Beacon Brook Center For Health & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record, interviews, facility documentation and facility policy for 1 of 3 (Resident #13) residents reviewed for pressure ulcers, the facility failed to ensure that an alternating air pressure mattress was implemented timely per facility policy. The findings include:Resident #13 was admitted to the facility in December 2023 with diagnoses that included dementia, cerebral infarction (stroke) with left side weakness, and malnutrition.The readmission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 was severely cognitively impaired, required maximum assistance with bed mobility and was at risk for developing a pressure ulcer. A Braden Scale (tool to assess the risk for development pressure injury) was used to determine Resident #13's risk for developing a pressure ulcer dated 9/14/25 and 10/14/25 identified Resident #13 was at mild risk developing a pressure ulcer. There were no further Braden Scale assessments completed since 10/14/25.Physician's orders 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, interviews and facility policy for the only sampled resident (Resident #13) reviewed for bowel and bladder incontinence/catheter, the facility failed to ensure Urologist orders were implemented for changing a urinary catheter. The findings included:Resident #13 was admitted in December 2023 with diagnoses that included obstructive and reflux uropathy (blockage in urinary system), urinary retention, and history of extended spectrum beta lactamase (ESBL) bacteria in urine (highly antibiotic-resistant bacteria in urine).The discharge Minimum Data Set, dated [DATE] identified that Resident #13 was unable to participate in a Brief Interview of Mental Status due to severe cognitive impairment, required moderate assistance with activities of daily living, and had an indwelling urinary catheter.Physician's orders dated 4/8/25 directed to replace indwelling urinary catheter size 16 French with 10 cubic centimeters (cc) [NAME] if removed/leaking or plugged as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, facility policy and staff interviews for 1 of 1 resident (Resident #14) reviewed for hospice, the facility failed to review and respond to pharmacy recommendations in a timely manner. The findings include:Resident #14's diagnoses included schizoaffective disorder, bipolar, and post-traumatic stress disorder.A physician order dated 5/14/24 and currently in effect directed Lurasidone HCL (an antipsychotic medication used to treat schizophrenia and bipolar disorder) 40 milligrams (mg) once a day.A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 was cognitively intact and was dependent on staff for all activities of daily living. Additionally, the MDS identified Resident #14 was administered antipsychotic medication, antianxiety and antidepressant medication.A Resident Care Plan (RCP) dated 2/26/25 identified Resident #14 had the potential for behavior problems related to schizoaffective disorder, bipolar and post traumatic…

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 1 of 2 (Resident #116) reviewed for positioning/mobility, the facility failed to provide rehabilitation services as recommended by the orthopedic physician. The findings included:Resident #116 was admitted to the facility in September 2024 with diagnoses that included pain to lower back, right shoulder, and left thigh, effusion of left knee (swollen joint), and spondylosis cervical region (fracture of vertebrae). The annual Minimum Data Set assessment dated [DATE] identified Resident #116 had intact cognition and was independent with all activities of daily living.The Resident Care Plan dated 9/16/25 identified Resident #116 had actual/potential for pain related to chronic pain syndrome, right shoulder bursitis, left knee effusion, lumbar spinal stenosis, and cervical spondylosis. Interventions included to administer medications as ordered for pain, identify and treat resident' existing conditions, monitor and document probable…

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 abuse, the facility failed to ensure supervision was provided in accordance with the resident plan of care, to prevent a resident incident. The findings include: Resident #1 had a diagnosis of dementia, major depressive disorder, anxiety, and cognitive communication deficit. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of three (3), indicating severely impaired cognition, and was independent with ambulation. The Resident Care Plan (RCP) dated 5/20/2025 identified the family approved a relationship with Resident #2. Interventions directed staff to supervise Resident #1 when resident visits Resident #2. Resident #2 had a diagnosis of dementia, anxiety, depression, and cognitive communication deficit. The quarterly MDS dated [DATE] identified Resident #2 had a BIMS of three (3), indicating severely impaired…

