Wadsworth Glen Health Care And Rehabilitation Cent

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records, facility policy, and interviews for 3 of 3 sampled residents (Resident #1, Resident #2, and Resident #49) reviewed for respiratory care, the facility failed to ensure that nebulizer tubing and masks were labeled, dated, and appropriately stored. The findings include:1. Resident #1's diagnoses included Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF).A physician's order dated 7/9/25 directed to administer Albuterol Sulfate inhalation treatment 1 vial every 3 hours as needed for wheezing and shortness of breath.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview of Mental Status (BIMS) score of 14 indicating no cognitive impairment and required moderate assistance from staff for activities of daily living and required a mechanical lift for transfers out of bed.The Resident Care Plan (RCP) dated 8/5/25 identified a history of COPD with interventions to administer oxygen and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, and interview for 2 of 2 sampled residents (Resident #1) reviewed for dental services, the facility failed to ensure a consent to treat was signed in a timely manner in order to provide dental services to a resident with known dental issues. The findings include:Resident #1 was admitted on [DATE] with diagnoses that included protein calorie malnutrition, type 2 diabetes, and Gastroesophageal Reflux Disease (GERD).Review of Resident #1's nursing admission Oral Health assessment dated [DATE] and subsequent Oral Health assessment dated [DATE] identified Resident #1 had more than 4 missing and decaying teeth. A physician order dated 6/26/25 direct to provide a diet that was small bite size solids with thin liquids and while sitting upright 90 degrees.A Physician's order dated 7/9/2025 directed to give a mechanical soft, ground texture diet. (the resident diet was downgraded)The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief…

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 the clinical record, facility policy, and interviews for 2 of 2 Residents (Resident #70) reviewed for dental services, the facility failed to ensure an outside dental provider appointment was scheduled and failed to update the Resident Care Plan for dental issues. The findings include: Resident #70's diagnoses included diabetes, bipolar disorder, and lesions of oral mucosa.A dental note dated 1/2/2025 identified crowns and bridges throughout mouth, and that a follow up visit was scheduled for 6/20/2025. The note did not identify a missing crown or lesion on Resident #70's tongue.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #70 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment, was independent when eating, and required set-up assistance for oral hygiene, and failed to indicate dental issues.A nurse's note dated 4/23/2025 at 11:04 PM identified Resident #70 informed LPN #5 that his/her third tooth on the top…

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 admission, the facility failed to ensure a comprehensive skin assessment was completed timely upon admission. The findings include: Resident #1's diagnoses included dementia and frontotemporal neurocognitive disorder. The RN admission assessment dated [DATE] identified that Resident #1 was alert, oriented to person, cooperative, aphasic (unable to communicate), unable to express ideas, incontinent of bowel and bladder and was dependent with ADL care. The Resident Care Plan (RCP) dated 12/28/2024 identified Resident #1 had the potential for pressure ulcer development related to immobility. Interventions directed follow facility policies/protocols for the prevention/treatment of skin breakdown. Review of RN admission nursing note dated 12/28/2024 at 12:47 PM indicated Resident #1 arrived to 11:10 AM for respite stay, resident alert, was nonverbal and had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation, review of facility policy and interviews for four of six sampled residents (Residents #8, #9, #10, and #12) reviewed for a potential allegation of verbal abuse, the facility failed to ensure the residents were treated in a dignified and respectful manner when a staff member used insensitive language when speaking to a resident and a staff member yelled in front of a resident. The findings include: 1. Resident # 8's diagnoses included overactive bladder, bipolar disorder, and paroxysmal atrial fibrillation. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #8 was cognitively intact and required extensive assistance of one (1) staff person for most Activities of Daily Living. The Facility Reported Incident report dated 7/22/21 at 10:00 AM indicated Resident #8 alleged a staff member called Resident #8 a liar and turned off the call bell without toileting Resident #8. The report identified the facility substantiated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) who were reviewed for the implementation of the care plan, the facility failed to ensure Resident #1 was transferred with the assistance of two (2) staff members. The findings include: Resident #1's diagnoses included fracture of the lateral condyle of the right tibia (lower leg), fracture of the left calcaneus (heel), unspecified head injury and arthritis. The nursing admission assessment dated [DATE] identified Resident #1 was alert and oriented to person, place and time and required assistance of two (2) staff members with toileting, transferring, and ambulation with the use of a walker (a device to assist with ambulation) with partial weight bearing restrictions. The Resident Care Plan dated 8/27/21 identified a risk for activities of daily living deficit related to recent hospitalization for fall with fractures and non-weight bearing to the left lower extremity and toe…

