Summit At Plantsville Center For Health & Rehabili

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were a potential for falls, the facility failed to implement a care plan intervention directing staff to encourage the resident to sleep in his/her own bedroom after the resident was observed by multiple staff sleeping in a chair in the dining room just prior to the resident sustaining a fall with fractures. The findings include:Resident #1's diagnoses included dementia without behavioral disturbances, muscle weakness, anxiety and major depressive disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15) indicating poor memory recall, had behaviors of rejection of care and wandering, was independent with bed mobility, transfers and ambulation, and had one (1) fall with minor injuries in the past ninety (90) days. The Resident Care Plan dated 9/12/25 identified Resident #1 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, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who had sustained a fall with injury, the facilityfailed to medicate the resident for severe pain while waiting one (1) hour to be transferred to the hospital. The findings include:Resident #1's diagnoses included dementia without behavioral disturbances, muscle weakness, anxiety and major depressive disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15) indicating poor memory recall, had behaviors of rejection of care and wandering, was independent with bed mobility, transfers and ambulation, and had one (1) fall with minor injuries in the past ninety (90) days. The Resident Care Plan dated 9/12/25 identified Resident #1 had a behavior of sleeping in the dining room at bedtime. Interventions directed staff to encourage the resident to sleep in his/her…

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

Based on observations, clinical record reviews, facility documentation and interviews for one (1) of five (5) resident units, the facility failed to ensure a medication cup containing pre-poured medications was secured in the medication cart when the medication cart was left unattended and not within the line of sight of the nurse. The findings include:During a tour of the facility with the Assistant Director of Nursing (ADON) on 7/9/25 observations of the medication cart on the Mountain Laurel unit at 9:50 AM identified the charge nurse, Licensed Practical Nurse (LPN) #3, walked away from her medication cart to assist a resident with putting his/her shoes on, leaving dispensed medications in a medication cup on top of the medication cart unattended in the hallway. The medication cart was noted not to be in LPN #3's line of sight. The observation was brought to the attention of the ADON at the time of occurrence and the ADON acknowledged that she saw the medication cup was left on top of the medication cart. Upon further observations several residents were noted to be sitting in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure a safe Hoyer lift (mechanical lift) transfer for a resident, due to environmental constraints that impeded stabilization of the Hoyer lift's legs, resulting in the resident being struck in the head by the Hoyer lift arm. The findings include: Resident #1's diagnoses included atrial fibrillation (irregular heart rate), neuropathy (nerve damage causing weakness, numbness and pain), right hand contracture, muscle wasting and atrophy (decreasing in size) and adjustment disorder (excessive reaction to stress that causes negative thoughts, emotions and behavioral changes). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition and required substantial assistance with bed mobility and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation review, facility policy review, and interviews for one of three residents (Resident #4) who were reviewed for an allegation of abuse, the facility failed to report an allegation of abuse to the Director of Nursing or Administrator and State Agency within two (2) hours after the incident occurred. The findings include: Resident #4's diagnoses included Alzheimer's disease, vascular dementia, hemiplegia and hemiparesis following cerebral infarction, post traumatic stress disorder, and anxiety disorder. The Resident Care Plan (RCP) dated 8/19/24 identified Resident #4 has the potential to be verbally abusive by making accusatory statements regarding care. Interventions include psychiatric/psychogeriatric consults as indicated. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Provide positive feedback for good behavior and emphasize positive aspects of compliance. The significant…

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 #2) who required staff supervision during meals due to dysphagia (difficulty with swallowing) and non-compliant with following the plan of care, the facility failed to ensure the resident's safety when the nurse aide left the resident unsupervised in the room and failed to inform the nurse that the resident refused meal supervision. The findings include: Resident #2's diagnoses included dysphagia, aphasia, traumatic brain injury, and right sided hemiplegia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had some difficulty in new situations, required staff supervision with eating and was dependent with all other daily living skills and was on a mechanically altered diet. The Resident Care Plan dated 9/12/24 identified Resident #2 had dysphagia, was at risk for aspiration, and often refused to be supervised during meals. Interventions directed…