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 of three Residents (Resident #1) reviewed for nutrition, the facility failed to provide a timely Dietician evaluation to address a documented significant weight loss. The findings include: Resident #1 was admitted to the facility with diagnoses that included Diabetes Mellitus, dysphagia, anemia, heart failure and chronic kidney disease. The Resident Care Plan (RCP) dated 4/1/2025 identified Resident #1 had nutrition related diagnoses of increased nutrient needs, malnutrition, a chronic wound and altered gastrointestinal status due to constipation, nausea and reflux. The RCP directed to allow Resident #1 time to eat, line of sight supervision at meals and a ground texture, thin consistency diet. A Dietician evaluation dated 5/6/2025 identified Resident #1 as a high risk for weight loss/nutritional needs and noted a 5 % weight loss over a month and a 11.4 % weight loss over a 6-month time frame. A protein…

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 and #3) reviewed for pressure injuries, the facility failed to complete and document skin risk assessment weekly post re-admission per facility protocol. The findings include: 1. Resident #1 was admitted to the facility with diagnoses that included dementia, peripheral vascular disease and sepsis. The quarterly MDS dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of ninety-nine (99) indicative of impaired cognition, was at risk for developing pressure ulcers/injuries, was frequently incontinent of bowel and required extensive assistance of two staff with activities of daily living (ADL's). The care plan dated 9/3/24 identified Resident #1 had impaired skin integrity and was at risk for further skin breakdown with interventions that included a low air loss (LAL) mattress, educate on risks to wound healing, inspect skin during care,…

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, clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed ensure the resident was free from neglect and care was provided timely. The findings include: Resident #1 was admitted with diagnoses that included a stroke with hemiplegia/hemiparesis (weakness/loss of movement) affecting the right dominant side. A quarterly MDs assessment dated [DATE] identified Resident #1 BIMs was 99, indicating Resident #1 was severely cognitively impaired and could not complete the interview, and Resident #1 did not speak, rarely understood verbal content and had highly impaired vision. Resident #1 was at risk for pressure ulcers, was incontinent, was dependent for all care, required two (2) staff for bed mobility and transfers. The RCP dated 8/12/2024 identified Resident #1 was incontinent of bowel and bladder. The RCP directed to provide incontinent care every two (2) to three (3) hours and use…

