and procedures review for one sampled resident (Resident #68), the facility failed to place a resident with an active drug-resistant infection on appropriate isolation precautions. The findings include: Resident #68's diagnoses included heart failure, enterocolitis (E. Coli) due to clostridium difficile (not specified as recurrent), and Extended Spectrum Beta-Lactamases (ESBL) infection in the urine. Review of the APRN note dated 2/25/21 at 1:27 PM noted that Resident #68 was being evaluated for follow-up regarding a urine culture, and Resident #68 was admitted for short term rehab with a history of congestive heart failure. Resident #68's urine culture returned positive for ESBL and E. Coli. Resident #68 was started on Ciprofloxacin empirically until the culture results returned, and plan to place Resident #68 on intravenous antibiotic (Imipenem) 1 gram every eight (8) hours for the next 1ten (10) days. Physician's orders dated 2/25/21 directed to place Resident #68 on Contact Precautions due to ESBL. Additional…

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.