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 mistreatment, the facility failed to ensure resident was treated with respect. The findings include: Resident #1's diagnoses included Alzheimer's and left sided hemiparesis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 had moderate cognitive impairment and was dependent for toileting, ADLs, transfers, and independent with manual wheelchair use. The Resident Care Plan (RCP) dated 6/24/2024 identified Resident #1 required assistance with ADLs. Interventions directed encourage independent mobility in wheelchair, assist if needed and give the resident sufficient time to accomplish each task. Review of nurse aide care card directed dependent with wheelchair use. Review of Facility Reportable Event Form dated 7/3/2024 at 2:30 PM identified the hairdresser reported a NA pushing Resident #1 quickly down the hallway, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observation, facility documentation, review of facility policy and interviews for 1 of 2 sampled residents ( Resident # 5) reviewed for skin condition non-pressure, the facility failed to consistently conduct weekly wound assessment per facility policy and for 1 of 3 residents (Residents #45) reviewed for dining, the facility failed to ensure a physician's order for supervision and staff assistance during meals and for 3 of 10 residents ( Residents # 69, # 106 and # 120) reviewed for smoking, the facility failed to conduct smoking evaluation and safety per policy and for 1 of 7 sampled residents ( Resident # 57), the facility failed to administer the resident's medications as directed by the physician. The findings included: 1. Resident #5's diagnoses included Peripheral Vascular Disease (PVD), chronic venous hypertension with ulcer of left lower extremity, and non-pressure chronic ulcer of other part of left foot with unspecified severity. A physician's order dated 3/7/23…

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, review, facility policy and interviews for 1 of 3 residents (Resident #30) review for self-administration of medications, the facility failed to provide an environment free of potential accident hazards when a syringe and prescribed medications were left unattended in the resident's room and for 2 of 7 residents ( Resident # 57 and Resident # 134) reviewed for smoking, the facility failed assess the resident's smoking compliance timely and failed to provide supervision during smoking per policy to ensure a hazard free environment . The findings included: 1. Resident #30's diagnoses included diabetes mellitus, heart disease, mood disorder and post-traumatic stress disorder. The Self Administration of Medication form dated 10/2/23 identified Resident #30 would like to maintain personal dignity and independence and self-administer insulin within the facility safety guidelines. The form further identified the resident can safely self-medicate…

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 of the nourishment refrigerator and snack area on the memory care unit and interviews, the facility failed to date and label and remove expired food items. The findings include. An observation and interview with NA #3 on 1/4/23 at 12:39 PM with NA#3 who led the surveyor to the nourishment room on the memory care unit which he/she unlocked with keys on his/her person, identified a refrigerator on the right side of the room with and up to date temperature log on the refrigerator door. On top of the refrigerator was a plastic bin labeled snacks had 2 open containers which NA#3 indicated family members brought into the facility and further indicated it was nice to have something to give the residents if they were hungry. The opened container of cookies had no dates when opened and no expiration date. The container of gluten free muffins had 2 muffins remaining and the container had a manufacturer date of expiration of 12/24/2023. Interview and observation with the Director of Dietary on 1/4/2023 at 1:15 PM indicated the dietary department only services 3 nourishment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observations, review of facility documentation, review of policy and interviews for 2 residents ( Residents # 7 and# 10), the facility failed to store urinals, bath basins and bed pans in a sanitary way and in accordance to the facility policy and for 2 of 5 residents (Resident #83 and Resident #111), the facility failed to ensure the residents were protected against infection by ensuring Transmission Based Precautions were implemented. and for 1 of 2 sampled residents ( Resident # 126) reviewed for pressure ulcer, the facility failed to ensure staff perform hand-hygiene to prevent of the spread of infection. The findings included: 1. Resident #7's diagnoses included repeated falls, muscle weakness, and bilateral osteoarthritis of the knees (Osteoarthritis is a long-term degenerative joint condition in which the tissues and parts of the joints gradually deteriorate, causing pain and stiff joints). The quarterly MDS assessment dated [DATE] identified Resident #7 was cognitively…