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, clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure care was provided in accordance with physician orders and failed to ensure the NA reported when she could not provide care timely, resulting in a delay in care. The findings include: Resident #1 was admitted with diagnoses that included a stroke with hemiplegia/hemiparesis (weakness/loss of movement) affecting the right dominant side. A quarterly MDs assessment dated [DATE] identified Resident #1 BIMs was 99, indicating Resident #1 was severely cognitively impaired and could not complete the interview, and Resident #1 did not speak, rarely understood verbal content and had highly impaired vision. Resident #1 was at risk for pressure ulcers, was incontinent, was dependent for all care, required two (2) staff for bed mobility and transfers. The RCP dated 8/12/2024 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 (1) of three (3) sampled residents (Resident #1) who's medications were put on hold when the resident was transferred to the Emergency Department, the facility failed notify the Advanced Practice Registered Nurse or physician at the time when the medications were not resumed when the resident returned to the facility, therefore the medications were omitted for eleven (11) days. The findings include: Resident #1's diagnoses included diabetes, cardiac infarction, atrial fibrillation and neuromuscular dysfunction of the bladder, and pain related to immobility. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 made reasonable and consistent decisions regarding tasks of daily life. The Resident Care Plan dated 9/3/24 identified altered cardiac status related to congestive heart failure and heart attack, neurological bladder with indwelling foley and pain related to decreased mobility. 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 reviews, facility documentation, facility policy, and interviews for one (1) of three (3) sampled residents (Resident #4) who were reviewed for an allegation of abuse, the facility failed to ensure appropriate supervision, for a resident on one-to-one (1:1) supervision due to aggressive and sexual behaviors, to prevent the resident from having inappropriate physical contact with another resident. The findings include: Resident #3's diagnoses included dementia with behavior disturbances, frontotemporal neurocognitive disorder, myocardial infarction, and antisocial personality disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 had short-and long-term memory recall deficits, made poor decisions regarding tasks of daily life, had verbal behavioral symptoms towards others, and was independent for mobility utilizing a wheelchair. The Resident Care Plan dated 7/26/24 identified Resident #3 has mood and behavior patterns including verbal expressions of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for transfer to the Emergency Department, the facility failed to ensure the residents' medication regimen was accurately reconciled after returning from the hospital to prevent the omission of medications for eleven (11) days. The findings include: Resident #1's diagnoses included diabetes, cardiac infarction, atrial fibrillation and neuromuscular dysfunction of the bladder, and pain related to immobility. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 made reasonable and consistent decisions regarding tasks of daily life. The Resident Care Plan dated 9/3/24 identified altered cardiac status related to congestive heart failure and heart attack, neurological bladder with indwelling foley and pain related to decreased mobility. The nurse's note dated 9/15/24 at 11:55 AM identified Resident #1 was having hallucination,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation and interviews for one (1) of three (3) sampled residents (Resident #1) who were required staff assistance with personal hygiene, the facility failed to maintain safety to prevent the resident from falling out of the bed while turning and repositioning the resident when incontinent care was provided. The findings include: Resident #1's diagnoses included neurocognitive disorder with Lewy bodies and dementia. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 made poor decisions regarding tasks of daily life, was dependent on staff with rolling from side to side, toileting, and personal hygiene, had functional limitation in range of motion impairments on both sides of the upper and lower extremities, and was always incontinent of urine and bowel. The Resident Care Plan dated 5/14/24 identified Resident #1 had an activities of daily living deficit related to generalized weakness, recent hospitalization, and impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interviews for 1 of 3 residents (Resident #1) reviewed for neglect the facility failed to provide incontinent care in a timely manner. The findings include: Resident #1 was admitted to the facility with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, anxiety, and aphasia (impaired ability to communicate). A quarterly minimum data set (MDS) dated [DATE] identified Resident #1 had moderately impaired cognition, required assistance with bed mobility and ADLs, and was incontinent of bowel and bladder. The Resident Care Plan dated 5/20/2024 identified Resident #1 required assistance with ADLS. Interventions directed to assist with toileting and provide incontinent care as needed. Facility incident report dated 6/17/2024 at 12:15 PM identified Resident #1 was alert and aphasic alert, aphasic and alleged neglect on 6/16/2024 at 9:30 PM. The report identified Resident #1 was alleged to have not received incontinent care for most of the evening shift 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 reviews, observations, facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) who were reviewed for the implementation of their care plan, the facility failed to ensure the care plan intervention of two (2) staff members for all care for Resident #1 was followed. The findings include: Resident #1's diagnoses included depression, anxiety, mood disorder and psychosis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 made poor decisions regarding tasks of daily life, required extensive assistance with turning and repositioning while in bed, was dependent with toileting and required two (2) staff members for transfers in and out of the bed and chair via a mechanical lift, Hoyer lift. The Resident Care Plan dated 2/2/24 identified Resident #1 had accusatory behaviors towards staff. Interventions directed two (2) staff to always be present in the room, one (1) for care and one (1) for support and assign staff 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, review of facility policy and interviews for 11 of 12 sample residents (Resident #20, Resident #21, Resident #44, Resident #45, Resident #54, Resident #61, Resident #72, Resident #76, Resident #98, Resident #102, and Resident #109) reviewed for timely physician's visits, the facility failed to ensure physician's visits were conducted timely. The findings included: 1 Resident # 20's was admitted to the facility on [DATE] with diagnoses that included respiratory failure, type 2 diabetes mellitus, dysphagia, psychosis, and depression. The quarterly MDS assessment dated [DATE] identified Resident #20 had moderate cognitive impairment, and required extensive assistance with bed mobility, toileting, hygiene, and transfer. Review of the physician's orders from August 2023 through May 2, 2024, identified Resident #20 physician's orders were not renewed and signed every 60 days. The most current physician's orders were last signed on 7/23/23. 2. Resident # 21's was admitted to 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 observations, review of facility policy and interview for 4 nursing units, the facility failed to ensure medications stored in the medication carts were labeled, refrigerator temperatures that contain vaccines were taken and documented consistently twice daily and for 1 of 1resident (Resident #101) observed on tour, the facility failed to properly secure medications. The findings include: 1.Observation and interview of the [NAME] view medication cart on 4/16/2024 at10:20 AM with LPN#6 identified a bottle of Humalog insulin without a prescription label, box/bag or when the medication was first opened was found in the top drawer of the medication cart along with an auto injector of epinephrine 0.3mg without label, box/bag of who it belonged to. A clear bag of medications was found in the bottom of the medication cart without labels and LPN #6 indicated s/he did not know who the medication belonged to and would consult with the RN supervisor as to what to do with the medications. 2.Observation and…