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 of three sampled residents (Resident #1) who were reviewed for pain management, the facility failed to ensure the hospital discharge order for ice to the lower extremities five (5) times a day for twenty (20) minute intervals was implemented. The findings include: Resident #1's diagnoses included fracture of the lateral condyle of the right tibia (lower leg), fracture of the left calcaneus (heel), unspecified head injury and arthritis. The nursing admission assessment dated [DATE] identified Resident #1 was alert and oriented to person, place and time and required assistance of two (2) staff members with toileting, transferring, and ambulation with the use of a walker (a device to assist with ambulation) with partial weight bearing restrictions. The Resident Care Plan dated 8/27/21 identified a risk for activities of daily living deficit related to recent hospitalization for fall with fractures and non-weight bearing…

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, and interviews for one of three sampled residents (Resident #1) who was at risk for falls and aspiration and required one (1) to one (1) with meals, the facility failed to ensure the safety of Resident #1 who fell and sustained a laceration while attempting to walk to his/her meal tray that was across the room. The findings include: Resident #1's diagnoses included history of fall with neck fracture, right subdural hematoma, dysphagia (difficulty swallowing), and repeated falls. The Fall Risk assessment dated [DATE] identified Resident #1 was at high risk for falls. The Physical Therapy assessment dated [DATE] identified Resident #1 demonstrated a poor standing balance, was unable to perform ambulation, and was at risk for falls. A physician's order dated 2/9/24 directed to transfer with one (1) person assistance with rolling walker or two (2) person assistance as needed due to fatigue following dialysis, ambulate with rehab only, toileting assistance…

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 of four sampled residents (Resident #1) who were reviewed for an allegation of neglect, the facility failed to ensure the resident was fed breakfast and failed to check and provide incontinent care during the 7AM-3PM shift. The findings include: Resident #1's diagnoses included Huntington disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily living, required set-up or clean-up assistance with eating, was dependent on staff with toileting, personal hygiene and was always incontinent of bowel and bladder. The Resident Care Plan dated 11/7/23 identified Resident #1 had activities of daily living self-care deficit related to Huntington's disease and restlessness. Interventions directed supervision with all meals (resident not to be left alone with any food), aspiration precautions and a total feed. The care plan identified Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policies and interviews for one of four sampled residents (Resident #1) who were reviewed for an allegation of neglect, the facility failed to report the allegation to the Administrator or the Director of Nursing at the time the allegation was reported by a family member. The findings include: Resident #1's diagnoses included Huntington disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily living, required set-up or clean-up assistance with eating, was dependent on staff with toileting, personal hygiene and was always incontinent of bowel and bladder. The Resident Care Plan dated 11/7/23 identified Resident #1 had activities of daily living deficit related to Huntington's disease and restlessness. Interventions directed supervision with all meals (resident not to be left alone with any food), aspiration precautions and a total feed. The care plan 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for one of four sampled resident (Resident #1) who were reviewed for an allegation of neglect, the facility failed to ensure agency certified staff received an initial orientation at the start of their employment. The findings include: Resident #1's diagnoses included Huntington disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily living, required set-up or clean-up assistance with eating, was dependent on staff with toileting, personal hygiene and was always incontinent of bowel and bladder. The Resident Care Plan dated 11/7/23 identified Resident #1 had activities of daily living deficit related to Huntington's disease and restlessness. Interventions directed supervision with all meals (resident not to be left alone with any food), aspiration precautions and a total feed. The care plan identified Resident #1 was incontinent of bowel…