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 documentation and interviews, the facility failed to ensure the kitchen ice machine was cleaned and sanitized regularly, the kitchen floor was free of a thick buildup of grease surrounding the grease trap, surrounding pipes were cleaned and failed to properly repaired hole in the dishwashing sink to ensure equipment was maintained in safe operating condition. The findings included. 1. Observation and interview with the Dietary Manager and Dietary Assistant #1 on 1/4/2023 at 9:30 AM identified the ice machine cover when opened the device was noted with a buildup of a dark substance along the top edge which makes the ice cubes. Dietary Assistant (DA #1) wiped the area with a paper towel which removed the dark substance. The Dietary Director indicated the maintenance of the ice machine included yearly maintenance and nightly wipe down of the inside of the ice machine by dietary staff. No logs or assignments for this task being completed by the dietary staff were provided. 2. Further observation in the kitchen on 1/4/2023 at 9:30 AM identified 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, facility documentation review of policy and interviews for 1 of 8 residents (Resident # 49) reviewed for Advanced Directive, the facility failed to provide evidence of the resident's complete and signed DNR wishes / code status form and failed to ensure a physician signed the resident's code status. The findings include: Resident #49's diagnoses included: dementia, neurological disease, and dysphagia (difficulty with swallowing). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident as severely cognitively impaired, dependent for bathing, dressing, personal hygiene and toilet use, substantial/maximal assist of one with sit to lying and lying to sit on side of bed, eating and receiving a special service program. A physician's order dated [DATE] directed code status full code and remained an active order. A physician's order dated [DATE] directed code status Do Not Resuscitate (DNR), Do Not Intubate (DNI), Do Not Hospitalize (DNH), no laboratory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility policy, facility documentation and interviews for 1 of 4 residents ( Resident # 134) reviewed for Abuse, the facility failed to ensure the resident was free from physical abuse. The findings include : Resident #134's diagnoses included depressive episodes and adjustment disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #134 was cognitively intact and was independent with transfer and ambulation. A nursing progress note dated 10/22/2023 at 12:48 PM by the RN supervisor indicated the resident had sustained a hematoma below the right eye with slight redness to the sclera and inner canthus bumping it on the bathroom door on the 11-7 AM shift, denied headache or dizziness ice compress applied Advanced Practice Registered Nurse (APRN) and family updated by the charge nurse. A physician's order dated 10/22/23, no time, with end date of 10/23/2023 at 11:59 PM directed to apply ice compress to hematoma below eye for 10…

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 of facility policy and interviews for 1 of 4 residents reviewed for abuse, the facility failed to ensure staff reported and investigated an allegation of abuse and timely. The findings included. Resident #134's diagnoses included depressive episodes and adjustment disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #134 was cognitively intact and was independent with transfer and ambulation. A nursing progress note dated 10/22/2023 at 12:48 PM by the RN supervisor indicated the resident had sustained a hematoma below the right eye with slight redness to the sclera and inner canthus bumping it on the bathroom door on the 11-7 AM shift, denied headache or dizziness ice compress applied Advanced Practice Registered Nurse (APRN) and family updated by the charge nurse. A physician's order dated 10/22/23, no time, with end date of 10/23/2023 at 11:59 PM directed to apply ice compress to hematoma below eye for 10…