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

Based on observation, review of facility policy and interviews, the facility failed to ensure dietary staff applied a beard guard when preparing food to ensure a sanitary environment. The findings include: Observation on 4/15/24 at 11:37 AM during the tray line with the Director of Dietary identified during plating of food from the cooking area to steam tables, [NAME] # 1 stirring a tray of beef stew at steam table #3. [NAME] #1 during the platting of food was observed with a beard and without the benefit of a beard guard. An interview with [NAME] #1 identified he had been told to wear a beard guard in the past. [NAME] #1 further indicated he had forgotten to use a beard guard since he usually does not have a long beard. After, [NAME] #1 proceeded to don a beard guard. An interview with the Director of Dietary identified Cook#1 should have been wearing a beard guard. A review of the facility's Uniform Policy notes in part that chefs or cooks should wear an apron, chef coat or shirt, chef pants, shoes, chef hat, hairnet or cap, and beard guards.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record interviews and facility policy for 1 of 1 resident (Resident #268) reviewed for change in condition , the facility failed to ensure staff notified the physician and the responsible party when the resident experienced a change in condition and for 1 of 3 residents (Resident #418) reviewed for pressure ulcers, the facility failed to notify physician when a treatments were not provided. The findings included: 1. Resident # 268's diagnoses included Cerebral infarction, aphasia following cerebral infarction, dysphagia, and atrial fibrillation. A physician's order dated 12/2/2022 directed Eliquis (Anticoagulant) 5 Milligrams ( MG) tablet orally twice daily for a Deep Vein Thrombosis (blood clot) of the left lower extremity for 12 weeks. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #268 was cognitively intact. The care plan dated 12/15/2022 indicated Resident #268 had a diagnosis of Atrial Fibrillation with interventions to provide medications as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, review of facility grievance file for 1 of 2 residents ( Resident #74) reviewed for dignity, the facility failed to ensure a residents grievance was addressed timely. The findings include: Resident #74's diagnoses included neuromuscular disfunction of the bladder and diabetes mellitus The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #74 was cognitively intact. The Resident Care Plan ( RCP) dated 3/4/2024 indicated ADL deficit related to generalized weakness and a neuromuscular condition with lower extremity weakness. Intervention included : to keep the call bell and needed items within reach and to provide assistance and or cueing to maximize current level of function. 0n 4/11/24 at 1:05 PM the Director of Nursing Services ( DNS) was updated regarding allegations Resident #74 made regarding change of shift noise at 7:00 AM on the unit and a 3-11 PM staff member (not identified) was not answering the call light timely. The DNS indicated s/he would look into the matter. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #92) reviewed for Preadmission Screening and Resident Reviews (PASRR), the facility failed to ensure a resident had a PASRR II or Level of Care re-screen completed upon admission to the facility. The findings include: Resident #92 was admitted to the facility on [DATE] with diagnoses that included a cerebral infarction, dementia, anxiety disorder, and depressive disorder. The Notice of Care Determination dated 7/7/22 identified Resident #92 was approved for long term care based on the submission data which included the following diagnoses: cerebral infarction, atrial fibrillation, hypertensive encephalopathy, transient ischemic attack, irritable bowel syndrome, head laceration, sequela, leukemoid reaction, headache syndrome, nausea, anxiety disorder, depressive episodes, and heart failure. The Inter-Agency Patient Referral report date 8/7/23 identified Resident #92's pertinent history…