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 policies and interviews for one of three sampled residents (Resident #1) who had sustained a skin tear, the facility failed to ensure the safety of Resident #1 during a transfer out of the bed. The findings include: Resident #1's diagnoses included hepatic encephalopathy, cirrhosis of the liver, generalized muscle weakness, and abnormal gait and mobility. The Resident Care Plan dated 10/6/23 for Resident #1 identified Resident #1 was at risk for increased weakness and confusion when ammonia levels are elevated and the need for assistance with mobility due to weakness and edema to the lower extremities. Interventions included two (2) half side rails to aid with bed mobility and transfers, to maintain the call bell in reach, assistance of one (1) for transfers and ambulation with a rolling walker and physical and occupational therapy to evaluate and treat as ordered. The physical therapy evaluation dated 10/8/23 identified that Resident #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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #3), reviewed for abuse, the facility failed to initiate an investigation timely when an allegation abuse was reported to staff. The findings include: Resident #3 was admitted to the facility with diagnoses that included multiple sclerosis and schizophrenia. The care plan dated 8/9/23 identified Resident #3 had an activities of daily living (ADL) deficit with interventions that included toileting and ADL's assist of one at the bed level, explain to the resident tasks, purpose, and breakdown tasks into simple subtasks as able. The care plan further identified Resident #3 was incontinent of bowel and bladder with interventions that included to provide incontinent care approximately every two hours and as needed. The MDS dated [DATE] identified Resident #3 had no impairments in cognition, required extensive assistance of two staff for toilet use and was totally dependent 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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents,(Resident #1), reviewed for pressure ulcers, the facility failed to implement new interventions when a resident changed from a moderate pressure ulcer risk to high pressure ulcer risk. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia, glaucoma and stroke. [NAME] plus assessment dated [DATE] identified Resident #1 was a moderate risk for developing pressure ulcers/injuries. The care plan dated 10/7/22 identified Resident #1 was at risk for skin breakdown with interventions that included to inspect Resident #1's skin for redness, irritation or breakdown during care, nutrition/hydration assessment as needed, offload heels, offer turning and repositioning approximately every two hours and as needed, pressure reducing cushion/mattress as needed, toileting/incontinent care as needed, treatments as ordered and weekly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation, review of facility policy, and interviews for five of seven sampled residents (Resident #1, #342, #343, #344, & #345) with an allegation of mistreatment, the facility failed to report the allegations of potential abuse to the State Survey Agency. The findings include: 1. Resident #1 had diagnoses that included osteoarthritis, overactive bladder, bipolar disorder, schizoaffective disorder, and depression. The Resident Care Plan dated 9/6/22 identified Resident #1 had a self-care deficit related to history of falls, weakness, and osteoarthritis, with interventions that included assistance with transfers, dressing, toileting, hygiene, and mobility. The care plan also identified that the resident was incontinent of bladder and was on a toileting program with interventions that included: offer toileting before and after meals before bed and as needed. The quarterly MDS assessment dated [DATE] identified Resident #1 was cognitively intact, required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation, facility policy, and interviews for six of seven sampled residents (Resident #1, #67, #342, #343, #344, & #345) with an allegation of mistreatment, the facility failed to complete an investigation and ensure residents were protected from potential further mistreatment regarding the allegations of abuse. The findings include: 1. Resident #1 had diagnoses that included osteoarthritis, overactive bladder, bipolar disorder, schizoaffective disorder, and depression. The Resident Care Plan dated 9/6/22 identified Resident #1 had a self-care deficit related to history of falls, weakness, and osteoarthritis, with interventions that included assistance with transfers, dressing, toileting, hygiene, and mobility. The care plan also identified that the resident was incontinent of bladder and was on a toileting program with interventions that included: offer toileting before and after meals before bed and as needed. The quarterly 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.

