Havencare At Valerie Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility policy and interviews for 1 of 7 residents (Resident #106) reviewed for nutrition, the facility failed to provide the appropriate consistency meal per the physician's order for a resident with dysphagia (difficulty swallowing). The findings include: Resident #106's diagnoses included dementia, swallow dysfunction, muscle weakness, and unspecified lack of coordination. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #106 was cognitively intact and was dependent with bed mobility, toileting, and transfers. The MDS indicated Resident #106 required setup or clean-up assistance with eating and was receiving a therapeutic diet. The Resident Care Plan (RCP) dated 10/15/25 identified Resident #106 had oropharyngeal dysphagia (difficulty swallowing) and was an aspiration risk with a risk for malnutrition. Interventions included to provide aspiration precautions and safe swallowing strategies. A physician's order dated 11/8/25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 7 residents (Resident #106) reviewed for nutrition, the facility failed to provide adaptive equipment at mealtime per the physician's order. The findings include:Resident #106's diagnoses included dementia, swallow dysfunction, muscle weakness, and unspecified lack of coordination. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #106 was cognitively intact and was dependent with bed mobility, toileting, and transfers. The MDS indicated Resident #106 required setup or clean-up assistance with eating and was receiving a therapeutic diet. The Resident Care Plan (RCP) dated 10/15/25 identified Resident #106 had oropharyngeal dysphagia (difficulty swallowing) and was an aspiration risk with a risk for malnutrition. Interventions included aspiration precautions and safe swallowing strategies and to provide an inner lip plate at meals. A physician's order dated 11/8/25…

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 2 of 6 residents (Resident #126, and Resident #143) reviewed for pneumococcal immunization, the facility failed to ensure that pneumococcal vaccines were administered when Resident #126 consented to receive and failed to offer or obtain a history of receiving the pneumococcal vaccine on admission (Resident #143). The findings include:1. Resident #126 was admitted to the facility on [DATE] on the short-term rehabilitation unit with diagnoses that included hypertension, dementia, and depression.A Resident admission Vaccination Education form dated 1/2/26 and signed by Resident #126 identified consent to receive the Pneumococcal conjugate vaccine (PCV20).Additionally, Resident #126's electronic medical record did not reflect any historical pneumococcal vaccinations nor indicate a pending pneumococcal vaccine order. 2. Resident #143 was admitted to the facility on [DATE] on the short-term rehabilitation unit.A 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 review of the clinical record, facility documentation and facility policy, and interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed to provide adequate supervision to prevent a resident-to-resident incident. The findings include: 1. Resident #1 had diagnoses that included dementia with agitation and adjustment disorder with mixed anxiety and depressed mood. Record review identified Resident #1 had a court appointed Conservator of Person (COP). The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of six (6), indicative of severely impaired cognition, and was independent with ambulation. The Resident Care Plan (RCP) dated 7/24/2025 identified Resident #1 had a history of inappropriate sexual behaviors and seeking out residents of the opposite sex, and observed on 2/26/2025 rubbing a Resident #2's thighs with his/her hand near or on Resident #1's breasts. Further the RCP identified the COP…

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 four (4) of four (4) residents (Resident #3, Resident #4, Resident #5, and Resident #6) reviewed for medication administration, the facility failed to ensure the clinical records were accurate to reflect when medications were administrated. The findings include:1. Resident #3 had diagnoses that included adult failure to thrive, weakness, and dementia.The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #3 had a Brief Interview for Mental Status (BIMS) score of two (2) indicative of severely impaired cognition, was always incontinent of bowel and bladder, dependent on staff for all ADLs, including bed mobility, and transfers, was non ambulatory, and dependent on staff for mobility in the wheelchair. The physician's orders dated 7/17/2025 directed to administer liquid protein supplement 30 milliliters once per day at 9:00 A.M., magic cup twice per day at 9:00 A.M. and 5:00 P.M, and supplemental…