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 interviews for 1 of 5 residents reviewed for accidents (Resident # 32), the facility failed to complete a significant change in condition for a resident with a decline in status. The findings include. Resident #32's diagnosis included unspecified fracture of the right tibia, other fractures of the upper and lower end of the right fibula, dementia, bipolar disorder, hemiparesis, and hemiplegia affecting the right side. The discharge Minimum Data Set (MDS) dated [DATE] indicated Resident #32 had short and long-term memory problems and had no functional limitation in upper and lower extremities. The MDS further indicated Resident #32 required set up and clean up for eating, supervision for oral hygiene, toileting, upper and lower body dressing, putting on and taking off footwear and assistance to perform personal hygiene. The MDS also indicated Resident #32 was independent in rolling left and right in bed and sit to stand and stand to sit but required supervision with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation and interview for 1 of 6 residents (Resident # 114) the facility failed to submit a level 2 preadmission screening and resident review (PASRR) with a newly identified psychiatric diagnosis. The finding include: Resident #114's diagnoses included dementia, anxiety, and delusional disorder. The quarterly MDS assessment dated [DATE] indicated Resident #114 was severely cognitively impaired and needed extensive assistance of 1 person for dressing, toilet use, and personal hygiene. The MDS further indicated Resident #114 had active psychiatric diagnoses of anxiety disorder and psychiatric disorder. The psychiatric resident log dated 11/2/23 identified Resident #114 as having a 1st visit with Supportive Care Psychiatric services and to add schizophrenia to the residents diagnoses. The psychiatric note dated 11/17/23 indicated Resident #114 had a newly added diagnosis of schizophrenia. The quarterly MDS assessment dated [DATE] indicated Resident #114 was severely cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility policy and interviews for 2 of 10 sampled residents (Residents # 69 and 134) reviewed for Accidents, the facility failed to develop and implement comprehensive person-centered care plan for smoking. The findings included: 1.Resident #69's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), asthma, depression, Cerebral Vascular Accident (CVA) and tobacco use. The annual Minimum Data Set assessment dated [DATE] identified Resident #69 as cognitively intact and a current tobacco user. The Smoking Evaluation and Safely Screen dated 7/17/23 identified Resident #69 as a current smoker. The Resident Care Plan dated 11/3/2023 failed to identify a comprehensive person-centered Resident #69 for smoking. 2. Resident #134 ' s diagnoses included COPD, depression, and heart failure. The annual Minimum Data Set assessment dated [DATE] identified Resident #134 as moderately cognitively impaired and a current tobacco user. Review of the Smoking Evaluation and Safety screen…

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 policy and staff interviews for 1 of 7 residents (Resident # 57), who required assistance with medication administration, the facility failed to meet professional standards of practice when administering a pain medication and 1 of 1 sampled resident who utilized Narcan, the failed to ensure that the Registered Nurse stayed with resident after the first dose of Narcan administration per facility practice. The findings included: Resident #57's diagnoses included pain in left shoulder, other low back pain, and unspecified displaced fracture of third cervical vertebra. A physician's order dated 10/7/23 directed administration of Dilaudid oral tablet, 4 Milligrams (MG), by mouth every 4 hours as needed for severe pain and not to exceed three doses in twenty-four hours. The annual Minimum Data Set assessment dated [DATE] identified Resident #69 was cognitively intact, independent with activities of daily living, and on a scheduled 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 clinical record reviews, observations, facility policy and interviews for 2 of 2 sampled residents (Resident #s 102 and 119) reviewed for Respiratory Care, the facility failed to ensure the resident oxygen was administered as directed by the physician. The findings included: 1. Resident #102's diagnoses included anxiety disorder, pulmonary embolism, and essential hypertension. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #102 as moderately cognitively impaired, required moderate assistance with toileting, dressing and performing personal hygiene and received oxygen therapy during residency. The Resident Care Plan dated 10/20/23 identified Resident #102 had respiratory disease related to asthma and a history of anxiety. Interventions directed to encourage the resident to report difficulty breathing and administer anti-anxiety medications per order. A physician's order dated 8/16/23 directed to administer oxygen via nasal cannula at 2 liters per minute and to check pulse…