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, review of policy and interviews for 1 of 5 residents reviewed for unnecessary medications( Resident #74), the facility failed to failed to ensure that the resident's care plan address the resident's use of antipsychotic medications per plan and for 1 of 5 residents (Resident #92) reviewed for PASSR, the facility failed to ensure the facility developed a comprehensive care plan for a resident with a history of mental disorder. The findings included: 1. Resident #74's diagnoses included a blood disorder not yet in remission and iron deficiency anemia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #74 was cognitively intact. The care plan dated 3/4/2024 indicated Resident #74 had a blood disorder not yet achieving remission and noted utilization of medication to treat the disorder. Intervention included in part to provide medications as ordered, to encourage consumption of fluids and to report any adverse medication side effects to 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 documentation, facility policy and interviews for 1 of 1 resident (Resident # 101) reviewed for smoking in a non-smoking facility, the facility failed to review and revise the resident's care plan to ensure safety as the resident continued to be non-compliant with smoking in the facility The finding include: Resident #101 was admitted to the facility on [DATE]. The resident's diagnoses included cellulitis of abdominal wall, alcohol abuse and nicotine dependence. Resident #101 had a conservator of both estate and person. The admission Smoking Evaluation assessment dated [DATE] identified no desire to smoke at the time of the admission. The Resident Care Plan (RCP) dated 3/14/24 identified both short- and long-term memory loss. Interventions included referring to time of day, date, and recent events with interactions, and to utilize simple direct communication, verbal cues, and task segmentation. The quarterly 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 record review, facility policy, and interviews for 1 of 4 residents (Resident # 418) reviewed for pressure ulcers, the facility failed to ensure wound treatments were transcribed and preformed per physician's orders. The findings include: Resident #418 was admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease, traumatic spinal cord dysfunction, and paraplegia (paralysis of the legs and lower body). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #418 required extensive assistance from at least two people for bed mobility and transfers. Additionally, the MDS identified Resident #418 had two stage 3 pressure ulcers. A care plan dated 6/29/22 identified Resident #418 had two stage 3 pressure ulcers to the right and left buttocks. Interventions included a low air loss mattress, turning and positioning every 2 hours, and providing treatments as ordered. The physician's order 6/17/22 through 7/27/22 directed offload…

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 1 of 1 resident (Resident #101) reviewed for bowel and bladder, the facility failed to assess the resident ability for self-care of a colostomy secondary to resident's refusals to allow staff to provide the care. The findings include: Resident #101 was admitted to the facility on [DATE]. The resident's diagnoses included cellulitis of abdominal wall, alcohol abuse and nicotine dependence. Resident #101 has a COP. The physician's order dated 3/11/24 directed to provide colostomy care every shift, and to apply Triad cream to macerated/reddened areas to abdomen, groin, and perineal area every shift for cellulitis. The hospital Discharge summary dated [DATE] at 5:28 PM identified because of a wellness check, Resident #101's colostomy stoma was covered with a diaper resulting in extensive redness, and skin breakdown in the abdominal area extending to the groin. Resident #101 acknowledged consuming alcohol for pain…

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, clinical record review, and staff interviews for 1 of 1 resident reviewed for oxygen (Resident #80), the facility failed to ensure the resident received oxygen therapy as prescribed. The findings include: Resident #80's diagnoses included chronic obstructive pulmonary disease (COPD) and heart failure. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident#80 was cognitively intact and did not exhibit any behaviors of rejecting evaluation or care. Additionally, the MDS indicated the resident was independent with toileting and personal hygiene and required setup or cleanup assistance with eating and bathing. The care plan dated 2/19/24 identified a diagnosis of COPD, shortness of breath on exertion, and oxygen dependence. Interventions included: administering oxygen and monitoring effectiveness, educating on the importance of wearing a BiPAP (a machine used to help to breathe during sleep), and elevating the head of the bed to assist in avoiding shortness of breath.…

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, interview, and policy for 1 of 5 residents (Resident #74) reviewed for unnecessary medications, the facility failed to ensure pharmacy recommendations were obtained and reviewed and failed to ensure an AIMS assessment was completed timely for a resident who was started on an antipsychotic medication. The findings included. Resident #74's diagnoses included a blood disorder not yet in remission and iron deficiency anemia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #74 was cognitively intact. The care plan dated 3/4/2024 indicated Resident #74 had a blood disorder not yet achieving remission and noted utilization of medication to treat the disorder. Intervention included in part to provide medications as ordered, to encourage consumption of fluids and to report any adverse medication side effects to the physician. A physician's order dated 3/14/2024 at 8:00 AM directed to provide Zyprexa (Antipsychotic medication) Oral Tablet 5 Milligrams…