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 review, and staff interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure the care plan intervention was implemented timely after a fall with an injury. The findings include: Resident #1 had a diagnosis of anxiety, dementia, history of falls, weakness, and insomnia. The quarterly Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10 indicating moderately impaired cognition, Resident #1 had no behaviors, and was required one (1) staff assistance for mobility. The Resident Care Plan (RCP) dated 4/23/2025 identified an alteration in mobility and a risk for falls. Interventions directed to place call bell within reach and assist of one (1) with bed mobility. The nursing note written by RN #2, dated 6/23/2025 at 2:03 AM identified the charge nurse reported Resident #1 was noted screaming and was found on floor at 1 AM. Resident #1 was lying in the prone position, partially…

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 resident (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from abuse by a staff member. The findings include: Resident #1's diagnoses included dementia, depression, adjustment disorder and anxiety. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment, required moderate assistance for personal hygiene. Resident Care Plan (RCP) dated 3/26/2025 identified Resident #1 had episodes of anxiety. The RCP directed to encourage resident to verbalize feelings, use a calm, gentle approach to quiet Resident and monitor for triggers and avoid them. A Facility Reportable Event (RE) report dated 4/12/2025 at 9:05 AM identified nursing and dietary staff in the dining room observed Nurse Aide (NA) #1 be verbally rude to Resident #1 and 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 review, facility documentation review, facility policy review, and interviews for two of three residents (Resident #1 and #2) reviewed for abuse, the facility failed to ensure staff reported an allegation of abuse timely. The findings include: A. Resident #1's diagnoses included Wernicke's encephalopathy, mild cognitive impairment, and adjustment disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of seven out of fifteen (7/15), indicative of severe cognitive impairment and ambulated independently. The Resident Care Plan (RCP) dated 1/2/2025 identified Resident #1 had behaviors/swearing at staff. Interventions directed to decrease visual or auditory stressors when over stimulated, and ask for resident cooperation with task. B. Resident #2's diagnoses included Parkinson's disease, vascular dementia, neurocognitive disorder, and anxiety disorder. The quarterly MDS assessment dated [DATE]…

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

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 sampled resident (Resident #3) who sustained an injury of the toes to the right foot, the facility failed to ensure injuries of unknown origin were thoroughly investigated. The findings include: Resident #3's diagnoses included osteoarthritis, contractures, protein-calorie malnutrition, dementia, anxiety, depression, delusional disorder and psychiatric disturbance. The quarterly MDS assessment dated [DATE] identified that Resident #3 had severely impaired cognition, had no behavioral symptoms, was always incontinent of bowel and bladder and required extensive two-person physical assist with bed mobility and toilet use, and was totally dependent with a two-person physical assist with transfers. The RCP dated 4/27/22 identified Resident #3 required assistance with activities of daily living. Interventions directed if Resident #3 refused a shower to offer a bed bath, report refusals and reapproach 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 review of the clinical record, facility documentation, facility policy, and interviews for one sampled resident reviewed for community discharge (Resident #24), the facility failed to ensure that required discharge information was documented and communicated to Person #10 to ensure a safe and effective discharge. The findings include: Review of Resident #24's clinical record identified a hospital Discharge summary dated [DATE] which identified Resident #24 lived alone at home and was brought to the emergency room when he/she was found wandering and confused. He/she did not remember what happened. The patient was not aware of why he/she was at the hospital and admitted at that time to drinking alcohol daily. There was no clinical evidence of alcohol withdrawl and his/her CIWA (Clinical Institute Withdrawal Assessment for Alcohol scale) remained low. The primary contact person contacted by the hospital identified that the patient was usually disoriented to time and drank alcohol regularly. At discharge…