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 policy and interviews for 1 of 1 resident reviewed for specialized treatment (Resident #58), the facility failed to ensure the resident intake and output were consistently monitored and the residents pre and post weight were monitored on the resident's communication log. The findings included: Resident #58's diagnoses included end stage renal disease and dependence on specialized treatment center. The annual Minimum Data Set assessment dated [DATE] identified Resident #58 as cognitively intact, required set-up assistance with meals, and was always incontinent of urine and bowel. The Resident Care Plan dated 11/14/23 identified the resident required specialized treatment had End Stage Renal Disease and was at risk for weight fluctuations related to the treatment. Interventions directed to encourage fluids, daily weights and monitoring of fluid intake and output. a. A physician's order dated 7/20/22 directed intake and output monitoring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interviews for 1 of 1 resident reviewed for medication administration of Narcan (Resident #57), the facility failed to ensure the licensed was educated and trained prior to administering the medication. The findings include: Resident #57's diagnoses included pain in left shoulder, other low back pain, and unspecified displaced fracture of third cervical vertebra. A physician's order dated 10/7/23 directed administration of Dilaudid oral tablet, 4 Milligrams (MG), by mouth every 4 hours as needed for severe pain and not to exceed three doses in twenty-four hours. The annual Minimum Data Set assessment dated [DATE] identified Resident #69 was cognitively intact, independent with activities of daily living, and on a scheduled pain medication regimen. Review of RN #9 nursing notes dated 1/7/24 at 12:57 PM noted was called to the floor by the charge nurse to assess Resident # 57 who was disoriented to time this morning which was outside of resident's baseline mentation of alert 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, review of facility policy, facility documentation and interviews for 1 of 4 residents ( Resident # 134) reviewed for Abuse, the facility failed to ensure psychiatric services were provided to a resident specifically related to trauma after an abusive incident . The findings included. Resident #134's diagnosis included depressive episodes and adjustment disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #134 was cognitively intact and was independent with transfer and ambulation. A nursing progress note dated 10/22/2023 at 12:48 PM by the RN supervisor indicated the resident had sustained a hematoma below the right eye with slight redness to the sclera and inner canthus bumping it on the bathroom door on the 11-7 AM shift, denied headache or dizziness ice compress applied Advanced Practice Registered Nurse (APRN) and family updated by the charge nurse. A physician's order dated 10/22/23, no time, with end date of 10/23/2023 at 11:59 PM…

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

Based on observation and staff interview for 1 of 4 medication carts, the facility failed to ensure resident safety by ensuring a medication cart was locked on the secure memory care unit. The findings include: Observations on 1/2/24 at 11:18 AM on the second floor, secure memory care unit, noted the medication cart located near the nurses' station, was unlocked and unattended while residents were noted to be sitting in the hall area near the medication cart and another resident was wandering the floor who had a diagnosis of dementia and unspecified psychosis. Interview with charge nurse, LPN #1 indicated the medication cart on a memory care unit should have been locked, she also indicated she thought it had swung closed and proceeded to immediately lock the medication cart. Review of facility policy, annual review 1/02/24 titled Medication Storage Room/Medication Cart Policy notes the facility provides pharmaceutical services that are conducted in accordance with ethical and professional standards of practice and that meet applicable Federal, State and Local Laws, rules, 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 observations, review of facility policy and interviews for 1 of 3 residents (Resident #45) who required assistance with ADL, the facility failed to ensure the resident's call light was accessible to resident while in bed. The findings include: Resident #45's diagnoses included: dementia, diabetes mellitus, depression, and dysphagia (difficulty with swallowing). The quarterly MDS assessment dated [DATE] identified the resident as severely cognitively impaired, extensive assistance of two for bed mobility, dependent for bathing, personal hygiene and toilet use, substantial/maximal assist of one with sit to lying and lying to sit on side of bed, partial/moderate assist with upper/lower dressing, mechanically altered diet and required supervision and set up help for meals. A Resident Care Plan dated 12/26/23, indicated Resident #45 required extensive assistance needed for activities of daily living (ADLs) and the resident has an ADL deficit related to cognitive loss/dementia limited to extensive assist.…