Based on review of facility documentation, review of facility policy, and interviews for two nurse aides reviewed as a part of the sufficient staffing tasks, the facility failed to ensure annual performance evaluations were completed. The findings include: Review of NA #2's employee file identified date of hire as 4/15/2016. The annual performance evaluations were not completed for the years 2020 and 2021. Review of NA #3's employee file identified date of hire as 3/17/2022. There was no annual performance evaluation completed for 2023, which was due in March/2023. Interview with the Regional Nurse on 6/5/23 at 1:30 PM identified that annual performance evaluations must be completed yearly. She also identified that the DNS was responsible for ensuring that the annual performance evaluations are completed yearly. She could not provide a reason that the former DNS had not ensured the completion of the annual performance evaluations for the two nurse aides. Review of the Performance Appraisal policy identified that the facility evaluates the job performance of each employee on a…

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

Based on reviews of facility documentation, facility policy and interviews for six of six nurse aides (NA #1, NA #2, NA #4, NA #6, NA #7, and NA #12) reviewed for annual mandatory training, the facility failed to ensure annual competency trainings were completed in accordance with the facility assessment. The findings include: Review of the facility's mandatory yearly trainings for NA #1, NA #2, NA #4, NA #6, NA, #7 and NA #12's identified that the facility was unable to documentation that the trainings were completed. Interview with RN #6 (corporate nurse) on 6/14/23 at 12:30 PM identified that she could not provide documentation that identified that the identified nurse aides completed the annual mandatory trainings and competencies. Review of facility assessment identified all employees must complete specific competencies at the general orientation, annually and as needed with return demonstration. Review of facility policy title Staff Development In-service Guideline identified that personnel in all department would be provided with continuing education program at least monthly.…

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 documentation, and facility policy for one sampled resident (Resident #346) who required extensive assistance with toileting, the facility failed to ensure the resident was spoken to in a dignified manner when there was a request for assistance to use the bathroom. The findings include: Resident #346'sdiagnoses included humerus fracture, Parkinson's disease, anemia, benign prostatic hypertrophy, and history of falls. The Resident Care Plan dated 3/8/23 identified Resident #346 had a self-care deficit related to Parkinson's disease with interventions that included: assist with hygiene, toileting, dressing, transfers, and ambulation. The admission MDS assessment dated [DATE] identified Resident #346 was cognitively intact, required extensive assistance for toileting and hygiene, limited assistance for transfers, ambulation, and dressing. In addition, Resident #346 required supervision for bed mobility and was independent with eating with set up assistance. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policy and interview for one sampled resident (Resident #38) reviewed for advance directives, the facility failed to ensure the advanced directive paperwork was completed. The findings include: Resident #38's diagnoses included stroke, hemiplegia, and reduced mobility. The resident care plan dated [DATE] did not identify code status. The admission MDS assessment dated [DATE] identified Resident #38 had intact cognition and required extensive assistance with transfers, bed mobility, and personal hygiene. The physician's order dated [DATE] identified Resident #38 was a full code (full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive. This process can include chest compressions, intubation, and defibrillation and is referred to as CPR). Interview with RN #2 on [DATE] at 8:35 AM identified that a completed advanced directive form was not in Resident #38 clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility's documentation and interviews for one of three sampled residents (Resident #17) reviewed for weight loss, the facility failed to notify the physician (health care practitioner) of a significant weight loss in a timely manner. The findings include: Resident #17 had diagnoses that included cerebral infarction, hemiplegia and hemiparesis, paroxysmal atrial fibrillation, seizures, Parkinson's disease, congestive heart failure, iron deficiency anemia, dysphagia, Type II diabetes mellitus, and protein calorie malnutrition. The quarterly MDS dated [DATE] identified Resident #17 had severe cognitive impairment, required extensive assistance for eating, had swallowing issues that included loss of liquids/solids from mouth when eating or drinking, coughing, or choking during meals or when swallowing medications, holding food in mouth/cheeks or residual food in mouth after meals. The assessment further identified that the resident complained of difficulty or pain when…