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, hospital documentation, facility policy, and interviews for one sampled resident (Resident #24) reviewed for admission, the facility failed to accept the resident for a return to the facility after an inadequate discharge plan resulted in hospitalization. This resulted in the resident remaining at the hospital for an extra 8 days until the facility eventually admitted the resident back. The findings include: Resident #24's diagnoses included metabolic encephalopathy, alcohol dependence, brain atrophy, Wernicke's encephalopathy (acute neurological condition), brain atrophy, adjustment disorder, anxiety, depression, diabetes and hypothyroidism. The care plan dated 8/14/24 identified Resident #24 was admitted for short term rehabilitation with plans to discharge home after completion of therapy. Interventions directed discharge planning meetings as needed to evaluate discharge potential, involve family with the resident's permission and set goals 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 review of the clinical record, staff interview and review of facility policy and procedures for one sampled resident (Resident #11) reviewed for pain management, the facility failed to develop a pain management care plan. The findings include: Resident #11 was admitted to the facility on [DATE] with diagnoses that included displaced fracture of the second cervical vertebra and pain in the left ankle and joints of the left foot. A Minimum Data Set (MDS) assessment dated [DATE] identified the resident had significant cognitive impairment (BIMS of 0) required extensive assistance with activities of daily living. Physician orders dated 12/22/22 directed Tramadol (pian medication) 25 milligrams every 8 hours for severe pain. Review of the medication administration record from 12/22/22 through 12/27/22 identified the resident was reporting pain daily. A subsequent physician order dated 12/27/22, directed 50 milligrams, scheduled two times a day for severe pain. A pain assessment dated [DATE] indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, and interview with facility staff, the facility failed to ensure for 1 of 2 residents reviewed for discharge (Resident #8), the resident received the correct medications upon discharge to home. The findings include: Resident #8's diagnoses included perforated gastric ulcer, peripheral vascular disease, and essential hypertension (high blood pressure). A care plan dated 12/21/21 identified the resident needed assistance with self-care, mobility, and medications for high blood pressure. Interventions included assist with personal care, ambulation, and administration of medications. The Minimum Data Set assessment dated [DATE] identified Resident #8 as cognitively intact (BIMS 14). Resident #8 required extensive assistance with dressing, toileting, showering, and setting up for meals. The assessment further identnfied the Resident was continent of both bowel and bladder function. A physician's order dated 1/4/22 at 10:15 AM indicated Resident # 8 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 review, review of facility documentation and interviews for 1 sampled resident (Resident #16) that required a specialized treatment, the facility failed to provide the treatment. The findings include: Resident #16 had diagnoses of chronic obstructive pulmonary disease, malignant neoplasm of pancreas, disease of the biliary tract, fatty liver and chronic kidney disease. Review of facility documentation dated 8/17/2021identified the Resident had a diagnosis of jaundice with a biliary drain. Review of the Hospital Discharge summary dated [DATE] by Surgeon #1dentified that Resident #16 underwent a biliary stent placement on 8/23/2021 with the plan to leave the tube open to external drainage to the bag until the bilirubin is seen to plateau or decrease. The discharge summary directed flush the biliary tube with 10cc normal saline twice daily to maintain tube patency. Review of the physician's order dated 8/29/2021 directed to cleanse right flank biliary drain site with normal saline and apply…

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, interviews with facility staff and review of facility documents for one resident (Resident #20), reviewed for reports of pain, the facility failed to evaluate or develop a plan of care to address pain management. The findings include: Resident #20 was admitted to the facility on [DATE] with diagnoses that included acute pulmonary edema, cellulitis of the left lower limb, pressure ulcer of the sacral region and left buttock. Physician orders dated 6/6/23 directed Acetaminophen 325 milligrams. 2 tablets every 6 hours as needed for pain. An admission Minimum Data Set (MDS) assessment dated [DATE] identified the resident had no cognitive impairment (BIMS of 13), required extensive assistance with activities of daily living, and no reports of pain. Review of the clinical record identified pain assessment dated [DATE] and 6/22/23 indicating the resident was able to vocalize pain and was currently not experiencing pain. Review of the progress notes from 7/2/23 through 7/5/23…