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

Based on observations, interviews, and review of facility documentation for 2 of 5 nursing units (with a total census of 68 residents affected), the facility failed to maintain safe/comfortable environmental temperatures, which are defined as a range of 71 to 81 degress Fahrenheit. The findings include: Observations on 7/18/23 at 2:45 PM identified resident room temperatures on the first floor reading 84-86 degrees Fahrenheit and on the second floor 89-91 degrees Fahrenheit. Interview with the Administrator on 7/18/23 at 2:45 PM identified on 7/13/23 the facility encountered a malfunction of the cooling system at which time a contractor was notified. The contractor was onsite on 7/13/23 and identified a problem with the 15 ton, rooftop, air conditioning unit for the affected areas. A replacement part was ordered and was anticipated to be delivered within 7-14 days. The facility installed 10 portable air conditioning units for both the first and second floors, however, the units were ducted incorrectly and ineffective in lowering temperatures for the affected floors on the resident…

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

Based on observations, interview, and review of facility documentation, the Administrator failed to ensure a safe and comfortable resident environment for 2 of 5 nursing units. The findings include: Observations on 7/18/23 at 2:45 PM identified resident room temperatures on the first floor reading 84-86 degrees Fahrenheit, and temperatures on the second floor reading 89-91 degrees Fahrenheit. Interview with the Administrator on 7/18/23 at 2:45 PM identified on 7/13/23 the facility encountered a malfunction of the cooling system for the first and second floors, at which time a contractor was notified. The contractor was onsite on 7/13/23 and identified a problem with the 15 ton, roof top, air conditioning unit for the affected resident areas. A replacement part was ordered and was anticipated to be delivered within 7-14 days. The facility installed 10 portable air conditioning units for both the first and second floors, however, the units were ducted incorrectly and were ineffective in lowering temperatures for the affected resident nursing units. The Administrator indicated he was…

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

Based on observations, facility's documentation review and interviews for kitchen maintenance, the facility failed to ensure food items were labeled and dated in accordance with facility policy, and the facility failed to ensure foods were discarded timely when spoiled. The findings include: Observations on 9/13/2021 at 10 AM with the Director of Dietary (DD), two trays of buttered bread were observed in the refrigerator without any date to identify when they were placed in the refrigerator. Observation of the food storage room identified five (5) plastic bags containing bread rolls on the shelf. the rolls were observed to be covered with a gray colored matter and no expiration date was noted on the outside of the bags. Subsequent to surveyor inquiry, the DD discarded the bags of rolls. During an interview with the DD on 9/13/2021 at 10:20 AM the DD indicated the rolls may have been covered with mold because they were delivered frozen and the facility stored bread thawed, and they should have been discarded. She further identified that food items in the refrigerator should be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation review and interviews for one of two residents (Resident #144) reviewed for advanced directives, the facility failed to complete advanced directive in a timely manner. The findings include: Resident #144 was admitted during [DATE] with diagnoses that included hypertension, Parkinson's disease, and cognitive communication deficit. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #144 had mild cognitive impairment and required extensive assistance with activities of daily living. The Resident Care Plan dated [DATE] identified that resident had an established advanced directive and that Resident #144's wishes were to have CPR. Interventions directed to review the code status with Resident #144 or his/her responsible party quarterly. Review of the clinical record identified Resident #1 had a family member designated as his/her responsible party (Responsible Party #1). A physician's order dated [DATE] directed that Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, facility policy review and interviews for one sampled resident (Resident #51) observed unsupervised with medications at the bedside, the facility failed to ensure licensed staff remained with the resident during medication administration and the facility failed to ensure medications were secure and inaccessible to unauthorized staff/residents. The findings include: Resident #51's diagnoses include dementia, hypertension, neuropathy, atrial fibrillation, and mood disorder. The quarterly MDS dated [DATE] identified Resident #51 had intact cognition and required limited assistance with ADLs. The Resident Care Plan (RCP) dated 8/26/2021 identified a diagnosis of dementia with long- and short-term memory deficits. Interventions directed assist Resident #51 in orienting to setting and routine. Observation on 9/14/2021 at 9:13 AM, identified Resident #51 was sitting at the edge of the bed in front of a tray table containing breakfast and a cup of medications. Further…

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.