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 documentation, review of facility policy, and interviews for one of three sampled residents (Resident #67) reviewed for an allegation of mistreatment, the facility failed to ensure that the resident was free of mistreatment. The findings include: Resident #67's diagnoses included atrial fibrillation, hypertension, osteoarthritis, history of falls, and mood disorder. The Resident Care Plan dated 11/17/22 identified Resident #67 had a self-care deficit related to atrial fibrillation, hypertension, and history of falls with interventions that included: assist with transfers, dressing, toileting, hygiene, and mobility. The care plan further noted that Resident #67 had difficulty adjusting to being in a skilled nursing facility with an intervention for psychiatric supportive care. The quarterly MDS assessment dated [DATE] identified Resident #67 was cognitively intact, did not display behaviors, and was independent with bed mobility, transfers, and ambulation. SW…

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 sampled residents (Resident #13) reviewed for nutrition, the facility failed to ensure a significant weight change was identified and monitored. The findings include: Resident # 13's diagnoses included dementia, depression, failure to thrive, gastro-esophageal reflux disease (GERD) and Alzheimer's disease. The quarterly MDS assessment dated [DATE] identified Resident #13 had moderate cognitive impairment, required extensive assistance with bed mobility, transfers, toileting and hygiene. The assessment further identified that Resident #13 was independent with eating with set-up assistance. Further review of the assessment identified the resident had not experienced a significant weight loss in the past six months and weighed 154 pounds. The nurse's note dated 3/1/23 identified Resident #13 was admitted to the hospital with acute cystitis without hematuria. The nurse's note dated 3/6/23 identified Resident #13 was re-admitted 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, review of facility documentation, review of facility policy, and interviews for one of five sampled residents (Resident #23) reviewed for unnecessary medications, the facility failed to have a policy in place for Physician and or Advanced Practice Registered Nurse review and follow up on pharmacy recommendations. The findings include: Resident #23's diagnoses included chronic obstructive pulmonary disease, anxiety disorder, and major depressive disorder. The admission MDS assessment dated [DATE] identified Resident #23 was without cognitive impairment, required extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. The assessment further identified that the resident required limited assistance with ambulation. A physician's order dated 4/10/23 directed to administer Lorazepam (anti-anxiety mediation)1 milligram every 8 hours as needed for anxiety. A pharmacy recommendation dated 4/11/23 identified a recommendation to evaluate and consider the…