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 review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from physical restraints. The findings include: Resident #1 had a diagnosis of dementia and muscle weakness. An annual Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview Mental Status (BIMS) score of two (2) indicating severely impaired cognition and used a walker and a manual wheelchair. The Resident Care Plan dated 11/15/2024 identified impaired cognition, required cueing for ambulation, and risk for falls. Interventions directed one (1) staff assist for transfers and ambulation, and speak slowly, clearly, and explain procedures. Physician order dated 9/24/2024 directed assist of one (1) for ambulation with rolling walker. Facility reportable event incident report dated 12/9/2024 at 12:21 PM identified Resident #1 was alert, confused, required assist of one (1) staff for transfers and one (1)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure staff reported an alleged mistreatment timely and failed to ensure the State Agency was notified timely after the facility became aware of an allegation. The findings include: Resident #1 had a diagnosis of dementia and muscle weakness. An annual Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview Mental Status (BIMS) score of two (2) indicating severely impaired cognition and used a walker and a manual wheelchair. The Resident Care Plan dated 11/15/2024 identified impaired cognition, required cueing for ambulation, and risk for falls. Interventions directed one (1) staff assist for transfers and ambulation, and speak slowly, clearly, and explain procedures. Physician order dated 9/24/2024 directed assist of one (1) for ambulation with rolling walker. Facility reportable event incident report dated 12/9/2024 at 12:21…

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

Based on review of the facility documentation and interviews for Resident Council funds, the facility failed to ensure resident council funds were utilized appropriately. The findings include: 1. Resident council meeting interview with Resident #8, #38, #44, #53, and #108 on 4/22/24 at 10:00 AM indicated Resident Council pays for bingo prizes, gift cards for the volunteers in addition to entertainment and art classes. Resident #44 identified his/her understanding was in order to have music, entertainment, art/painting classes that the Resident Council had to pay for it and the facility does not provide the entertainment. Resident #8, #38, #44, #53, and #108 all indicated they were obligated to vote yes in Resident Council to the music, entertainment, and art classes in order to have these activities at the facility. A review of the Resident Council minutes for the period of January 2023 to April 2024 identified evidence of the voting for the use of the Resident Council Funds. Interview with Administrator on 4/23/24 at 2:27 PM indicated that Resident Council funds can be used for…

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

Based on review of the facility documentation, employee files, and interviews for 6 out of 6 (NA #2, NA #6, LPN #5, LPN #6, RN #2, and RN #6) personnel files reviewed, the facility failed to ensure the required references and background checks were completed prior to hire. The findings include: Interview and review of personnel files with the Director of Human Resources (HR) on 04/23/24 at 12:11 PM indicated that she was responsible to make sure all employee files were completed at hire. HR indicated that she was responsible to do the background checks and get the 2 professional references. HR indicated that she is responsible to make sure the employee files were complete prior to the employee starting. HR once employment is offered to someone then the potential employee will come back to the facility and fill out the background form and she enters ABCMS and then ABCMS will tell if already had fingerprints or need fingerprints. HR indicated that if a potential new employee need fingerprints ABCMS will tell her immediately if they need fingerprints. HR will call the new employee 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 policy, and interviews for 4 of 6 residents (Resident #7, #16, #20 and #81) reviewed for respiratory care, the facility failed to ensure oxygen tubing was changed and dated, in accordance with the facility policy. The findings include: 1. Resident #7 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease (COPD). A physician's order dated 12/26/23 directed to change Resident #7's oxygen tubing every Sunday on 11:00PM- 7:00 AM shift. The annual MDS assessment dated [DATE] identified Resident #7 had intact cognition and was dependent on supplemental oxygen. The care plan dated 1/23/24 identified Resident #7 had the potential for cardiopulmonary complications related to diagnoses of chronic respiratory failure, COPD, emphysema, anemia, atrial fibrillation, hypertension, pleural effusion, and pneumonia. Interventions included administering oxygen via nasal…