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 interview for 1 of 1 resident (Resident # 101) reviewed for smoking, the facility failed to ensure that a copy of the resident's conservatorship was in the clinical record in accordance with accepted professional standards and practices of complete an accurate medical record. The findings include: Resident #101 was admitted to the facility on [DATE]. The resident's diagnoses included cellulitis of abdominal wall, alcohol abuse and nicotine dependence. Resident #101 had a conservator of both estate and person. The admission Smoking Evaluation assessment dated [DATE] identified no desire to smoke at the time of the admission. The Resident Care Plan (RCP) dated 3/14/24 identified both short- and long-term memory loss. Interventions included referring to time of day, date, and recent events with interactions, and to utilize simple direct communication, verbal cues, and task segmentation. The quarterly Minimum Data Set (MDS)…

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, review of policy and interviews for 1 of 1 resident (Resident #74) reviewed for urinary catheter the facility failed to ensure the catheter collection bag was stored in a sanitary manner and for 1 of 1 resident ( Resident # 101) observed during a tour of the facility, the facility failed to ensure that resident equipment was stored in a sanitary manner to prevent the spread of infection. The findings include: 1.Resident #74's diagnosis included neuromuscular disfunction of the bladder and diabetes mellitus. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #74 was cognitively intact. The care plan dated 3/4/2024 indicated Resident #74 had a foley catheter due to neurogenic bladder and was at risk for infection. Interventions included: to change the foley catheter and bag per physician's order and the catheter monthly, to provide catheter care every shift and to attach a securement device to the foley catheter. Observation on 4/11/24…

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 two of three sampled residents (Residents #4 and #5) who were reviewed for an allegation of resident to resident sexual abuse, the facility failed to ensure Resident #4 was not touched inappropriately by Resident #5. The findings include: Resident #4's diagnoses included dementia, anxiety, and difficulty ambulating. The annual Minimum Data Set assessment dated [DATE] identified Resident #4 had memory recall deficits, was totally dependent on staff for eating, hygiene, showers, toileting, and dressing and utilized a wheelchair for mobility. The Resident Care Plan (RCP) dated 12/19/23 identified that Resident #4 had a self-care deficit and was unable to maintain an upright seated position. Interventions included mechanical lift with two (2) staff to transfer the resident into and out of bed and utilized a modified tilt in space wheelchair for mobility. The RCP addressed anxiety and depression with interventions 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 policies and interviews for one of three sampled residents (Resident #1) who was dependent on staff with getting in and out of the bed and chair and who had sustained a laceration, the facility failed to ensure the safety of Resident #1 during a Hoyer lift transfer into the bed. The findings include: Resident #1's diagnoses included pulmonary embolism, weakness, gait and mobility abnormalities, anemia, and anxiety disorder. The physical therapy evaluation dated 12/8/23 identified Resident #1 was receiving physical therapy services six (6) times a week for thirty (30) days. The evaluation indicated Resident #1 required maximum assistance with bed mobility and transfers with a Hoyer lift and the assistance of two (2). The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had memory recall deficits, required maximum assistance to roll in the bed and transfer from one (1) surface to another, utilized a wheelchair for mobility,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #87 and Resident #94) reviewed for dental services, the facility failed to ensure Resident #87 and Resident #94 were seen by dentist in a timely manner. The findings include: 1. Resident #87 was admitted to the facility with diagnoses that included a degenerative nerve disease, dementia without behaviors, gastro-esophageal reflux disease, and dysphagia. A Dental consultative form dated 11/12/19 identified Resident #87 was seen by the dentist and noted a moderate amount of plaque, gingivitis and recommended annual exams and a prophylactic fluoride varnish in 6 months. The Dental consult also identified Resident #87 was missing tooth #7 and #32, #28 was fractured and #24, #25, #26 retained root. A Dental consultative form dated 6/22/20 indicated Resident #87 was seen by the Dental Hygienist for prophylaxis with a fluoride varnish and tooth #7 was not missing but retained root,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for one of twelve residents reviewed for Advance Directives (Resident #25), the facility failed to obtain a physician's order related to the resident's preferred code status. The findings include: Resident #25's diagnoses included dementia without behavioral disturbances, alcohol abuse, anxiety disorder and adjustment disorder with depressed mood. A Resident Care Plan dated [DATE] identified Resident #25 had an established Advance Directive and wished to be a Do Not Resuscitate (DNR). Interventions included to do not administer Cardio Pulmonary Resuscitation (CPR), review Advanced Directives with resident and/or healthcare decision maker quarterly, and RN may pronounce (RNP). The quarterly MDS assessment dated [DATE] identified Resident #25 was severely cognitively impaired and required extensive assistance with one person for physical assist for all activities of daily living. An Advanced Directives…