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

Based on observation, review of facility policy and interviews for one of two medication storage rooms, the facility failed to ensure that personal food items were not stored in the secured medication storage refrigerator. The findings include: Observation of the second-floor medication storage room on 6/6/23 at 12:40 PM with the Infection Control Nurse (RN #3) identified an unopened and unlabeled container of yogurt (Chobani brand) in the medication storage refrigerator. Interview with the Infection Control Nurse (RN #3) at the time of the observation identified that resident food should be stored in the nourishment refrigerator on the unit. She could not identify who the yogurt belonged to or why the yogurt was being stored in the medication refrigerator. Interview with LPN #4 on 6/6/23 at 12:50 PM identified that some food items are kept in the medication refrigerator because they tend to go missing. She did not identify who the yogurt belonged to. Interview with the Dietary Director on 6/6/23 at 2:53 PM identified that for the last month he has only ordered yogurt from a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation, review of facility policy and interviews for one of four sampled residents, (Resident #20) who had difficulty swallowing, the facility failed to ensure the resident was served the appropriate diet consistency to prevent an incident of choking while eating lunch. The findings include: Resident #20's diagnoses included dysphagia (difficulty swallowing), obsessive compulsive disorder, schizoaffective disorder, and weakness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #20 made reasonable and consistent decisions regarding tasks of daily life and required one (1) person supervision when eating after set-up. The Resident Care Plan dated 11/17/22 identified Resident #20 had a diagnosis of dysphagia and a history of choking when consuming a potato from another resident's plate with Heimlich maneuver performed. Interventions directed to monitor for symptoms of aspiration that may include coughing, fever, changes in mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility policy and staff interviews for 2 of 5 sampled resident's (Resident #31 and Resident #48), the facility failed to submit a Preadmission Screening and Resident Review (PASSR) within the required timeframe after admission to the facility to determine the resident's need for specialized services. The findings included: Resident # 31 was admitted to the facility on [DATE] with diagnoses that included Schizoaffective Disorder. Review of the notice of PASSR Level 1 Screen outcome dated [DATE] identified Resident #37 met the conditions for an exempted hospital discharge to the skilled nursing facility and was approved for admission for a period of 30 days. Additionally, the notice indicated that if Resident #31 required a stay at the facility that was longer than 30 days, the facility must update the resident's Level 1 Screen and submit an updated level of care form by or before the 30th day after admission. The resident care plan dated [DATE] identified a problem 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 review of the clinical record and interview for one sampled resident reviewed for Respiratory care (Resident #49), the facility failed to meet professional standards of practice when transcribing a medication . The findings include: Resident # 49's diagnoses included Chronic Pulmonary Disease (COPD) with acute exacerbation, chronic respiratory failure with hypoxia, pulmonary hypertension and pneumonia. The admission MDS assessment dated [DATE] identified the resident had intact cognition, required extensive assistance of one staff for bed mobility and transfers, had occasional pain, was on oxygen therapy and had shortness of breath on exertion and when lying flat. The care plan dated 4/23/21 identified a problem of COPD, chronic respiratory failure, with hypoxia, and oxygen dependent. Intervention include: to administer medications as ordered. The care plan revision dated 5/25/21 identified the resident had pneumonia. Interventions include: to monitor vital signs and pulse oximetry as indicated. 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 and interview for one sampled resident reviewed for Respiratory care (Resident #49), the facility failed to the resident received the desired medication treatment/dose of Prednisone in accordance to the plan of care. The findings include: Resident # 49's diagnoses included Chronic Pulmonary Disease (COPD) with acute exacerbation, chronic respiratory failure with hypoxia, pulmonary hypertension and pneumonia. The admission MDS assessment dated [DATE] identified the resident had intact cognition, required extensive assistance of one staff for bed mobility and transfers, had occasional pain, was on oxygen therapy and had shortness of breath on exertion and when lying flat. The care plan dated 4/23/21 identified a problem of COPD, chronic respiratory failure, with hypoxia, and oxygen dependent. Intervention include: to administer medications as ordered. The care plan revision dated 5/25/21 identified the resident had pneumonia. Interventions include: to monitor vital signs 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, review of facility's policy and interviews for 4 medication carts and 1 of 2 medication rooms reviewed for medication storage and labeling. The facility failed to maintain proper medication storage to ensure standards of professional practice was maintained for medication administration. The findings included: 1 a. Observation on 6/03/21 at 9:25 A.M. of the Meadow Glen unit's medication room and 2 mobile medication carts on unit in the presence of Licensed Practical Nurse (LPN #2) identified 1 of the 2 mobile medication carts noted with 63 loose tablets/ capsules/ pills lying at the bottom of the cart drawer. Further observations on 6/03/21 at 9:45 A.M. in the presence of LPN #2 identified 2 mobile medication carts on the [NAME] Glen unit with 10 pills/tablets/ capsules in the bottom of the medication cart. The second mobile medication cart had greater than 60 pills/tablets/ capsules at the bottom of cart drawer. (b) Observation of cart# 2 on [NAME] Glen unit on 6/3/21 noted 2 pill cups with pills/tablets/capsules in the top drawer of cart. After surveyor's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, review of facility documentation and interviews for one of three residents reviewed for dental for (Resident #37), the facility failed to ensure timely dental follow up following the loss of a tooth or part of a tooth. The findings include Resident #37's diagnoses included hemiplegia and hemiparesis and cognitive communication disorder. The annual MDS assessment dated [DATE] identified the resident had no cognitive deficits, had no delusions, required extensive assistance of one staff for personal hygiene and had no dental problems. The care plan dated 2/4/21 identified a focus of oral/dental health problems related to poor dentition. Interventions included to coordinate arrangements for dental care as needed. The nurse's notes dated 4/12/21 identified while the resident was eating breakfast, a front tooth fell out. Denies pain, socket clean, mouth rinsed, able to resume his/her regular diet. The APRN was made aware, will monitor for infection. The quarterly…

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.