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

Based on review of the facility documentation, facility employee handbook, and interviews for 5 of 5 nursing assistant (NA #2, NA #3, NA #4, NA #5, and NA #6) for staffing , the facility failed to ensure the introductory period and the last annual performance reviews were conducted. The findings include: Interview with Director of Human Resources (HR) on 4/23/24 at 12:11 PM indicated it was her responsibility to make sure all employee files were complete. HR indicated that all new employees or transfer employees prior to June 2023 would have a performance evaluation at 6 months and annually. HR indicated after June 2023 all new employees will have a performance evaluation at the end of 3 months and annually from date of hire. HR indicated she keeps track of when evaluations are due to be completed and the department heads keeps track of when the 3 month and annual evaluations are due to be completed. HR indicated the department head must give her the completed evaluations to put in the employees file as soon as they are completed and are they are kept in the HR office. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, and interviews for 1 sampled resident (Resident #63) reviewed for insulin administration, the facility failed to notify the APRN/MD and responsible party of a blood glucose reading exceeding the ordered parameters; and for 1 of 2 residents (Resident #114) reviewed for medications, the facility failed to ensure the physician was notified of refusal of medication. The findings include: 1. Resident #63 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, end stage renal disease, and dependence on renal dialysis. The quarterly MDS assessment dated [DATE] identified Resident #63 had intact cognition, was independent with eating, had taken a hypoglycemic medication during the last 7 days, and required dialysis while a resident at the facility. The care plan dated 1/17/24 identified Resident #63 has diabetes; therefore, blood sugars may fluctuate. Interventions included administering insulin/medications…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #63) reviewed for dialysis, the facility failed to complete vital sign monitoring in accordance with the physician's order and for 1 of 1 resident (Resident #94), reviewed for abuse, the facility failed to ensure neurological monitoring was conducted in accordance with the facility policy. The findings include: 1. Resident #63 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD), end stage renal disease (ESRD), and congestive heart failure (CHF). The quarterly MDS assessment dated [DATE] identified Resident #63 had intact cognition and received dialysis while a resident at the facility, during the last 14 days. The care plan dated 1/17/24 identified that Resident #63 had respiratory disease related to CHF, COPD, chronic respiratory failure, obstructive sleep apnea and pneumonia. Interventions included monitoring lung sounds, oxygen…

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 3 residents (Resident #36) reviewed for pressure ulcers, the facility failed to ensure the air mattress was utilized per manufacturer recommendations. The findings include: Resident #36 was admitted to the facility with diagnoses including: dementia, severe malnutrition, stage 4 pressure injury of left hip, stage 4 pressure injury of sacral region, unstageable pressure injury of right hip, stage 3 pressure injury of left buttock, and a suspected deep tissue injury of left heel. Review of the Weights Summary dated 2/27/24- 3/11/24 identified: Weight 2/27/24 was 95 lbs. Weight 3/4/24 was 91 lbs. Weight 3/9/24 was 88 lbs. Weight 3/10/24 was 81 lbs. Weight 3/11/24 was 81 bs. A physician's order dated 3/10/24 directed to apply a specialty air mattress at check setting cycle 10/105 and check function every shift. The care plan dated 3/11/24 identified Resident #36 as a risk for skin breakdown. Interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, review of facility documentation, facility and interviews for 1 of 8 residents reviewed for nutrition (Resident #60), the facility failed to ensure weight monitoring was completed and reviewed per physician's order and facility policy for a resident with a history of weight loss. The findings include: Resident # 60 was admitted to the facility on [DATE] with diagnoses which included mild protein calorie malnutrition, weakness, and dementia. The physician's orders dated 2/13/24 directed to obtain Resident #60's weight on admission and then weekly for 4 consecutive weeks every Monday on day shift. The orders also directed Resident #60 required a regular diet. Review of the clinical record identified Resident #60 had an admission weight of 112 lbs. on 2/13/24. The care plan dated 2/16/24 identified Resident #60 had a history of malnutrition related to significant weight loss and dementia. Interventions included weights per physician's order, monitor oral intake,…

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 policy, and interviews for 1 of 6 residents (Resident #7) reviewed for accidents, the facility failed to ensure medications were stored appropriately. The findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. A physician's order dated 12/26/23 directed to administer 325mg of Acetaminophen, 2 tablets by mouth every 6 hours, as needed, for pain. The annual MDS assessment dated [DATE] identified Resident #7 had intact cognition, was independent with eating and ambulation, and received or was offered an as needed (PRN) pain medication within the last 5 days. The care plan dated 1/23/24 identified Resident #7 had pain or the potential for pain related to generalized weakness status post low hemoglobin and a right arm deep vein thrombosis (DVT). Interventions included administering pain medications as ordered and assessing…