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 two sampled residents (Residents #16 and #94) reviewed for abuse, the facility failed to ensure the residents were free from mistreatment. The findings include: 1. Resident #16's diagnoses included dementia, adjustment disorder, anxiety, depression, encephalitis and macular degeneration. The annual MDS assessment dated [DATE] identified Resident #16 was severely cognitively impaired, was independent with ambulation and locomotion, required supervision with dressing and personal hygiene and had no behavioral symptoms. The Resident Care Plan (RCP) dated 11/24/21 identified sometimes when seated close to others, the resident reached out and touched them, the resident was not mindful of what she/he was doing. Interventions included for staff to not seat resident too close to other residents. The RCP further identified Residents #16 had impaired cognitive function, dementia and impaired thought process related 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 sampled residents (Resident #50) reviewed for accidents, the facility failed to ensure adequate supervision during a meal and failed to follow the facility aspiration precautions policy. The findings include: Resident #50 was admitted to the facility with diagnoses that included intestinal obstruction, a degenerative nerve disease, gastroenteritis, colitis, disease of stomach and duodenum, and irritable bowel syndrome. A Speech Therapy Discharge summary dated [DATE] indicated swallow strategies were to take small, single bites, eat slowly, avoid talking while chewing immediately after swallowing with continual supervision. The physician's order dated 12/21/21 directed a controlled carbohydrate diet with no added salt, regular consistency and thin liquids. Aspiration precautions directed to encourage resident to take small bites, eat slowly, and avoid talking with food in the mouth. The Medicare…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 2 of 5 residents (Resident #77 and Resident #99) reviewed for a significant weight loss, that facility failed to document the amount consumed from a nutritional supplement (Resident #77), failed to obtain a re-admission weight and failed to consistently obtain daily weights per physician orders for Resident #99. The findings include: 1. Resident #77 was admitted to the facility on [DATE] with diagnoses that included a Stage 3 pressure ulcer, Type 2 Diabetes Mellitus, and Alzheimer's Disease. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #77 was severely cognitively impaired and required extensive assistance of two for bed mobility. The MDS further identified Resident #77 required extensive assistance of one for dressing and was totally dependent on one staff for eating, toilet use and personal hygiene. Additionally, the MDS identified Resident #77's weight was 80…

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 1 resident (Resident #109) reviewed for discharge, the facility failed to ensure Social Services documented Resident #109 leaving Against Medical Advice (AMA), failed to follow up with Resident #109/Person #2 after leaving AMA and failed to notify Elderly Protective (EPS) when Person #1 signed Resident #109 out Against Medical Advice (AMA). The findings include: Resident #109 was admitted to the facility on [DATE] with diagnoses that included altered mental status and diabetes. The face sheet identified Resident #109 was responsible for him/herself and Person #2 was the emergency contact for Resident #109. The Hospital Discharge summary dated [DATE] at 6:13 AM indicated Resident #109 was discharged from the hospital with a diagnosis of encephalopathy from toxic causes and other diagnosis of diabetes, hyperlipidemia, Vitamin B-12 deficiency, and orthostatic hypotension. The Discharge summary further 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #109) reviewed for discharge, the facility failed to document the notification to the physician/Advanced Practice Registered Nurse when Person #2 signed Resident #109 out Against Medical Advice (AMA).The findings include: Resident #109 was admitted to the facility on [DATE] with diagnoses that included altered mental status and diabetes. The face sheet identified Resident #109 was responsible for him/herself and Person #2 was the emergency contact for Resident #109. The Hospital Discharge summary dated [DATE] at 6:13 AM indicated Resident #109 was discharged from the hospital with a diagnosis of encephalopathy from toxic causes and other diagnosis of diabetes, hyperlipidemia, Vitamin B-12 deficiency, and orthostatic hypotension. The Discharge summary further identified Resident #109 was confused to person and place for the previous 10 days to date of hospital discharge and had been having…

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.