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 for 1 of 6 nursing units, the facility failed to ensure residents were provided palatable and presentable meals. The findings include: Observation of meal test trays provided to the survey team on 4/22/24 at 12:00 PM by the Dietary Director identified test trays that included 2 plates of cheese ravioli with tomato sauce, one of the main meals being served for lunch. The plates included an opaque cover over the meals that prevented observation of the meals prior to removal The 2 test trays that included ravioli were observed to have at least 50% of the meal blackened and hardened. Continuous observation on 4/22/24 beginning at 12:30 PM of the meal service to the Skyview unit, where Resident #60 resided, identified that the steam table included a large sheet metal tray of cheese ravioli with a tomato based sauce. The tray of cheese ravioli was observed to have charred and blackened areas of ravioli on all 4 sides of the inner portion of the tray. A tomato based sauce, used to top the ravioli underneath, was also…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #506) who required staff assistance when ambulating and was at risk for falls, the facility failed to ensure an alarm was functioning to alert the staff when the resident stood up from the chair. The findings include: Resident #506's diagnoses included cerebral palsy and cognitive communication deficit. The admission Minimum Data Set( MDS) assessment dated [DATE] identified Resident #506 rarely or never made decisions regarding tasks of daily life, required extensive two (2) person assistance with turning and repositioning while in the bed, getting in and out of the bed and chair, totally dependent on two (2) staff with toilet use, had impairment in range of motion with both lower extremities, had a history of one (1) fall in the past two (2) to six (6) months and utilized a wheelchair for mobility. The Resident Care Plan (RCP) dated 12/16/21 identified Resident #506 was at risk for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation, facility policy and interviews for two of three sampled residents (Residents #501 and #504) who were dependent on staff for personal hygiene and were always incontinent of bowel, the facility failed to implement the bowel evacuation protocol when the residents were noted to be constipated. The findings included: 1. Resident #501's diagnoses include glioblastoma, chronic respiratory failure, tracheostomy due to vocal cord paralysis, and cerebral vascular accident with left-side hemiparesis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #501 had some difficulty making decisions regarding tasks of daily life, required extensive two (2) person assistance with turning and repositioning while in the bed, toilet use and personal hygiene, was non-ambulatory, and always incontinent of bowel. The Resident Care Plan initiated on 7/15/19 and currently in place identified Resident #501 was at risk for constipation 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 clinical record review, facility policy and interviews for one of two sampled residents (Resident #500) who was reviewed for a death in the facility, the facility failed to ensure the resident's Responsibly Party was notified when the resident exhibited a change of condition. The findings include: Resident #500's diagnoses include dementia, chronic obstructive pulmonary disease, and hypertensive heart disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #500 rarely or never made decisions regarding tasks of daily life. The admission Record identified a family member was Resident #500's Responsible Party. A physician's active order dated as of [DATE] identified Resident #500's Advanced Directives were Do Not Resuscitate (DNR), Do Not Hospitalize (DNH), Comfort Measure Only (CMO) and Registered Nurse May Pronounce (RNP). The nurse's note dated [DATE] at 4:11 PM indicated Resident #500 spent the day in bed, had a poor appetite, tolerated fluids in small amounts, 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for one resident (Resident #117) reviewed for tube feeding, the facility failed to ensure the resident's tube feeding was administered in accordance to practice and the plan of care. The findings include: Resident #117 's diagnoses included muscle weakness, diabetes mellitus type 2, severe protein-calorie malnutrition, rhabdomyolysis, ileostomy, gastrostomy, and dysphagia. A physician's order dated 9/29/21 directed to give enteral tube feeding starting at 5:00 PM and off at 3:00 AM and to change tube feeding system every 24 hours (bag, tubing, and syringe). The admission MDS assessment dated [DATE] identified Resident #117 had intact cognition and identified the utilization of enteral feeding tube. The care plan dated 10/6/21 identified the resident is on a therapeutic diet, receives nutrients via enteral tube feeding, and has increased nutrient needs for wound healing. Intervention directed to treat 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.